foster care
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ASystematicReviewofMentalHealthDisordersofChildreninFosterCare.pdf
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A Systematic Review of Mental Health Disorders of Children in Foster Care
Amy D. Engler3, Kwabena O. Sarpong1,2, Bethanie S. Van Horne1,2 , Christopher S. Greeley1,2, and Rachael J. Keefe1,2
Abstract
Objectives: This article summarizes the rate of mental health disorders of foster children, the specific types of disorders faced by this population, and how factors such as type of abuse or placement variables can affect mental health outcomes. Method: A search in PsycInfo Ovid, EMBASE Elsevier, and Cochrane Library Wiley resulted in 5,042 manuscripts that were independently reviewed by two authors, yielding 25 articles. Inclusion criteria: Published in or after 2000, written in English, and having a population sample of foster children (ages 0–18) in Western countries including the United States, Norway, Australia, and Canada. Results: Foster children have higher rates of mental health disorders than those of the general population. The most common diagnoses include oppositional defiant disorder/conduct disorder, major depressive disorder, post-traumatic stress disorder, and reactive attachment disorder. Variables such as type of maltreatment and type of placement predicted mental health outcomes. Conclusions and implications of key findings: Children in foster care experience more mental health disorders, as a response to either the circumstances that led to being removed from their homes or the experience of being placed in foster care. These results demonstrate the necessity for providers to consider mental health issues when caring for children in foster care and to perform appropriate screenings and assessments. With adequate trauma-informed training, providers can quickly become comfortable and competent in identifying mental health needs of children in foster care who have experienced trauma.
Keywords foster care, children, mental illness, placement, trauma
According to the Child Welfare Information Gateway (2019),
more than 425,000 children are in foster care in the United States
on any given day. The most updated Report to Congress of Child
Welfare Outcomes was published in 2014, when approximately
415,000 children were in foster care nationwide (U.S. Depart-
ment of Health and Human Services, 2017). A child is placed in
foster care when that child is no longer able to live safely at
home. A court grants the state temporary legal guardianship for
the child, and Child Protective Services is subsequently granted
temporary legal possession to place the child in foster care.
There are various types of foster care settings, including family
homes, group homes, and residential group care facilities.
Numerous studies have demonstrated that children in foster
care have higher rates of various mental health disorders, includ-
ing attention deficit hyperactivity disorder (ADHD), depression,
anxiety, oppositional defiant disorder (ODD), conduct disorder,
post-traumatic stress disorder (PTSD), reactive attachment dis-
order, and behavioral problems, as compared with the general
population (Greiner & Beal, 2017; Havlicek et al., 2013; Lohr &
Jones, 2016; McMillen et al., 2005; Tarren-Sweeney, 2008).
Children in foster care transitioning to adulthood are up to 4
times as likely to have mental health disorders as children not
in foster care (Havlicek et al., 2013; Lohr & Jones, 2016). Even
when compared to children not in foster care in similar socio-
economic situations, children in foster care are 3–4 times more
likely to be diagnosed with a mental health disorder (Greiner &
Beal, 2017). Numerous studies have also demonstrated that
approximately 60% of children who have been in foster care have a lifetime prevalence of mental health disorders, with as
many as half of children in foster care having clinically signif-
icant mental health difficulties while in care (Havlicek et al.,
2013; McMillen et al., 2005; Tarren-Sweeney, 2008).
The purpose of this literature review is to examine the current
data investigating the mental health problems faced by children
in foster care. This article summarizes the rate of mental health
disorders of children in foster care, the specific types of disor-
ders experienced by this population, and how factors such as
1 Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
2 Section of Public Health and Child Abuse Pediatrics, Texas Children’s
Hospital, Houston, TX, USA 3 Baylor College of Medicine, Houston, TX, USA
Corresponding Author:
Rachael J. Keefe, 6621 Fannin Street, MC A2275, Houston, TX 77030, USA.
Email: [email protected]
TRAUMA, VIOLENCE, & ABUSE 1-10 ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1524838020941197 journals.sagepub.com/home/tva
type of abuse or placement variables can affect mental health
outcomes. To our knowledge, the most recent review summar-
izing specific mental health diagnoses included literature from
1998 to 2009 (Oswald et al., 2010). Previous reviews have found
higher rates of mental health diagnoses in this population,
including conduct disorder and ODD, adjustment disorder, and
ADHD. However, these reviews were published over a decade
ago. Understanding the current mental health need of foster
children will help providers better understand and screen for the
specific needs of this at-risk population.
