Mental disorders in foster children

The aim of this study is to examine the prevalence of mental disorders in 6- to 12-year-old foster children and assess comorbidity and risk factors.

Methods

Information on mental health was collected from foster parents and from teachers using Developmental and Well-Being Assessment (DAWBA) Web-based diagnostic interview. Child welfare services provided information about care conditions prior to placement and about the child’s placement history.

Results

Diagnostic information was obtained about 279 (70.5%) of 396 eligible foster children. In total, 50.9% of the children met the criteria for one or more DSM-IV disorders. The most common disorders were grouped into 3 main diagnostic groups: Emotional disorders (24.0%), ADHD (19.0%), and Behavioural disorders (21.5%). The comorbidity rates among these 3 main groups were high: 30.4% had disorders in 2 of these 3 diagnostic groups, and 13.0% had disorders in all 3 groups. In addition, Reactive attachment disorder (RAD) was diagnosed in 19.4% of the children, of whom 58.5% had comorbid disorders in the main diagnostic groups. Exposure to violence, serious neglect, and the number of prior placements increased the risk for mental disorders.

Conclusions

Foster children in Norway have a high prevalence of mental disorders, compared to the general child population in Norway and to other societies. The finding that 1 in 2 foster children presented with a mental disorder with high rates of comorbidity highlight the need for skilled assessment and qualified service provision for foster children and families.

Background

In Western societies, the number of children placed out of home converged at approximately 5 per 1000 in 2006-2007 [1]. In Norway [2], as in most western societies [3], parental neglect endangering a child’s development and health is the primary reason for out-of-home placement, and families receiving services from the child welfare system are often characterised by low socioeconomic status [4]. Child welfare services in Norway are typically family-oriented, emphasising voluntary and preventive home-based interventions. After a family’s first contact with child welfare services, children continue to stay, on average, 3 years with their biological families receiving home-based services, before they are placed out of home [5]. However, once the child has been placed in a foster family, the placements tend to last longer than in Anglo-American countries [3].

The prevalence of mental health problems in foster children has primarily been investigated using symptom checklists, providing an overall estimated prevalence of mental health problems in the range of 42.7% to 61.0% [6, 7, 8, 9, 10, 11]. Because questionnaires do not allow for detailed enquiry into symptom patterns, duration, or functional impact, these estimates may not be equated with estimates based on diagnostic assessments. Furthermore, symptom checklists do not take into account comorbidity rates.

Standardised diagnostic interviews are seen as the best way to achieve reliable prevalence estimates for mental disorders in different populations. However, only a few studies so far have used such diagnostic interviews to estimate the prevalence of mental disorders among foster children. One early study reported a point-prevalence of DSM-III-R disorders of 57.0% in foster youth [12]. A rather similar overall prevalence rate of 50,0% has been found in a more recent study of foster youth aged 11-17 years. [13] McMillen et al. [14] reported a somewhat lower past-year prevalence of 33.0% in a comparable sample, with 17.0% having Conduct Disorders (CD) or Oppositional Defiant Disorder (ODD), 15.0% Major depression, and 10.0% Attention Deficit Hyperactive Disorder (ADHD). Consistent with other studies, [12, 15, 16] the prevalence was higher for youths placed in congregate care [14]. In a study of foster youths aged 17 years and older, Keller, Salazar and Courtney [15] reported a lifetime prevalence of DSM-IV disorders of 10.5% for Major Depression and 16.1% post-traumatic stress disorder (PTSD).

These interview-based diagnostic studies all assessed older foster youths, using self-report only. The only sample that included younger foster children was the study by Ford, Vosansis, Meltzer and Goodman [16]. They reported a point-prevalence of 38.6%, where 9.7% suffered from Emotional disorders, 32.3% had CD/ODD and 8.5% had Hyperactivity. In this study, the diagnostic information was obtained from teachers, caregivers, and youths from 11 years of age. A higher prevalence rate was found in boys than in girls, and the rates increased with age. Whether this age-related increase could be attributed to later placement and longer exposure to neglect and abuse was not explored. Furthermore, the prevalence was only reported for broader diagnostic groups and not for single disorders among children living in foster families.

In contrast to the general agreement regarding the diagnostic criteria and methods of assessment for most mental disorders in children, the validity and relevance of the criteria for the diagnosis of Reactive Attachment Disorder (RAD) have been more controversial, especially regarding how these features should be characterised and assessed after the age of 5 years old [17, 18]. Some longitudinal studies have continued to use the Strange Situation Procedure up until school age, in combination with parental reports and standardised investigator ratings of child behaviour [19, 20], while others have developed their own semi-structured interviews and rating scales [21].

