The Relationship Between Caregivers and Youth in Foster Care: Examining the Relationship for Mediation and Moderation Effects on Youth Behaviors

Abstract

Youth in foster care often experience many negative outcomes. Fortunately, the empirical examination of potential protective factors is beginning to grow. The aim of this study was to investigate the influence that a warm relationship with one’s caregiver has on the well-established association between trauma symptoms and youth reports of internalizing and externalizing behaviors. Mediation and moderation analyses were conducted to explore the impact of this protective factor on this association. A warm relationship with a caregiver was a significant moderator of trauma and youth report of internalizing behaviors. Implications for practice and policy are discussed.

Keywords

child welfare adolescent behavior(s)externalizing internalizing caregiver relationships

Introduction

Youth in foster care often face significant developmental, physical, mental, and behavioral health challenges due to experiences in and prior to foster care (Oosterman, Schuengel, Slot, Bullens, & Doreleijers, 2007). Currently, there are more than 400,000 children in foster care, and approximately one third of this population is between the ages of 11 and 16 (Adoption and Foster Care Analysis and Reporting System [AFCARS] FY 2013 data, 2011–2012). The foster care system was developed to provide a safe, family-like environment for youth who must be removed from their parents due to severe abuse or neglect. It is probable that each youth who has been removed from his or her primary caregiver and placed in foster care has experienced trauma in some form due to abuse or neglect. Furthermore, researchers have indicated that removal from their primary caregiver is traumatic in itself (McCrae, 2009).

There is increasing concern about the behavioral and mental health needs that youth in foster care face as a result of traumatic experiences (McKay, Lynn, & Bannon, 2005). Exposure to trauma has been positively associated with internalizing and externalizing behaviors, such as depression, anxiety, negative self-esteem, substance abuse, defiant behavior, and running away, to name a few (McCrae, 2009; Orme & Buehler, 2001; Shulz et al., 2014; Tarren-Sweeney, 2013). Negative emotional and behavioral issues have garnered a lot of attention over the past years because of the strong relationship with placement instability (Barth et al., 2007; Oosterman et al., 2007). Placement instability and negative youth behaviors are a problem for both the youth and the foster care system. Despite the potential feelings of depression that come with involvement in foster care (Anctil, McCubbin, O’Brien, & Pecora, 2007), youth who experience more placement instability often face more severe behavioral problems and more negative long-term outcomes (Fisher, Stoolmiller, Mannering, Takahashi, & Chamberlain, 2011). Moreover, researchers have found that problem behaviors displayed by youth are particularly challenging for caregivers (Octoman, McLean, & Sleep, 2014). Dealing with problem behaviors may hurt their relationship with their foster youth or even lead foster caregivers to terminate their placement (J. D. Brown & Bednar, 2006; Coakley, Cuddeback, Buehler, & Cox, 2007), which could cause more long-term issues for the youth and foster care system. However, finding ways to improve outcomes for youth in foster care may provide a chance for greater placement stability (Thorpe & Swart, 1992; White et al., 2009).

Our intention is to investigate a potential protective factor that may have an influence on the relationship between trauma and negative internalizing and externalizing behaviors of youth in foster care. This potential protective factor is a positive relationship with their traditional or kinship foster caregiver, as reported by the youth. The relationship between foster youth and their caregiver is dynamic, which could provide a place of intervention with the hopes of increasing placement stability.

Trauma

Youth are removed from their homes and placed in foster care when child maltreatment has been substantiated, and the courts have declared that it is too dangerous for them to continue to reside with their primary caregivers (Lawrence, Carlson, & Egeland, 2006). Due to the maltreatment experienced that lead to placement in foster care, it is assumed that all youth in foster care have experienced some type of trauma prior to their placement (McCrae, 2009). Trauma has been associated with various negative outcomes for youth. For instance, youth in foster care who have experienced trauma are at a greater risk of experiencing internalizing and externalizing behaviors (McCrae, 2009; Shulz et al., 2014; Tarren-Sweeney, 2013). Berzenski and Yates (2011) found that young adults who had reported various forms of abuse during childhood were more likely to report depressive symptoms and problems with substance use. O’Brien and Sher (2013) found that a search of multiple studies indicates that a history of childhood sexual trauma is related to various internalizing behaviors and subsequent suicidal behavior. In addition, Farrell and Sullivan (2004) utilized latent growth analysis to determine that exposure to violence (a form of trauma) was significantly predictive of a range of problem behaviors during adolescence. Given the likelihood of youth in foster care experiencing trauma and the association with increased mental health concerns, it is imperative to identify potential protective factors that can mitigate some of these negative effects and help improve outcomes for these youth.