Method
Literature Search
An initial search in Ovid Medline was done using terms har-
vested from relevant documents and discussions. These terms
were then mapped to subject headings in addition to title,
abstract, and keyword searches. The terms were tested for rele-
vancy, and the main search was finalized. The search in Medline
Ovid was limited to emphasize the subject heading “Foster
Home Care” in order to retrieve relevant information on foster
care. The search strategy was then translated to PsycInfo Ovid,
EMBASE Elsevier, and Cochrane Library Wiley from inception
through July 29, 2019, for studies on children in foster care’s
health-related problems such as behavior, mental disorders, and
educational challenges. The complete search strategy can be
found in Online Appendix A.
The search was limited to children who have been in foster
care. The search was not limited by language, year of publica-
tion, or type of publication. The majority of Medline duplicate
records were eliminated from Embase from within the database
using the limit [embase]/lim. The remaining external duplicates
were removed using EndNote X7.71. Additional studies that
were not published but available in the Grey literature were not
included. Citation results were imported into EndNote X7.71
and Rayyan, a web application for reviewers and authors of
systematic reviews.
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
Records iden�fied through database searching
(n = 5193)
Addi�onal records iden�fied through other sources
(n = 0)
Records a�er duplicates removed (n = 4093)
Records screened (n = 5042)
Records excluded (n = 0)
Full-text ar�cles assessed for eligibility
(n = 270)
Full-text ar�cles excluded, with reasons
(n = 4790)
Studies included in qualita�ve synthesis
(n = 25)
Studies included in quan�ta�ve synthesis
(meta-analysis) (n = 0)
Figure 1. PRISMA 2009 flow diagram.
2 TRAUMA, VIOLENCE, & ABUSE XX(X)
focused on robust analyses of health problems of children in
foster care. The inclusion criteria included the following: pub-
lished 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.
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 ¼ 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 apprai-
sal 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 regard-
ing 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 demo-
graphics 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.
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 attach-
ment 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 maltreat-
ment experienced, placement variables, and other factors unique
to children in foster care.
Higher Rates of Disorders
Eighteen of the 25 articles included in this systematic review
assessed the rate of mental health disorders of children in foster
care and the specific types of disorders most commonly faced by
this population (Baker et al., 2007; Beal et al., 2018; Greiner &
Beal, 2017; Havlicek et al., 2013; Holtan et al., 2005; Jacobsen
et al., 2013; Lawrence et al., 2006; Lehmann et al., 2013; Lohr &
Jones, 2016; McMillen et al., 2005; Okpych & Courtney, 2018;
Oswald et al., 2010; Persi & Sesson, 2008; Staudt, 2003; Tarren-
Sweeney, 2008; Thompson & Hasin, 2012; Turney & Wilde-
man, 2016; Vasileva & Petermann, 2018). The studies reported
that as few as 32% (Oswald et al., 2010) and up to 80% (Lohr & Jones, 2016) of children in foster care were diagnosed with
mental illness. See Table 2.
In nine of the studies that assessed the rate of disorders of
children in foster care, the authors compared this rate of mental
illness in children in foster care to the rate of children not in
care. All nine of these studies found that children in foster care
have higher rates of mental health disorders compared to chil-
dren in the general population (Greiner & Beal, 2017; Havlicek
et al., 2013; Lawrence et al., 2006; Lohr & Jones, 2016; Oswald
et al., 2010; Persi & Sesson, 2008; Staudt, 2003; Thompson &
Hasin, 2012; Turney et al., 2016). For example, in one study, the
rate of mental health disorders was higher compared to a robust
control group of children not in foster care with similar socio-
economic status and education levels, and living in similar
neighborhoods. The children in foster care were found to be
3–4 times more likely to be diagnosed with a range of mental
health illnesses, including attention-deficit disorder/ADHD
(OR ¼ 3.00, 95% CI [1.91,4.71]), depression (OR ¼ 4.92, 95% CI [2.63,9.18]), anxiety (OR ¼ 3.94, 95% CI [2.36, 6.60]), and behavioral problems (OR ¼ 4.22, 95% CI [2.59, 6.88]; Greiner & Beal, 2017).