Findings indicate that children exposed to early adverse childhood experiences in general [22] and more specifically children placed in foster care have a heightened risk of attachment difficulties [23, 24]. Further, attachment difficulties have been related to other mental health problems both among foster and adopted children [25, 26]. It is therefore important to include measures of attachment disorders when assessing mental disorders of foster children.

Recently, a RAD section was added to the Developmental and Well-Being Assessment (DAWBA) structured diagnostic interview manual [27], developed from the corresponding section of the Child and Adolescent Psychiatric Assessment interview [28]. The first study using the DAWBA-RAD section reported a very high RAD point-prevalence of 63.0% (96/153) in a sample of looked after youth in a variety of placement forms [29]. In this study however, RAD was not defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [30] criteria, but as a symptom score 2 standard deviations greater than the mean. There is therefore a need for further studies of the prevalence of RAD among school-aged children living in foster families, as this age range and placement form are the most common in child protection services.

Age, sex, and learning difficulties [31, 32], as well as low socioeconomic status [33, 34], are well-established predictors of mental health problems in children in general. Foster children are exposed to a range of other risk factors as well [35]. Adverse childhood experiences, such as psychological and physical abuse and neglect, parental substance abuse and mental illness, all increase the risk of both physical and mental health problems, as well as health risk behaviours [36, 37, 38, 39, 40, 41]. In addition, older age at placement, frequent placement changes, the number of placements and persistent adverse events after placement pose additional risks for these children [42, 43]. However, few studies so far have examined whether such risk factors show specific associations with certain types of mental disorders [44].

In summary, previous studies have converged on the finding that foster children represent a high-risk group for mental health problems and that these problems might be associated with experiences of early neglect, abuse, and other adverse childhood experiences. However, only a few studies have used diagnostic interviews, covering the full range of mental disorders, and only one of these studies included school-aged foster children who were still living in foster families.

The purpose of this study was to estimate the point-prevalence and comorbidity of DSM-IV disorders in school-aged foster children. Further, we aimed to investigate the predictive value and specificity of risk factors related to adverse childhood experiences prior to placement, and placement history with regard to mental disorders in these children.

Because most foster children have been exposed to neglect and abuse before placement, we expected them to show increased rates of mental disorders compared to the general population [32]. We expected greater exposure to risk factors to be related to a higher prevalence of mental disorders, and in line with existing research findings, we expected that psychological and physical abuse, parental substance abuse and mental illness in the family of origin would be positively associated with mental disorders. Further, we expected to find associations between the prevalence of mental disorders and an unstable placement history.

Methods

Sample: eligibility and recruitment

The inclusion criteria were children aged 6 to 12 years old, living in foster families encompassed by the Southern Regional Office for Children, Youth and Family Affairs for at least 5 months following legally mandated placement. According to records from the Regional Office for Children, Youth and Family Affairs, there were 391 eligible children living in the 63 municipalities of the region.

Informational letters were sent to the head of each municipal child welfare office. The office heads were asked to review the list from the regional register of foster children and to complete the list by adding eligible children who were not registered. This process led to the identification of 28 additional eligible children. Of the registered children, the municipalities reported that 20 had either returned to their biological families or had been adopted. Three additional children were deemed ineligible because of serious neurological disabilities. Thus, the final number of eligible children was 396. The child welfare offices in the municipalities were asked to provide contact information for these children’s schools and teachers. They were also asked to answer a short purpose-made questionnaire about the children’s care conditions prior to placement and their placement histories. The caseworkers did not provide any diagnostic information, so the diagnoses are based on the DAWBA from the foster parents and the child`s teacher.

Foster parents of the 396 eligible children received postal letters with detailed information about the study, as well as instructions on how to complete the DAWBA interview online. They were also asked to return contact information for the children’s schools and teachers. In total, contact information was obtained for 307 teachers, who were then contacted by postal mail and asked to complete a version of the DAWBA diagnostic interview online. Figure 1 provides a flowchart of the entire data collection.

Figure 1

Flow-chart of data collection.

Ethics

The study was approved by the Regional Committee for Medical and Health Research Ethics, Western Norway. The Ministry of Children, Equality and Integration provided exemptions from confidentiality for caseworkers, foster parents, and teachers participating in this study. In accordance with Norwegian ethics requirement, oral assent is required from children aged 12 years old. The children and their foster parents were instructed about this in the information letters that included a version especially adapted for children. If the child did not assent, the foster parents were instructed not to participate in the survey.

Measurements and diagnostic rating procedures

We used the Developmental and Well-Being Assessment (DAWBA) [27] interview to assess DSM-IV mental disorders. The DAWBA is a Web-based diagnostic interview that combines structured questions on symptoms and impairment with open-ended questions in which the respondents describe the child’s problems in their own words. The DAWBA administered to parents or caregivers has a total of 17 sections, covering diagnostic areas, child and family background, and child strengths. The time needed to complete the interview by carers vary from 30 minutes to several hours, depending on the amount of problems reported. Due to skip-rules included in the web-based interview, the interview becomes shorter if no problems are reported in the initial questions of a section. Teachers respond to a shorter version of the interview, which typically can be completed in 15-30 minutes.