Internalizing and Externalizing Behaviors of Youth in Foster Care

Youth in foster care have been shown to be at risk of internalizing and externalizing behaviors (Anderson, 2005; Leathers, 2002). Internalizing and externalizing behaviors can range from depressive symptoms to more severe behaviors such as delinquency and openly defiant behaviors (Orme & Buehler, 2001). Heflinger, Simpkins, and Combs-Orme (2000) found that approximately one third of youth in care had a clinical level of reported behavioral concerns. Moreover, the occurrence of mental health diagnoses in this population has been significantly higher when compared with youth in a similar socioeconomic status (Harmon, Childs, & Kelleher, 2000). It is possible that the prevalence of various behaviors of foster youth may be directly related to their initial reason for involvement in the foster care system, namely, child abuse and neglect (Nemeroff, 2008).

Another issue to consider is that internalizing and externalizing behaviors have been significantly correlated with each other when examining nonfoster care populations (Donnellan, Trzesniewski, Robins, Moffitt, & Caspi, 2005). Researchers have found that internalizing symptoms may develop into other negative outcomes, such as mood disorders, substance use, and possible suicidal ideation (Hughes & Gullone, 2008). Exploring these behaviors concurrently may provide a more complete perspective of youth outcomes in foster care as well. One study examined the co-occurrence of internalizing and externalizing behaviors from the perspective of both the youth and their caregiver, and each reported high levels of negative behaviors, such as depressive symptoms, anxiety, social difficulties, delinquency, and aggression (Hazen, Connelly, Roesch, Hough, & Landsverk, 2009). Furthermore, Newton, Litrownik, and Landsverk (2000) found that youth in foster care with multiple placements display high levels of both internalizing and externalizing behaviors.

As previously discussed, youth in foster care have had a range of traumatic experiences before their involvement in the child welfare system (Nemeroff, 2008), and these experiences may increase behavioral concerns. Behaviors have long been identified as a significant predictor of placement disruptions for youth in care (Chamberlain et al., 2006; Newton et al., 2000). The correlation between more severe behavioral concerns and subsequent placement disruptions has been replicated in more recent studies as well (Fisher et al., 2011). It appears as though a circular relationship exists between behaviors and placement disruptions: Initial negative behaviors can lead to placement disruptions and instability, which can lead to more severe behaviors and outcomes for youth in care (Newton et al., 2000). Some interventions, such as a Keeping Foster Parents Trained and Supported (KEEP; Leathers, Spielfogel, McMeel, & Atkins, 2011; Price, Chamberlain, Landsverk, & Reid, 2009), multisystemic therapy (MST; Henggeler, Clingempeel, Brondino, & Pickrel, 2002), and other interventions for youth in care, have highlighted the important role that caregivers may play in helping to reduce negative behaviors for youth in care (Henggeler & Sheidow, 2012). These interventions aim to reduce these behaviors with the goal of maintaining placements for children and adolescents with difficult to manage behaviors. This research supports the notion that understanding how behaviors may relate to placement stability may be critical for enhancing the permanency and well-being of youth in foster care.

Taking previous research into consideration, utilizing self-report of youth behaviors may be particularly important. Researchers have found that youth and their caregivers do not always report the same frequency or severity of both internalizing and externalizing behaviors (Rosenthal & Curiel, 2006; Salbach-Andrae, Lenz, & Lehmkuhl, 2009). In addition, internalizing and externalizing behaviors of youth in foster care may not be readily observable or investigable to persons other than the youth. It is also possible that youth do not fully disclose certain behaviors to their caregivers, and caregivers are only modestly aware of the behaviors of youth (Barker, Bornstein, Putnick, Hendricks, & Suwalsky, 2007). Given that youth may report more externalizing behaviors than their caregivers (e.g., substance use, sexual behavior, etc.; Sourander, Helstela, & Helenius, 1999; Verhulst & Van der Ende, 1992), utilizing adolescent report of internalizing and externalizing behaviors could portray a more accurate representation of true conduct and experiences.