Along with the high rate of diagnosis of mental illness com-
pared to the general population, this population had a high rate of
comorbidity. Of children in foster care diagnosed with depres-
sion, anxiety, ADHD, or behavioral disorders (including con-
duct disorder and ODD), 30.4% had diagnoses in two of these three categories of disorders. In this sample, 13% were also found to have diagnoses in all three categories (Lehmann
et al., 2013).
Common psychiatric diagnoses. The most common diagnoses of children in foster care include ODD/conduct disorder, major
depressive disorder, PTSD, and reactive attachment disorder.
The data of rates of specific disorders from each article are
summarized in Table 2.
In general, children in foster care tend to experience more
externalizing than internalizing symptoms (Jacobsen et al.,
2013; Lohr & Jones, 2016; Persi & Sesson, 2008). One study
found that 43% of children in foster care experienced externa- lizing disorders, compared to 30% of the comparison group not in foster care (Persi & Sesson, 2008). Externalizing disorders
include disruptive impulse control, conduct disorders, and
substance-related and addictive disorders. Internalizing disor-
ders include depressive disorders, anxiety disorders, obsessive-
compulsive and related disorders, trauma and stressor-related
disorders, and dissociative disorders (Regier et al., 2013).
Engler et al. 3
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
4 TRAUMA, VIOLENCE, & ABUSE XX(X)
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5
Suicidality. Five of the 25 articles included in this systematic review discussed the topic of suicidality, including suicidal idea-
tion and suicide attempt (Anderson, 2011; Lohr & Jones, 2016;
Okpych & Courtney, 2018; Tarren-Sweeney, 2008; Taussig
et al., 2014). Children in foster care were found to have a higher
rate of suicidality than that of children in the general population.
One study reported that children in foster care were found to
experience suicidality at 5 times the rate of suicidality of the
general population of 9- to 11-year-olds, and 26.4% of children in foster care had a history of suicidality by self-report or care-
giver report (Taussig et al., 2014). Specifically, 16.6% of the children in foster care experienced suicidal ideation, 3.9% had plans to die by suicide, and 3.7% had attempted suicide (Taussig et al., 2014). One study found that children in foster care are 4
times more likely to have attempted suicide than are children not
in foster care (Lohr & Jones, 2016). Children in foster care were
also found to have higher rates of self-injury, though there was
little data addressing this topic specifically in the articles
reviewed (Tarren-Sweeney, 2008).
The risk factors for suicidality were evaluated by three of the
articles included in this review (Anderson, 2011; Okpych &
Courtney, 2018; Taussig et al., 2014). Children were at higher
risk of suicidal ideation with younger age, non-Hispanic ethni-
city, abuse, multiple types of maltreatment, more referrals to
child welfare, more transitions, and longer time in foster care
(Taussig et al., 2014). The most robust predictors of suicidality
included physical abuse and chronicity of maltreatment (Taus-
sig et al., 2014). Another study found that placement instability
was associated with increased suicidality (Okpych & Courtney,
2018). The likelihood of suicidal ideation increased by 68% each time a child experienced a placement in out-of-home care
(Anderson, 2011). The mediating factor between suicidal idea-
tion and the number of times a child was relocated to an out-of-
home placement within the foster care system in this study was
found to be clinically significant depressive symptoms (Ander-
son, 2011). These data convey the importance of screening for
and accurately diagnosing psychiatric disorders such as depres-
sion in this vulnerable population.
Effects of Types of Maltreatment
Six of the 25 articles addressed the effects of different types of
maltreatment on mental health outcomes in children who have
been in foster care (Bruskas, 2010; Gonzalez, 2014; Lawrence
et al., 2006; McMillen et al., 2005; Okpych & Courtney, 2018;
Oswald et al., 2010). Neglect, physical abuse, and sexual abuse
were the most common types of maltreatment experienced by
children in foster care (Oswald et al., 2010). These three types
of maltreatment were also found to be the largest predictors of
mental illness in this population (Bruskas, 2010). Specifically,
sexual abuse was associated with higher levels of depression in
maltreated youth (Okpych & Courtney, 2018).