The task of the clinical rater is to judge the answers from the different informants. For most disorders, the diagnostic criteria only require that problems are evident in one setting (e.g. at home or at school). The different informants are usually treated as complementary adding to the understanding of the child. Where informants give contradictory information, the rater has to use her judgment as to witch informant is the most reliable. The DAWBA interview has shown good ability to discriminate between children from community and clinical settings [27], and it has generated realistic prevalence estimates of mental disorders when used in public health services [32, 45].

In this study, all of the available DAWBA information from both foster parents and teachers were reviewed by first and last author, who separately assigned diagnoses according to the DSM-IV criteria. Both raters are clinical specialists in child and youth mental health. Last author has documented high inter-rater agreement with Robert Goodman, who developed the DAWBA [32]. The agreement between the 2 raters regarding the presence/absence of a disorder was excellent (Kappa = 0.95, 95% CI: 0.88-1.00).

If informants reported a definitive impairment in function but not sufficient symptoms to fulfill a specific diagnosis, an “other” or NOS diagnosis was given. A previously given ADHD diagnosis by a specialist in child mental health services was accepted, even if the ADHD interview section reported sub-threshold symptoms and impairment, because the symptoms might have been suppressed by medication. For children from the age of 11 years, the RAD section is not a part of the DAWBA interview. For the children aged 11-12 years old, we therefore used free-text description of symptoms and impairments meeting the DSM-IV criteria to assess RAD. A previously given RAD diagnosis by a specialist in child mental health services was also accepted for this age group.

A short child welfare questionnaire was developed for the study to obtain information from caseworkers in the child welfare services, about 12 possible care conditions in the biological family; the caseworker could mark any number of these conditions, corresponding to their records of characteristics of the child’s care experiences. The questionnaire also asked about placement history and the country of birth of both the child and biological parents.

Procedures

The data collection started in September 2011 and lasted for 6 months. If foster parents or teachers had not responded within 2 weeks after the first information letter, a reminder was sent. Consenting foster parents who still had not completed the DAWBA within 2 months were offered a telephone interview. Thirty-one DAWBA interviews were completed over the phone. Teachers were compensated with NOK 250 (31 Euro) for their participation, while foster parents were not offered compensation for participating.

Analysis

Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS), version 19 for Windows. Comparison between subsamples was performed with t-tests and Chi-square tests. The prevalence of disorders was calculated by frequency analyses with 95% confidence intervals (CIs). In subsequent analysis, single disorders were clustered into 3 main diagnostic groups. Due to the relatively low prevalence of depression, this disorder was grouped together with all of the anxiety disorders and with undifferentiated anxiety/depression in the main diagnostic group of Emotional disorders (see Table 1). Diagnoses related to ADHD were grouped into ADHD disorders. Similarly, CD, ODD, and other disruptive disorders were grouped into the diagnostic group of Behavioural disorders. This grouping of disorders corresponded to that used in Ford et al.’s study of looked-after children [16]. Further, the RAD group comprised only that diagnosis. The group labelled “Any disorders” comprised all single disorders referred to in Table 1, except for the NOS diagnosis.

Table 1

Characteristics of foster children with both DAWBA and municipal care history information (n = 219)

	%	Mean	SD
Age (years)		8.97	2.04
Female gender	47.0
Former placements		0.90	0.85
0	32.0
1	52.2
2	12.5
3-5	3.1
Age at first placement		3.74	2.98
0–6 months	16.0
7 months–2 years	26.0
3–5 years	28.8
6–12 years	29.2
Years in current foster home		5.08	3.06
0-2	23.5
3-5	25.3
6-7	25.3
8-12	25.8
Number of adverse childhood experiences1		3.00	1.60
Violence exposure (range 0–4)2		0.71	1.14
0	64.1
1-2	26.2
3-4	9.7
Serious neglect	86.3
Parent`s drug/alcohol abuse	55.3
Parent`s mental disorder	52.3
Parent`s mental disability	9.6

¹Experiences in family of origin; ²Violence exposure = the sum of witnessing domestic violence; exposure to physical violence; exposure to emotional abuse; witnessing emotional abuse.

Cross-tabulations were used to examine patterns of comorbidity, first between each of the 3 main diagnostic groups — Emotional disorders, ADHD and Behavioural disorders — and all other disorders, and then among these 3 main diagnostic groups only. These 3 groups were further recoded into 1 variable to examine the overlap between RAD and any of these 3 main diagnostic groups. Estimates of the odds of comorbidity between any 2 of 4 diagnostic groups (Emotional disorders, ADHD disorders, Behavioural disorders, and RAD) were calculated with logistic regression analyses.