Relationship With Caregiver

Similar to youth behaviors, researchers have highlighted the importance of focusing on relational protective factors for youth in foster care (Cooley, Wojciak, Farineau, & Mullis, 2014; Griffin et al., 2011). The relationship between foster youth and caregiver has been a growing area of research providing information on both individual and overall family functioning. Anderson (2005) found that outcomes of youth in foster care were significantly related to their attachment with their caregivers. A positive relationship with one’s caregiver may relate to more positive outcomes from these youth who may have experienced multiple adverse life events. Other studies have shown the potential for interactions with one’s caregiver to act as an intervening variable aimed at improving outcomes for youth in care. For example, Vuchinich, Ozretich, Pratt, and Kneedler (2002) found that more positive communication between adolescents and their caregivers was related to lower levels of negative behaviors for the youth. Leathers (2002) found that males in foster care placements who reported stronger attachments to their caregivers were more likely to report less severe conduct problems. Understanding the foster parent–child relationship and ways to increase positive interactions could provide a base for developing holistic interventions that are focused on improving outcomes for adolescents in foster care (Cooley et al., 2014).

As mentioned previously, placement disruptions are a concern for youth in foster care. While behaviors of youth are a significant predictor of placement disruptions, there may also be an important association between the youth–caregiver relationship and placement disruptions. Multiple placements have been found to be associated with detachment from caregivers in future placements. Male adolescents in particular may have difficulty developing relationships with their caregiver after being in several placements (Leathers, 2002). A later study found that youth who had a more positive relationship with their caregivers, specifically youth who felt a sense of belonging in their foster home, were less likely to disrupt from their placement even when negative behaviors were present (Leathers, 2006). These findings indicate that the relationship with one’s caregiver may be a significant potential protective factor against various behaviors in regard to other outcomes and warrants further investigation.

To date, progress has been made in the development of holistic evidence-based interventions for youth in foster care and their foster caregivers (Fisher, Chamberlain, & Leve, 2010). However, less of this literature explicitly examines whether the youth or foster parent perceive a more positive or warm relationship based on the intervention. In addition, there has been an effort to standardize interventions or promote the use of standardized interventions that have originally been developed for nonfoster families for use with families in foster care (see Leathers et al., 2011; Price et al., 2008; Timmer et al., 2006). However, the outcomes examined generally relate to child behavioral outcomes, placement changes, or parenting stress but no specific examination of the perception of relationship as a separate protective factor. This produces some important implications to support this research. More specifically, the authors intend to analyze how the parent–child relationship may be the mechanism through which we see internalizing and externalizing behaviors in youth or it is a potentially moderating variable which can have significant clinical implications.

Resilience Theory

Resilience theory may be one way of understanding the relationship between foster youth trauma, negative behaviors, and the importance of a positive relationship between youth and caregiver. Resilience theory proposes that there may be identifiable protective factors that help youth to cope and adapt to highly stressful situations, such as abuse or exposure to violence, economic disadvantage, or parental dysfunction (e.g., mental illness, substance abuse, high conflict; Kaplan, 1999). Multiple studies have been conducted that build upon a framework for better understanding the influence of risk and protective factors on well-being, with many studies focusing on adolescent development in particular (Benard, 1991; Fergus & Zimmerman, 2005). In resilience theory, risk factors are usually environmental stressors or ongoing conditions that may lead to poorer outcomes for youth in domains such as mental health, physical health, school achievement, or other social indicators (Braverman, 2001). Pertaining to this study, experiencing trauma would be a risk factor. Protective factors would be physical, interpersonal, or psychological assets of the youth or their environment that diminish or moderate the harmful effects of the risk factor (Braverman, 2001). This study proposes that a positive youth–caregiver relationship is a potential protective factor for youth who have experienced trauma. We suggest that the beneficial impact of having a more positive youth–caregiver relationship may help reduce the occurrence of negative youth behaviors as a result of trauma experienced.

