A Systematic Review of Mental Health Disorders of Children in Foster Care

Method

Inclusion and Exclusion Criteria

Two authors independently reviewed 5,042 manuscripts based on title and abstract, eventually yielding 25 articles that were identified as meeting the inclusion criteria (Figure 1). Research focused on robust analyses of health problems of children in foster care. The inclusion criteria included the following: published in or after 2000, written in English text, and having a population sample of children in foster care in the Western countries, including the United States, Norway, Australia, and Canada. Exclusion criteria included a population sample that did not evaluate children younger than 18 years old in foster care and methods that did not assess the mental health disorders of this population.

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Figure 1.

PRISMA 2009 flow diagram.

As the purpose of this study was to report on behavioral and mental health conditions in children in foster care, studies describing therapeutic strategies (i.e., randomized clinical trials) or risk factors (i.e., case-control studies) were not included. The resulting articles (n = 25) were all descriptive in nature, with all using standardized diagnostic criteria for assessing mental health conditions. Seventeen of the articles presented original research, and eight of the articles were literature reviews. A meta-analysis was not intended; thus, a formal literature appraisal tool was not utilized to asses for study quality.

Results

The search strategy resulted in 25 articles for final review. Seventeen of the selected articles presented new data, whereas eight articles were literature reviews of the prior studies regarding the mental health of children in foster care (Table 1). The literature reviews cited in this article presented data that varied in terms of how mental health diagnoses were identified, what diagnoses were reported, and what sample of foster children were evaluated. This article attempts to clarify the demographics of children sampled (including age and race/ethnicity) and outline the reported rates of diagnoses within this population in order to help providers have a clearer understanding of the common diagnoses in foster children.

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Table 1.

Included Articles.

Article	Country	Design	Sample Size	Age Range (m or y)	Race/Ethnicity of Sample
Anderson (2011)	United States	Cohort	2,145	7–15 y	White: 47.2% Black: 29.1% Hispanic: 15.4% Other: 8.3%
Baker et al. (2007)	United States	Cohort	2,274	3–21 y	White: 49.4% Black: 30.6% Latino/a: 9.7% Other: 10.2%
Beal et al. (2018)	United States	Cohort	351	15–21 y	African American: 68.4% White, non-Hispanic: 27.3%
Bramlett et al. (2017)	United States	Cohort	1,122	1–17 y	Hispanic: 20.1% Non-Hispanic White: 34.7% Non-Hispanic Black: 36.3% Non-Hispanic other: 8.9%
Bruskas (2010)	United States	Review	N/A	N/A	N/A
Gonzalez (2014)	United States	Review	N/A	N/A	N/A
Greiner & Beal (2017)	United States	Cohort	95,677	0–17 y	Not reported
Havlicek et al. (2013)	United States	Literature review	N/A	N/A	N/A
Holtan et al. (2005)	Norway	Cohort	214	4–13 y	Not reported
Jacobsen et al. (2013)	Norway	Cohort	T1: 102/T2: 96	T1: 22–25/T2: 34–36 m	Norwegian: 91.7% Norwegian/other: 3.3% Other: 5.0%
Lawrence et al. (2006)	United States	Cohort	189	0–17 y	Caucasian: 37% Other races/ethnicities not reported
Lehmann et al. (2013)	Norway	Cohort	279	6–12 y	Not reported
Lohr & Jones (2016)	United States	Review	N/A	N/A	N/A
McMillen et al. (2005)	United States	Cross-sectional	373	17 y	African American: 52% White: 42%
					Mixed race: 4%Native American: 1%Asian: 1%Latino: 0%Middle Eastern: 0%
Okpych & Courtney (2018)	United States	Cohort	727	16.75–17.75 y	White: 18.0%African American: 17.5%Mixed race: 15.3%Hispanic: 46.9%Other race: 2.3%
Oswald et al. (2010)	Germany	Literature review	N/A	N/A	N/A
Persi & Sesson (2008)	Canada	Cohort	616	5–18 y	Not reported
Stanley et al. (2005)	United Kingdom	Cohort	80	5–16 y	Minority ethnic groups: 0.04%
Staudt (2003)	United States	Literature review	N/A	N/A	N/A
Tarren-Sweeney (2008)	New Zealand	Literature review	N/A	N/A	N/A
Taussig et al. (2001)	United States	Cohort	T1: 214, T2: 149	T1: 7–12 y, T2: 13–18 y	White: 41.5%Hispanic: 20.7%Black: 37.8%
Taussig et al. (2014)	United States	Cohort	515	9–11 y	Hispanic: 49.9%Caucasian: 25.2%African American: 25.2%Native American: 12.2%Asian/Pacific Islander: 3.3%
Thompson & Hasin (2012)	United States	Cohort	423	18–21 y	Black: 59%White: 3%Hispanic: 26%Other: 12%
Turney & Wildeman (2016)	United States	Cohort	95,677	0–17 y	Non-Hispanic White: 45.6%Non-Hispanic Black: 16.0%Hispanic: 25.9%Non-Hispanic Other: 12.5%
Vasileva & Petermann (2018)	United States	Literature review	N/A	N/A	N/A

Thirteen of the articles included information about race and ethnicity of participants. Only one evaluated the relationship between these demographic factors and mental health outcomes, finding that White race was associated with increased mental health diagnoses (Beal et al., 2018).