Compared to a nonmaltreated control group, one study found
that children placed in foster care after maltreatment and mal-
treated children who remained at home had poorer adaptation,
more behavior problems, and more externalizing symptoms
(Lawrence et al., 2006). The authors of this article noted that
these findings were difficult to specifically attribute to either
placement in foster care or maltreatment itself as the specific
cause of poorer outcomes.
Further, in a literature review examining the effects of dif-
ferent maltreatment types on the risk of mental illness of those in
foster care, children who were physically abused were more at
risk for conduct disorder, ODD, major depressive disorder, anxi-
ety, and PTSD (Gonzalez, 2014). Neglected children were more
likely to express internalizing behaviors, depression, anxiety,
and insecure attachments (Gonzalez, 2014). Finally, sexually
abused children were more likely to experience suicidal idea-
tion, depression, anxiety, dissociative identity disorder, PTSD,
and substance abuse disorders (Gonzalez, 2014). Another study
found that emotional abuse was associated with increased sui-
cidality (Okpych & Courtney, 2018).
The number of maltreatment types experienced by a child
was found to be the strongest predictor of a mental health dis-
order, implying a potential additive effect of maltreatment
(McMillen et al., 2005). Another study found that the type of
maltreatment was the most important factor affecting diagnostic
rates, with a higher percentage of children with a diagnosis of
PTSD after experiencing sexual abuse (64%) compared to a history of physical abuse (42%) or no abuse (18%; Oswald et al., 2010). However, a difference in the rate of diagnosis was
not found for other disorders such as major depressive disorder
(Oswald et al., 2010).
Effects of Placement Variables
Ten of the 25 articles discussed the effects of placement vari-
ables such as number of placements and type of placement on
mental health outcomes for children in foster care (Anderson,
2011; Beal et al., 2018; Holtan et al., 2005; Jacobsen et al., 2013;
Lawrence et al., 2006; Lehmann et al., 2013; Okpych & Court-
ney, 2018; Stanley et al., 2005; Tarren-Sweeney, 2008; Taussig
et al., 2001). In four of the studies, the authors found that a higher
number of placements within the foster care system was corre-
lated with increased risk of poor mental health outcomes (Leh-
mann et al., 2013; Okpych & Courtney, 2018; Stanley et al.,
2005; Tarren-Sweeney, 2008). However, two studies found that
there was no effect of the number of placements on mental health
disorders suggesting that this relationship may be undetermined
(Jacobsen et al., 2013; Lawrence et al., 2006).
Type of placement was found to have an effect on mental
health outcomes. For example, children in foster care in a group
home were found to have clinically significant depressive symp-
toms at 4.6 times the rate of children who were living with a
relative in kinship care (Anderson, 2011). Further, the children
in a group home experienced suicidal ideation at 7.25 times the
rate of those in kinship care (Anderson, 2011). Similarly, in a
cross-sectional sample of Norwegian children in kinship (living
with a relative or family friend) and nonkinship foster care,
35.8% of kinship children in foster care and 51.8% of those in nonkinship care experienced a total borderline or clinical prob-
lem level measured by the child behavior checklist (Holtan et al.,
6 TRAUMA, VIOLENCE, & ABUSE XX(X)
2005). However, these data do not necessarily indicate that
maintaining a relationship with family promotes better out-
comes. In a prospective study of children in foster care who
reunited with biological parents after placement, researchers
found that reunified youth had more self-destructive behaviors,
internalizing behaviors, substance use, total risk behaviors, and
delinquent behaviors (Taussig et al., 2001).
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 high-
lights 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 popula-
tions. Similar to prior reviews, we found that children in foster
care experience a broad range of mental health disorders (Hav-
licek et al., 2013; Lohr & Jones, 2016; Oswald et al., 2010;
Tarren-Sweeney, 2008) and that the prevalence of specific con-
ditions 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 appli-
cable. Along with a thorough social history, providers ought to
screen this vulnerable population for psychiatric diagnoses and
suicidality.
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 chil-
dren 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, includ-
ing 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 under-
standing 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 chil-
dren 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 (kin-
ship 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 impor-
tance 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
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.
Engler et al. 7
Community Pediatrics, 2016; Shankoff et al., 2012; Sokol et al.,
2019). Given the profound impact of childhood adversity, ini-
tially 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 inten-
tion behind broad screening is understandable, there are a num-
ber 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 read-
ily imply that the child is currently in foster care. Second, the
value of screening for an ACE without a clear response or ther-
apeutic 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 disincenti-
vize them from further care. Third, given the profound emo-
tional 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.