Purpose

Given the many negative outcomes that youth in foster care often experience, the purpose of this study was to examine a potential protective factor, positive relationship with their caregiver, and if that relationship may influence the common negative effects of trauma symptoms on the likelihood of experiencing internalizing and externalizing behaviors. MacKinnon, Lockhart, Baraldi, and Gelfand (2013) highlighted the importance of “third variables” when understanding the interconnection between two constructs. Mediators are said to be the intermediate variable between two constructs, and therefore, it is part of a causal chain. In this particular study, we hypothesize that the experience of trauma for adolescents in foster care will influence the subsequent parent–child relationship with one’s foster parent, which will ultimately influence youth’s internalizing and externalizing behaviors, and ultimately significantly mediate the relationship between trauma and internalizing and externalizing behaviors. Furthermore, MacKinnon and colleagues also explained that moderators are also influential in the interconnection between two constructs, but in that they influence the strength of this relationship. For this study, this would mean that the relationship between the experience of trauma and internalizing and externalizing behaviors of youth would be stronger, or weaker, depending on the strength of the parent–child relationship. We hypothesize that those with a stronger relationship would have a weaker association between trauma and internalizing and externalizing behaviors. Given the important role that both mediators and moderators can play in the significance of understanding experiences of youth in foster care, researchers elected to test for both mediation and moderation of the relationship with one’s caregivers in this study.

Method

Procedure

Data from the restricted release version of the National Survey of Child and Adolescent Well-Being (NSCAW, 2002) were examined in this study. The goal of NSCAW was to obtain a longitudinal understanding of the outcomes and well-being of children and families involved with the child welfare system. Participants were selected from 92 sampling units throughout the United States. This data set includes four waves of data, collected over a 7-year period. The first wave of data collection occurred over a 15-month period between October 1999 and December 2000. RTI International, a nonbiased research partner, recruited state and local child welfare agencies to participate. Data from youth and their caregivers were collected by a designated liaison within each child welfare agency via in-person interviews utilizing an electronic survey format. Child and caregiver interviews were scheduled within the same visit when it was possible, and 70% of interviews and related measures were completed within one visit (NSCAW, 2002). Other visits were rescheduled and completed at a later time. Although the manual did not clearly state that children were interviewed separate from caregivers, it was indicated that many interviews of children and caregivers were scheduled at different dates and locations due to scheduling conflicts (NSCAW, 2002). Variables including sensitive information, such as type of abuse experienced, were collected from children and caregivers using audio-computer-assisted self-interviewing (ACASI) to increase response rate.

The total sample consists of approximately 6,200 children, separated into two subsamples: (a) child protective services (CPS) subsample consisted of 5,501 children and families who have been involved with the child welfare system, and (b) long-term foster care (LTFC) subsample consisted of 727 children and families who were removed from their home and placed in foster care for at least 1 year when Wave 1 was collected. For the purposes of this study, Wave 1 of the LTFC subsample was utilized. These children had been living with caregivers for a time period of at least 8 months and a maximum of 18 months. Further details on the data collection procedures can be found in NSCAW (2002).

Sample

This sample was drawn from 727 children or adolescents specifically in the LTFC data set of NSCAW, as described above. To focus specifically on adolescents, age was the primary sampling parameter. In this study, a sample of adolescents between ages 11 and 16 years (M = 12.89, SD = 1.40) was targeted, resulting in a sample size of 188 youth. At Wave 1, the oldest youth was 16 years of age. In addition, out-of-home placement was analyzed to ensure that all adolescents included in the sample were with substitute caregiver and not residing with a biological parent, which resulted in a final sample size of 131 youth. The gender of participants was relatively equal between females (50.4%, n = 66) and males (49.6%, n = 65). The racial distribution of the youth was as follows: White (42.7%, n = 45), Black (42.7%, n = 56), Hispanic (12.2%, n = 16), and 9.9% of the sample were in an “Other” category (n = 13). Given the nature of this study and the interest in relationship with caregiver for youth in out-of-home placement, the sample was restricted to only those currently living with a foster parent (67.2%, n = 88) in traditional foster care or a relative (32.8%, n = 43) in kinship care. For this sample, the majority of the youth experienced neglect (30%, n = 35), followed by parental behaviors such as domestic violence or substance abuse (13.9%, n = 16), physical abuse (13%, n = 15), sexual abuse (13%, n = 15), and “other,” which can include multiple types of abuse (10.4%, n = 12).