In the analyses of associations between possible risk factors and mental disorder, the 5 diagnostic groups (Emotional disorders, ADHD disorders, Behavioural disorders, RAD and Any disorders) were included as the dependent variables in separate binary logistic regression analyses. To reduce the number of predictors, the associations between single risk factors and diagnostic groups were examined in preliminary analyses (see Table 1 for information about the included predictors). Among the demographic variables, Age, but not Gender or Parents ethnicity, was related to at least 1 of the 5 diagnostic groups. Variables related to the child’s placement history (Age at first placement, Number of placements, and Time in current foster home) were all related to at least 1 diagnostic group. Time in current foster home and Age at first placement were highly inter-correlated (r = -0.69). To avoid collinearity, only Age at first placement was included in the subsequent analyses.

Among the possible risk factors reflecting care experiences in the family of origin, as reported by the child welfare services, Parental substance abuse, Mental illness and Mental disability were unrelated to any of diagnostic groups. Five variables — Serious neglect, Exposure to physical violence, Witnessing domestic violence, Exposure to emotional abuse (threats, hostility, rejection, harsh verbal punishment), and Witnessing emotional abuse towards other family members — all had a significant associations with at least one diagnostic group. These 5 variables were then included in an exploratory principal component analysis with oblimin rotation. The latter 4 of the 5 variables were loaded on one factor with an eigenvalue of 2.18, explaining 43.7% of the total variance, whereas Serious neglect was loaded as a separate factor, with an eigenvalue of 1.08, explaining 21.1% of the total variance. Based on these findings, the 4 variables loading on Factor 1 were added into a continuous variable termed Violence exposure, with a range of 0–4 (M = 0.89, SD 1.22) and Cronbach’s alpha = 0.72. Thus, in the final logistic regression analyses, the following predictors were included: Age; Age at first placement; Number of placements; Violence exposure; and Serious neglect. All of the predictors were used as continuous variables, except for Serious neglect, which was defined as a dichotomous variable (no = 0, yes = 1), using a simple contrast with no serious neglect as the reference category. We first ran unadjusted logistic regression analyses for each of the predictors. Next, each predictor was included in an adjusted model to control for the 4 other predictors. The results are presented as un-adjusted and adjusted odds ratios (ORs) with 95% CIs. If a predictor only had a significant contribution in the adjusted model and not in the unadjusted model, a suppressor effect was suspected. Here, a Wald backward stepwise regression procedure (exit criterion p = 0.05), starting with all of the predictors in the model, was used to identify the suppressor variables.

 

Children in the United States who have been in foster care are at significantly higher risk of mental and physical health problems, including learning disabilities, depression, asthma, and obesity, compared with children who have not been in foster care. This is the finding of a new study published in the journal Pediatrics.

Researchers say children in foster care have much worse health than children in the general population.

In 2014, more than 650,000 children in the U.S. spent time in foster care. On average, children in foster care spend 2 years waiting to be adopted.
Previous studies have suggested that children in foster care may develop physical and mental health issues, primarily as a result of the trauma they have experienced, such as abuse and neglect.
However, the authors of the new study - including Kristin Turney of the University of California-Irvine - note that no research has compared the health of children in foster care with that of children in the general population.
With this in mind, Turney and team analyzed 2011-2012 data from the National Survey of Children's Health, which included more than 900,000 children across the U.S. Of these, around 1.3 percent had been in foster care.
The researchers used logistic regression models to compare the risks of mental and physical health problems of children who had and had not spent time in foster care.

Foster care 'a risk factor for health problems in childhood'

On looking at the risks of physical health problems, the researchers found children who had been in foster care were twice as likely to have asthma and obesity and three times as likely to have hearing and vision problems, compared with children who had not spent time in foster care.
When it came to mental health, children who had been in foster care were found to be at seven times greater risk of depression and five times greater risk of anxiety.
Behavioral problems were six times more likely among children who spent time in foster care, the team reports, and they were also at three times greater risk of attention deficit hyperactivity disorder (ADHD), and twice as likely to have learning disabilities and developmental delays.
Turney says their study makes an "important contribution to the research community" by being the first to demonstrate that the health of children in foster care is much worse than children in other living conditions.
"Our findings also present serious implications for pediatricians by suggesting that foster care placement is a risk factor for health problems in childhood," she adds.

"This is typically a difficult-to-reach population, so having access to descriptive statistics on their living arrangements, physical well-being and behavior provided an excellent opportunity to help identify the health challenges they face.
This study expands our understanding of the mental and physical health of these highly vulnerable children, but we must take a closer look if we are to understand how foster care really affects child well-being."

Kristin Turney

Read about a study that suggests depression may be passed down from mothers to daughters.

Written by Honor Whiteman