Limitations
One limitation of this review is that the data were not readily
comparable between studies due to widely variable methods of
assessing mental health outcomes. For example, some studies
relied on self-report of children in foster care or their foster
parents to gather information about diagnoses of mental health
disorders, whereas others used a standardized evaluation by
licensed clinicians for each participant. Therefore, performing
a multivariate analysis or meta-analysis of the articles was not
possible. A comparison of data in the articles also was difficult
because the methods were so variable. Study design along with
measures could additionally influence the findings. Further
research should incorporate a more standardized mechanism
of assessing mental illness in this population of children who
clearly have an increased need for mental health services.
A second limitation includes differences in reporting the
demographic factors associated with mental health outcomes
for foster children. Only half of the articles included in this
article reported racial and ethnic identities of the foster children,
making it difficult to evaluate any differences in outcome based
on these demographics. Of note, the articles that did report racial
and ethnic demographic data found that minorities are dispro-
portionately represented in this sample of foster children com-
pared to the general population. It is important to recognize that
racism and bias on the part of providers may affect the diagnoses
given to children in foster care, especially in the setting of
behavioral issues that affect mental health diagnoses. While
providers ought to be aware of the rates of psychiatric diagnoses
in this population, they must also be prudent about labeling and
medicating this vulnerable population.
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 assess-
ments. With adequate trauma-informed training, providers can
quickly become comfortable and competent in identifying men-
tal 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 place-
ment (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 inter-
nalizing and externalizing behaviors, as well as long-term neg-
ative outcomes for the child, including decreased likelihood of
reunification (Newton et al., 2000). Additionally, research has
revealed that children in foster care without symptomatic beha-
vior 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 ser-
vices for children in foster care quickly after placement can help
mitigate long-term mental health effects of neglect and abuse
(Zlotnick et al., 2012).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
8 TRAUMA, VIOLENCE, & ABUSE XX(X)
Funding
The author(s) disclosed receipt of the following financial support for
the research and/or authorship of this article: This systematic review
was possible through the generous funding of a Texas Medical Center
Health Policy Institute grant titled “Policies and Practices Addressing
Medical and Mental Health Needs for Children in Foster Care.”
ORCID iD
Bethanie S. Van Horne https://orcid.org/0000-0002-4820-4809
Supplemental Material
Supplemental material for this article is available online.
References
Anderson, H. D. (2011). Suicide ideation, depressive symptoms, and
out-of-home placement among youth in the U.S. child welfare
system. Journal of Clinical Child and Adolescent Psychology,
40(6), 790–796.
Baker, A. J. L., Kurland, D., Curtis, P., Alexander, G., & Papa-Lentini,
C. (2007). Mental health and behavioral problems of youth in the
child welfare system: Residential treatment centers compared to
therapeutic foster care in the Odyssey Project population. Child
Welfare, 86(3), 97–123.
Beal, S. J., Nause, K., Crosby, I., & Greiner, M. V. (2018). Under-
standing health risks for adolescents in protective custody. Journal
of Applied Research on Children: Informing Policy for Children at
Risk, 9(1), 2.
Bramlett, M. D., Radel, L. F., & Chow, K. (2017). Health and well-
being of children in kinship care: Findings from the national survey
of children in nonparental care. Child Welfare, 95(3), 41–60.
Bruskas, D. (2010). Developmental health of infants and children
subsequent to foster care. Journal of Child and Adolescent Psy-
chiatric Nursing, 23(4), 231–241.
Child Welfare Information Gateway. (2019). Foster care statistics
2017. U.S. Department of Health and Human Services, Children’s
Bureau.
Council on Community Pediatrics. (2016). Poverty and child health
in the United States (Report). Pediatrics, 137(4), e20160339–
e20160339. https://doi.org/10.1542/peds.2016-0339
Cronholm, P. F., Forke, C. M., Wade, R., Bair-Merritt, M. H., Davis,
M., Harkins-Schwarz, M., Pachter, L. M., & Fein, J. A. (2015).
Adverse childhood experiences: Expanding the concept of adver-
sity. American Journal of Preventive Medicine, 49(3), 354–361.
