The Mental Health of Children in Out-of-Home Care

Michael Tarren-Sweeney


Curr Opin Psychiatry. 2008;21(4):345-349. 

In This Article


Mental-health interventions for in-care populations can be construed within four categories: first, interventions that are not specific to these populations; second, interventions and treatment services designed for these populations; third, interventions directed to caregivers, with a view to maximizing the therapeutic potential of alternate care; and four, therapy-focused models of alternate care. There are limited and inconclusive findings on the effectiveness of generic psychological and pharmacological treatments for these populations,[44] while findings for other populations may not generalize to children in care. For example, the mechanisms accounting for the characteristic inattention/overactivity of severely deprived children[45] may differ from those that account for other inattention/overactivity, in which case alternative treatments may be warranted. Furthermore, generic treatment modalities are mostly designed for discrete disorders rather than complex biopsychological phenomena.

A recent literature review concluded that six of 18 reviewed therapeutic interventions were both well supported and efficacious for children in care.[46] Of greatest interest to clinicians who work in this field is the development of effective treatments for attachment difficulties. Howard Steele[47] however, cautioned that ‘…there is, as yet, no systematic evidence-based approach for treating children with attachment disorders…’.

Nurturing responsive caregiving is therapeutic for children who enter care with preexisting attachment difficulties and related emotional disturbances, especially at younger ages. Several interventions have been designed to effect therapeutic change for children via specialized training and therapy for caregivers.[48] An attachment perspective asserts that therapeutic recovery for these children comes primarily through the development of trusting and loving relationships with caregivers.[32] Therapists working within alternate care agencies have traditionally focused on strengthening carers’ relationships with children who have attachment and behavioural difficulties. They do this by providing caregivers with, first, skills for managing severely disruptive behaviour; second, some understanding of their children's attachment difficulties and how this interacts with their own attachment style; and third, validation, emotional support and encouragement. This is no easy task! Foster parents require a lot of support to unconditionally nurture children who, in addition to being disruptive, are detached, avoidant or indiscriminately affectionate.[49] One such approach has been formalized for intervention with foster parents of infants.[48]

The presumed therapeutic potential of alternate care also provides a conceptual basis for therapy-focused models of care. One such model is treatment (or therapeutic) foster care (TFC). Initially developed as an intervention for youth with behaviour disorders (including young offenders), TFC has also been employed for maltreated children in court-ordered care.[50•] The intervention consists of time-limited family-based care by professional foster parents with specialist training and knowledge, blurring the boundaries between parenting and psychotherapy. While treatment foster care seeks to (among other goals) repair relationship capacity through sensitive caregiving, its impermanence should restrict its application to older children and youth residing in short-term care.


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