Measures

Internalizing and externalizing symptoms

The Youth Self-Report (YSR) was used in this study. The measure was derived from the Child Behavior Checklist (CBCL; Achenbach, 1991). The CBCL measures emotional and behavioral disturbances that youth may experience. The measure is intended as a YSR measure for those aged 11 to 18 years old. The measure consists of 118 items and is broken down into eight subscales. For the purposes of this study, the Internalizing subscale consisting of 37 items and the Externalizing subscale consisting of 33 items were used. The measure has acceptable internal consistency and test–retest reliability (Achenbach, 1991). The reliability for the Internalizing and Externalizing subscales for the NSCAW sample was good (r = .85 and r = .84).

Trauma

The Trauma Symptom Checklist for Children (TSCC; Briere, 1996) was administered to the youth in this study. The youth were asked 10 questions exploring their symptoms related to the trauma they experienced. Such questions included the following: To what extent they remember scary things? How often they are scared of either a man or a woman? How often they remembered things they did not want to remember?. For the NSCAW sample Cronbach’s alpha was good (r = .99).

Closeness to caregiver

This measure was created using two items the youth were asked about their relationship with their caregiver: (a) “How close do you feel to our primary caregiver?” and (b) “How much do you feel your primary caregiver cares about you?” Each item had a 5-point Likert-type scale ranging from “not at all” to “very much.” The reliability of this measure was good (α = .81).

Results

First, descriptive statistics and correlations were conducted with all the study variables (see Tables 1 and 2). Second, several ANCOVAs were conducted to examine the significant correlations between covariates and study variables, specifically between youth age and externalizing symptoms, youth race and trauma symptoms, and caregiver type and perceived closeness to caregivers. The only significant association occurred between relationship with caregiver and closeness to caregiver. To examine this association, an ANOVA was conducted. Youth living with a relative (M = 9.1, SD = 1.2) reported feeling closer to their caregiver than those in traditional foster care (M = 7.9, SD = 2.5), F(1, 130) = 8.61, p < .05.

Table 1.

Descriptive Statistics of Sample (n = 131).

Variable	% or M (SD)
Youth gender (male)	49.6
Youth demographic characteristics
Age (years)	12.89 (1.40)
Race
White	34.4
Black	42.7
Hispanic	12.2
Other	9.9
Relationship with caregiver
Traditional foster parent	67.2
Relative/kin	32.8
Type of abuse
Physical	15.3
Neglect	41.2
Sexual	8.4
Maltreatment	25.2
Youth trauma symptoms	47.50 (9.9)
Youth perception of relationship with caregiver	8.31 (2.25)
Youth internalizing behaviors	47.65 (10.5)
Youth externalizing behaviors	52.08 (11.3)

Table 2.

Correlation Matrix for Study Measure (n = 131).

Variables	1	2	3	4	5	6	7	8	9
Youth age	—
Youth gender	.25*	—
Youth race	−.01	−.08	—
Type of abuse	.03	.05	−.02	—
Relationship with caregiver	.02	.08	.05	.19*	—
Closeness to caregiver	−.01	.14	−.07	.07	.25**	—
Youth internalizing behavior	−.00	−.07	.02	.13	−.09	−.24**	—
Youth externalizing behavior	.21*	−.00	.08	−.04	−.01	−.21*	.59**	—
Youth trauma symptoms	−.00	−.02	.20*	.12	−.04	−.15	.65**	.44**	—

p < .05. **p < .01.

Mediation

To test the hypotheses that youth’s positive perception of their relationship with their caregiver would serve as a mediator between the negative effects of trauma on youth’s perception of their own internalizing and externalizing symptoms, we used the bootstrapping approach described by Preacher and Hayes (2008), as it provides higher power and a lower chance of a Type I error. The bootstrapping approach produces confidence intervals (CIs) for the indirect effect of the mediator being tested, youth’s positive perception of their relationship with their caregiver. Furthermore, we used the PROCESS macro developed by Hayes (2013) to examine the influence of the significant covariates on the mediation tests. A mediator is statistically significant if the upper and lower confidence limits do not include zero. Efron (1987) recommended examining the bias-corrected and accelerated intervals as an improvement in traditional bootstrapping and CI. Significance was determined at α < .05.