Felitti, V. J., Anda, R. F. N., Dale, W., David, F. S., Alison, M. E.,
Valerie Koss, M. P., & Marks, J. S. (1998). Relationship of child-
hood abuse and household dysfunction to many of the leading
causes of death in adults. The adverse childhood experiences
(ACE) study. American Journal of Preventive Medicine, 14(4),
245–258.
Gonzalez, M. J. (2014). Mental health care of families affected by the
child welfare system. Child Welfare, 93(1), 7–57.
Greiner, M. V., & Beal, S. J. (2017). Foster care is associated with
poor mental health in children. The Journal of Pediatrics, 182,
401–404.
Gypen, L., Vanderfaeillie, J., De Maeyer, S., Belenger, L., & Van
Holen, F. (2017). Outcomes of children who grew up in foster care:
Systematic-review. Children and Youth Services Review, 76,
74–83. https://doi.org/10.1016/j.childyouth.2017.02.035
Havlicek, J., Garcia, A., & Smith, D. C. (2013). Mental health and
substance use disorders among foster youth transitioning to adult-
hood: Past research and future directions. Children and Youth Ser-
vices Review, 35(1), 194–203.
Holtan, A., Ronning, J. A., Handegard, B. H., & Sourander, A. (2005).
A comparison of mental health problems in kinship and nonkinship
foster care. European Child & Adolescent Psychiatry, 14, 200–207.
Jacobsen, H., Moe, V., & Ivarsson, T. (2013). Cognitive development
and social-emotional functioning in young foster children: A
follow-up study from 2 to 3 years of age. Child Psychiatry and
Human Development, 44(5), 666–677.
Kerns, S. E., Pullmann, M. D., Negrete, A., Uomoto, J. A., Berliner, L.
, Shogren, D., Silverman, E., & Putnam, B. (2016). Development
and implementation of a child welfare workforce strategy to build a
trauma-informed system of support for foster care. Child Maltreat-
ment, 21(2), 135–146. https://doi.org/10.1177/1077559516633307
Lawrence, C. R., Carlson, E. A., & Egeland, B. (2006). The impact of
foster care on development. Development and Psychopathology,
18, 57–76.
Lehmann, S., Havik, O. E., Havik, T., & Heiervang, E. R. (2013).
Mental disorders in foster children: A study of prevalence, comor-
bidity and risk factors. Child and Adolescent Psychiatry and Men-
tal Health, 7, 39.
Lohr, W. D., & Jones, V. F. (2016). Mental health issues in foster care.
Pediatric Annals, 45(1), e342–e348.
Mclennan, J., Macmillan, H., & Afifi, T. (2020). Questioning the use
of adverse childhood experiences (ACEs) questionnaires. Child
Abuse & Neglect, 101, 104331.
McMillen, J. C., Zima, B. T., Scott, L. D., Jr., Auslander, W. F.,
Munson, M. R., Ollie, M. T., & Spitznagel, E. L. (2005). Preva-
lence of psychiatric disorders among older youths in the foster care
system. Journal of the American Academy of Child and Adolescent
Psychiatry, 44, 88–95.
Newton, R. R., Litrownik, A. J., & Landsverk, J. A. (2000). Children
and youth in foster care: Distangling the relationship between
problem behaviors and number of placements. Child Abuse &
Neglect, 24(10), 1363–1374.
Okpych, N. J., & Courtney, M. E. (2018). Characteristics of foster care
history as risk factors for psychiatric disorders among youth in
care. American Journal of Orthopsychiatry, 88(3), 269–281.
Oswald, S. H., Heil, K., & Goldbeck, L. (2010). History of maltreat-
ment and mental health problems in foster children: A review of
the literature. Journal of Pediatric Psychology, 35(5), 462–472.
Persi, J., & Sisson, M. (2008). Children in foster care: Before, during,
and after psychiatric hospitalization. Child Welfare, 87(4), 79–99.
Racine, N., Killam, T., & Madigan, S. (2019). Trauma-informed care
as a universal precaution: Beyond the adverse childhood experi-
ences questionnaire. JAMA Pediatrics, 1–2. https://doi.org/
10.1001/jamapediatrics.2019.3866
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM-5:
Classification and criteria changes. World Psychiatry, 12(2),
92–98.