In reviewing the 25 manuscripts, three main themes regarding children in foster care were identified: (1) Children in foster care have higher rates of mental health disorders than children not in foster care. Based on the data gathered in this systematic review, the most common diagnoses across articles are ODD/conduct disorder, major depressive disorder, PTSD, and reactive attachment disorder (Table 2). (2) Children in foster care have higher rates of suicidality, including suicidal ideation and suicide attempt, compared to children in the general population. (3) The rate and types of mental health disorders in children in foster care can vary based on numerous factors such as the type of maltreatment experienced, placement variables, and other factors unique to children in foster care.

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Table 2.

Lifetime Prevalence of Mental Health Disorders Experienced by Children in Foster Care.

Article	Methods	Total Disease	Conduct Disorder/Oppositional Defiant Disorder	Depression	Adjustment Disorder	Attention Deficit Hyperactivity Disorder	Post-Traumatic Stress Disorder	Any Substance Use Disorder	Bipolar Disorder	Mania	Reactive Attachment Disorder	Anxiety	Suicidality	Other
Baker et al. (2007)	Child and family characteristics form; child behavior checklist (CBCL)	53.9%						31.3%					32.7%	Anxiety/depression: 15.7%
Havlicek et al. (2013)	Literature review	Lifetime prevalence: 61–66%, 12-month prevalence: 37–49%	40–47%	27–32%	32%	13–20%	14–15%	20–37%	9%	6%
Holtan et al. (2005)	CBCL	51.8% nonkinship, 35.8% kinship
Lehmann et al. (2013)	Developmental and well-being assessment	50.9%	21.5%	4.0%		19%	5.0%				19.4%	8.6%		Obsessive compulsive disorder: 0.4%
Lohr & Jones (2016)	Literature review	Up to 80%					19.2–25%				Up to 40%
McMillen et al. (2005)	Diagnostic interview schedule for DSM-IV and Childhood Trauma Questionnaire	Lifetime: 61%, 12-month prevalence: 37%	47%	27%		20%	14%			6%
Oswald et al. (2010)	Literature review	32–44%	CD: 2–8%, ODD: 4–10%	5–15%	0.4–21%	10–21%					4–17%	3–12%
Tarren- Sweeney (2008)	Literature review		CD: 17–45%	4–36%		10–30%	40–50%					4–26%
Thompson & Hasin (2012)	Self-report	42%	ODD: <1%	10%		3%	2%		5%			1%
Turney & Wildeman (2016)	Parent report			14.2%		21.8%						14.2%		Behavioral problems: 17.5%

Discussion

This systematic review confirms findings from prior reviews that children in foster care have higher rates of mental health disorders compared to children not in foster care, and also highlights recent studies that include assessments of substance use and suicidality, both of which are national topics of discussion due to increased rates in the general child/adolescent populations. Similar to prior reviews, we found that children in foster care experience a broad range of mental health disorders (Havlicek et al., 2013; Lohr & Jones, 2016; Oswald et al., 2010; Tarren-Sweeney, 2008) and that the prevalence of specific conditions could vary widely depending on the specific population and methods used (e.g., parent report, electronic medical records, validated instruments). The most common diagnoses found in this review include ODD/conduct disorder, substance use disorder, suicidality, major depressive disorder, and reactive attachment disorder (Table 2).

Table 3 summarizes our findings and provides implications of the review for practice, policy, and research. Specifically, those who are providing care to foster children ought to obtain a thorough social history of placement variables such as type of foster care and number of placements within the foster care system, along with types of maltreatment experienced, if applicable. Along with a thorough social history, providers ought to screen this vulnerable population for psychiatric diagnoses and suicidality.

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Table 3.

Implications of the Review for Practice, Policy, and Research.

Finding	Implication
Foster children experience higher rates of disease than children in the general population.	Health care providers ought to screen foster children for psychiatric diagnosis, including the most common illnesses found in this review (ODD/CD, MDD, PTSD, RAD, SUD). There should be a low threshold to refer foster children to psychiatric care.
Foster children are more at risk of suicidality than children in the general population.	Foster children should be screened for suicidal ideation and history of attempt at every visit with a medical provider.
Factors unique to foster children, such as type of maltreatment experienced and placement variables, affect type and rate of diagnoses.	A thorough social history, including type of maltreatment experienced by a foster child and placement variables, should be obtained by medical providers.

Numerous explanations account for the higher rate of mental health disorders in children in foster care compared to children in the general population. Most likely, children in foster care truly do have higher rates of psychiatric disorders than do children not in foster care. A precautionary note is that surveillance bias may partially explain the higher rate of diagnosis in children in foster care, as this population is more likely to be identified as having mental health needs and subsequently assessed by professionals.