Internalizing

Bootstrapping results indicated significant direct effects of trauma on internalizing symptoms, t(131) = 9.907, p < .001, 95% CI = [0.569, 0.853], and youth’s perception of closeness with caregiver on internalizing symptoms, t(131) = −2.1, p = .04, but there was no significant effects between trauma on youth’s perceptions of closeness with caregiver, t(131) = −1.46, p = .14, 95% CI = [−0.068, 0.010]. As such, the youth’s perception of their relationship with their caregiver did not significantly mediate the association between trauma and internalizing symptoms for youth in foster care. With the exception of caregiver type, when examining the association between trauma and closeness to caregiver, t(131) = 2.80, p = .01, 95% CI = [0.334, 1.949], none of the other covariates had a significant influence on the mediation model tested.

Externalizing

Bootstrapping results indicated significant direct effect of trauma on externalizing symptoms, t(131) = 5.6, p < .001, 95% CI = [0.324, 0.682]; however, there was not a significant association between trauma and youth’s perceptions of closeness with caregiver, t(131) = −1.46, p = .14,95% CI = [0.334, 1.949], and youth’s perception of closeness with caregiver on externalizing symptoms, t(131) = −1.87, p = .06, 95% CI = [−1.568, 0.045]. The youth’s perception of their relationship with their caregiver did not significantly mediate the association between trauma and externalizing symptoms for youth in foster care. Similar to the internalizing model, youth’s caregiver type continued to be significant, as well as youth age when examining externalizing behaviors in the total mediation model, t(131) = 2.65, p = .01, 95% CI = [0.430, 2.984].

Moderation

To test the hypothesis that youth’s positive perception of their relationship with their caregiver would serve as a moderator of the association between trauma and youth’s perception of their own internalizing and externalizing symptoms, we followed the methods Baron and Kenny (1986) outlined by centering trauma symptoms and youth’s perception of their relationship. Next, an interaction variable was computed. Finally, to test whether the interaction between trauma symptoms and perceived relationship had an influence above and beyond that of the covariates, predictor, and moderator, hierarchical regression with three models was conducted.

Internalizing

The initial model included the covariates: age, gender, race, type of abuse, and type of caregiver (foster or kin) on internalizing behaviors, R² = .04, F(5, 117) = 0.89, p > .05. The second model included the covariates, trauma symptoms, and youth perception of relationship on internalizing behaviors, and this model was significant, R² = .51, F(7, 117) = 16.89, p < .05. Finally, the interaction between trauma symptoms and youth perception of relationship was added in the third step and was significant, R² = .54, F(8, 117) = 15.81, p < .05, indicating that youth’s perception of their relationship is a significant moderator of trauma and internalizing behaviors (see Figure 1). The positive relationship between trauma symptoms and internalizing behaviors was still present for both youth who report higher and lower relationship scores. However, the positive relationship between trauma symptoms and internalizing behaviors was less strong for youth who reported a more positive relationship with caregiver.

Figure 1.

Moderation effect of youth perception on trauma symptoms and internalizing behaviors.

Externalizing

The initial model included the covariates: age, gender, race, and type of abuse on externalizing behaviors, R² = .06, F(5, 117) = 1.33, p > .05. The second model included the covariates, trauma symptoms, and youth perception of relationship on externalizing behaviors, and this model was significant, R² = .32, F(7, 117) = 7.37, p < .05. Finally, the interaction between trauma symptoms and youth perception of relationship was added in the third step, and the overall model was significant, R² = .32, F(8, 117) = 6.48, p < .05; however, the interaction was not. This indicated that youth’s perception of their relationship was not a significant moderator of trauma and externalizing behaviors.

Discussion

The purpose of this study was to investigate whether youth’s perception of closeness with their current caregiver could mediate and/or moderate the association between trauma symptoms and the expression of internalizing and externalizing behaviors. The results from this study do not support our hypothesis that youth’s perception of closeness with their caregiver mediates the association between trauma symptoms on internalizing and externalizing behaviors. This may indicate that a close relationship between foster youth and caregiver cannot explain or fully account for the outcomes that a child faces due to traumatic experiences before coming into foster care. However, youth’s perception of a close relationship with their current caregiver was a significant moderator between the association between trauma symptoms and internalizing behaviors for youth who are placed in traditional foster care homes as well as those in kinship care. Specifically, when youth reported a more close relationship with their caregiver, the relationship between trauma symptoms and internalizing behaviors was weaker compared with the youth who reported a less close relationship with their caregiver. This indicates that a close relationship with their caregiver may be a potential protective factor when dealing with the effects of traumatic experiences prior to coming into foster care. There was not a moderating relationship when examining externalizing behaviors. The results of the moderation effect hold even greater impact when considering type of caregiver. In preliminary analyses, there was a significant difference in how youth perceived their relationship by type of caregiver. Those who were living with a relative in kinship placement reported a significantly more positive relationship than those in traditional foster care placements. However, when controlled for in this model, the type of caregiver did not have any significant effect. The results of this study have important implications for practice, research, and policy.

Implications for Practice, Research, and Policy

This study supports the concept that youth perceiving a close relationship with their out-of-home caregiver may serve as a protective factor for youth experiencing internalizing behaviors. This is particularly important as internalizing behaviors can be overlooked but can have very costly long-term effects. Internalizing behaviors may be more difficult to identify in youth as these occur within the child, whereas externalizing behaviors are more readily noticed by adults and thus are more likely to receive a diagnosis. Penney and Skilling (2012) found that caregiver’s reports of internalizing behaviors were not correlated with clinical diagnoses of mood or depressive disorders. In addition, while there are some evidence-based interventions for mood and anxiety disorders among children (Slesnick, Guo, & Feng, 2013; Tompson, McNeil, Rea & Asarnow, 2000; Uliaszek, Wilson, Mayberry, Cox, & Maslar, 2014), the majority of research regarding evidence-based psychotherapies for children and adolescents focus on externalizing behaviors such as attention-deficit hyperactivity disorder and conduct disorder (Weisz & Kazdin, 2010). This may be because externalizing behaviors “demand” more attention. Nonetheless, youth with internalizing behaviors are at a greater risk as well and deserve the same level of attention. The World Health Organization reported that unipolar depression was the leading cause of disability for those aged 15 to 44 years old (Costello et al., 2002). Furthermore, internalizing symptoms can also develop into mood or anxiety disorders, substance use, and suicidal ideation and attempts (Hughes & Gullone, 2008). In addition, it has been found that some interventions may work to reduce externalizing behaviors, but adolescents themselves do not report a reduction of internalizing symptoms (Uliaszek et al., 2014). Given the potential for internalizing symptoms to turn into these negative outcomes and the fact that youth in foster care have 3 to 10 times the mental health diagnoses as compared with youth in similar socioeconomic conditions (Harmon et al., 2000), exploring avenues to improve these outcomes is paramount. Riebschleger, Day, and Damashek (2015) also found that youth reported significant trauma before, during, and after placement in foster care. They further recommended the use of earlier family-based interventions that highlighted the important role foster parents can play in a trauma-informed system of care. As such, understanding the potential protective relationship of a strong relationship with one’s caregiver could be extremely beneficial and cost-effective for youth in foster care.

Buehler, Cox, and Cuddeback (2003) emphasized the importance of focusing on familial factors in preservice training with foster parents, such as how to manage interactions with youth and relationship-building. Furthermore, Barth, Crea, John, Thoburn, and Quinton (2005) emphasized the importance of understanding youth’s attachments to others in consideration when intervening with foster youth with extreme behavioral concerns. It may be that children in foster care may have experienced multiple broken attachments, resulting in trauma-related symptoms, as supported by our results of the association between trauma symptoms and behaviors. Although there was a positive association between trauma and internalizing behaviors for youth who perceived a less and more positive relationship with their caregiver, it is worthy of future investigation. A positive relationship might not be the only buffer or the most important buffer between trauma and negative behaviors, but it may be one protective factor out of many that can be developed to help counteract the negative impact of abuse or neglect for youth in the child welfare system. Therefore, focusing on the relationship and attachment with one’s current caregiver can potentially help diminish some of the negative behaviors. Given the results of this study, it may also be important to encourage foster parents to understand their role and provide ways for a caregiver to build the relationship with the youth in their home. Capps (2012) promoted the use of filial therapy as a means for strengthening relationships between adolescents and their foster parents. In addition, Henggeler and Sheidow (2012) highlighted several family-based interventions that have been previously evaluated that have shown a reduction in negative behaviors of youth. While youth who come into foster care may have experienced significant trauma before placement, the findings of this study support the use of interventions that focus on improving the caregiver–adolescent relationship as a means for reducing problem behaviors in youth.