Another explanation for the high rate of disorders is that the most common disorders faced by children in foster care, including ODD, conduct disorder, and major depressive disorder, may actually be manifestations of PTSD. Children in foster care often experience trauma before placement into foster care, which is what initially led to their placement into the foster care system. Further, the trauma of being in foster care itself may also lead to severe stress for these children. The explanation that many of the mental health disorders diagnosed are actually manifestations of PTSD is possible because historically, trauma-informed care has not been available to children in foster care. Trauma-informed care developed in response to the experience of veterans in the Vietnam War, and it has expanded only within the last 30 years to apply to civilian traumas such as maltreatment and violence, as well. A trauma-informed care practice is one that emphasizes safety, collaboration, trust, choice, empowerment, and an understanding of the many ways that trauma affects the lives of people seeking services (Wilson et al., 2013).

The social history of children in foster care was also found to affect mental health outcomes. Specifically, the data indicate that the type of abuse experienced and the type of foster care placement can predict mental health outcomes of children in foster care. There was support for improved outcomes for children in kinship care compared to nonkinship care, implying that closer familial relationships could be protective for children in foster care. However, data also indicated that being reunited with biological parents led to worse outcomes for children in foster care. Therefore, the effect of the types of placement (kinship or nonkinship care) on mental health outcomes for children in foster care may depend on the individual’s relationship with their family and what led to that child’s removal from the home.

Data are conflicting about the predictive value of the number of placements on the diagnoses of mental health disorders. Some of the data reviewed in this article suggest that an increased number of placements is associated with higher rates of mental illnesses in children in foster care, likely indicating the importance of stability in a child’s home life.

One of the considerations for a practicing clinician is the increased interest in broad screening of pediatric populations for adversity and social determinants of health (Council on Community Pediatrics, 2016; Shankoff et al., 2012; Sokol et al., 2019). Given the profound impact of childhood adversity, initially reported by Felitti et al. (1998), the desire to identify children at risk of future potential health and well-being threats is a logical desire. Broad screening often takes the form of adverse childhood experiences (ACE) screens. While the intention behind broad screening is understandable, there are a number of significant cautions, particularly as it applies to children in foster care (McLennan et al., 2020; Racine et al., 2019). First, the initial ACEs study by Felitti et al. (1998) utilized a narrow set of specific historic occurrences but were not a comprehensive screen of adversities many children encounter (Cronholm et al., 2015). A history of being in foster care is not included as an original ACE and thus would not be identified on a routine screen. Growing up in a household where physical abuse, sexual abuse, or neglect had occurred is an ACE, but these do not readily imply that the child is currently in foster care. Second, the value of screening for an ACE without a clear response or therapeutic strategy would have no value to the patient. While there may be epidemiologic value, there would be limited clinical value. Simply applying a number to a child or family (i.e. “Your ACE score is 4”) would stigmatize and potentially disincentivize them from further care. Third, given the profound emotional and physical burden many children in foster care have suffered, there is a great risk of triggering the patient by having them recount and relive their prior experiences, if they are not adequately prepared to manage the accompanying emotional or psychological burden.

Conclusion

Children in foster care experience more mental health disorders as a response to either the experiences that led to them being removed from their homes or the experiences of being in foster care. These results demonstrate the necessity for providers to consider the possibility of mental health diagnoses in children in foster care and to perform appropriate screening and assessments. With adequate trauma-informed training, providers can quickly become comfortable and competent in identifying mental health needs in children in foster care who have experienced trauma (Kerns et al., 2016).

Untreated mental health disorders have both immediate and long-term consequences for children in foster care. Children who have experienced trauma are more likely to demonstrate externalizing behaviors, including disruptive behaviors, impulse control, and conduct disorders, and children in foster care are more likely to demonstrate these behaviors upon placement (Lohr & Jones, 2016). If left unaddressed, externalizing behaviors are a risk factor of increased number of changes of foster home placements, which further leads to increased internalizing and externalizing behaviors, as well as long-term negative outcomes for the child, including decreased likelihood of reunification (Newton et al., 2000). Additionally, research has revealed that children in foster care without symptomatic behavior at the time of placement could experience even more severe mental health consequences for multiple placements than their peers with symptoms at time of placement, emphasizing the need for appropriate screening for all children in foster care entering the system (Newton et al., 2000). Addressing even subclinical internalizing and externalizing behaviors through adequate mental health care can facilitate the stability of the placements and reduce further disruption to the lives of children in foster care. Placement instability has been shown to be a risk factor of continued mental health problems into adulthood (Gypen et al., 2017; Villegas & Pecora, 2012).

Thus, it is imperative that those who provide care for children in foster care consider the possibility of mental health disorders and perform appropriate screening. It is essential that providers understand the unique mental health needs of children in foster care in order to appropriately screen this at-risk population and provide them with trauma-informed care and the mental health resources needed. Obtaining appropriate mental health care services for children in foster care quickly after placement can help mitigate long-term mental health effects of neglect and abuse (Zlotnick et al., 2012).

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