Several evidence-based interventions have been investigated to help foster parents with externalizing behaviors (Fisher et al., 2011; Vanschoonlandt, Vanderfaellie, Van Holen, & De Maeyer, 2012). One example is Multidimensional Treatment Foster Care (MTFC), a family-based intervention, that involves continual training and support for foster caregivers, and has been shown to be effective in reducing problem behaviors in foster youth (Fisher et al., 2011). Equally, more research is needed to investigate the effectiveness of interventions aimed at helping foster parents reduce the internalizing behaviors and ways to build the relationship with the youth in their home that have experienced trauma. These internalizing behaviors may have significant implications for the outcomes for youth, beyond just their placement stability. For example, Liu, Chen, and Lewis (2011) highlighted that internalizing behaviors can develop into more severe behaviors that can affect foster parents and other members of society.

When examining cost, researchers and policy makers alike may also need to consider the short-term need for intervention with youth who have experienced trauma, as well the effects or potential long-term cost if youth do not receive the necessary support. Economic and program evaluation research on both the cost and effectiveness of interventions that focus on the parent–child relationship may need to be done to help policy makers see the overall benefits of these interventions. In addition, some states have taken significant efforts to implement trauma-informed training with their child welfare workers to ensure that the impact of trauma is considered in working with these children and their families. In a study by Kramer, Sigel, Conners-Burrow, and Tempel (2013) in Arkansas, it was found that specialized training significantly improved the knowledge base and use of trauma-informed practices for their child welfare professionals. Despite the increasing number of evidence-based programs available, cost may be a significant barrier for policy makers if they are not provided with information and more diverse options for intervention. Finally, as more research is conducted to support the protective nature of relationships for youth in foster care, policy makers and bureaucrats need to be made aware of potential options such as family therapy or family-related supports as a means of treatment and intervention, as previously described.

Limitations

The data in this study were all derived from Wave 1 of the NSCAW data set and are thus cross-sectional. In addition, the measurement of the closeness between youth and caregiver only consisted of two items. Although validity has not been established, the measure demonstrated adequate internal consistency (α = .81). Given the dynamic nature of the constructs selected and the amount of time that youth may reside with one particular caregiver, it is possible that behaviors and relationships may differ across time. As such, interpretation of these results requires some caution. It is possible that a youth who was recently placed with a new caregiver may not be as close as someone who has been with a caregiver for a longer time. In future studies, it may be helpful to look at these variables and relationships longitudinally. In addition, there was an uneven distribution of those in traditional foster care and those in kinship care. While there is an uneven distribution, the breakdown of the distribution prior to the removal of other types of out-of-home placement mirrors that of the general foster care population (AFCARS FY 2013 data, 2011–2012). Future researchers should have a matched sample to investigate for any differences. Finally, the reliance on youth report may lead to potential measurement bias if youth are not able to respond objectively to their experiences or they may want to respond in a way that they feel is socially acceptable.

Conclusion

This study adds to the current literature by showing a connection between the experiences of trauma and subsequent internalizing symptoms of youth in foster care. Furthermore, this study highlights a potential protective factor in the foster parent–caregiver relationship for these internalizing symptoms. The authors presented the implications this study has in regard to both clinical practice and policy. Namely, interventions for youth who have experienced trauma should focus on improving the relationships with youth’s caregivers as a means for reducing internalizing symptomatology in these youth.

Footnotes

Authors’ Note

This document includes data from the National Survey on Child and Adolescent Well-Being, which was developed under contract with the Administration on Children, Youth, and Families, U.S. Department of Health and Human Services (ACYF/DHHS). The data were provided by the National Data Archive on Child Abuse and Neglect. The information and opinions expressed herein reflect solely the position of the authors. Nothing herein should be construed to indicate the support or endorsement of its content by ACYF/DHHS.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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