Engler et al. 9
Shonkoff, J. P., & Garner, A. S., Committee on Psychosocial Aspects
of Child and Family Health; Committee on Early Childhood,
Adoption, and Dependent Care; & Section on Developmental and
Behavioral Pediatrics. (2012). The lifelong effects of early child-
hood adversity and toxic stress. Pediatrics, 129(1), e232–246.
Sokol, R., McFarlane, A. E., Szefler, S. J., & Abrams, E. M. (2019).
Screening children for social determinants of health: a systematic
review. Pediatrics, 144(4), e20191622.
Stanley, N., Riordan, D., & Alaszewski, H. (2005). The mental health
of looked after children: Matching response to need. Health &
Social Care in the Community, 13, 239–248.
Staudt, M. M. (2003). Mental health services utilization by maltreated
children: Research findings and recommendations. Child Maltreat-
ment, 8, 195–203.
Tarren-Sweeney, M. (2008). The mental health of children in out-of-
home care. Current Opinion in Psychiatry, 21, 345–349.
Taussig, H. N., Clyman, R. B., & Landsverk, J. (2001). Children who
return home from foster care: A 6-year prospective study of beha-
vioral health outcomes in adolescence. Pediatrics, 108, e10.
Taussig, H. N., Harpin, S. B., & Maguire, S. A. (2014). Suicidality
among preadolescent maltreated children in foster care. Child Mal-
treatment, 19, 17–26.
Thompson, R. G. Jr., & Hasin, D. S. (2012). Psychiatric disorders and
treatment among newly homeless young adults with histories of
foster care. Psychiatric Services, 63, 9.
Turney, K., & Wildeman, C. (2016). Mental and physical health of
children in foster care. Pediatrics, 138(5), e20161118. https://
doi.org/10.1542/peds.2016-1118.
U.S. Department of Health and Human Services. (2017). Child wel-
fare outco mes 2010 –2014: Report to Co ngress. https://
www.acf.hhs.gov/cb/resource/cwo-10-14
Vasileva, M., & Petermann, F. (2018). Attachment, development, and
mental health in abused and neglected preschool children in foster
care: A meta-analysis. Trauma, Violence, & Abuse, 19(4) 443–458.
Villegas, S., & Pecora, P. J. (2012). Mental health outcomes for adults
in family foster care as children: An analysis by ethnicity. Children
and Youth Services Review, 34(8), 1448–1458. https://doi.org/
10.1016/j.childyouth.2012.03.023
Wilson, C., Pence, D. M., & Conradi, L. (2013). Trauma-informed
care. Encyclopedia of Social Work, https://doi.org/10.1093/acre
fore/9780199975839.013.1063
Zlotnick, C., Tam, T. W., & Soman, L. A. (2012). Life course out-
comes on mental and physical health: The impact of foster care on
adulthood. American Journal of Public Health, 102(3), 534–540.
https://doi.org/10.2105/ajph.2011.300285
Author Biographies
Amy D. Engler, BA, is a medical student at Baylor College of Med-
icine. She plans to go into internal medicine. Her areas of interest
include the social determinants of health and how factors outside of
the physician’s office contribute to health outcomes.
Kwabena O. Sarpong, MD, MPH, is an associate professor of pedia-
trics at Baylor College of Medicine. He earned his medical degree at
the School of Medical Sciences, University of Science and Technol-
ogy in Kumasi, Ghana. He practices child abuse pediatrics.
Bethanie S. Van Horne, DrPH, is an assistant professor of pediatrics
at Baylor College of Medicine and the director of research for the
Section of Public Health and Child Abuse Pediatrics at Texas Chil-
dren’s Hospital. Current projects and areas of interest include post-
partum depression, perinatal substance use, behavioral health, child
abuse and neglect, and services and programs for foster and at-risk
families.
Christopher S. Greeley, MD, MS, is Chief of the Section of Public
Health and Child Abuse Pediatrics at Texas Children’s Hospital. He is
Professor and Vice-Chair for Community Health in the Department of
Pediatrics at Baylor College of Medicine. He is board certified in
General Pediatrics as well as Child Abuse Pediatrics and is a member
of the AMA and the AAP.
Rachael J. Keefe, MD, MPH, is an assistant professor of pediatrics at
Baylor College of Medicine. She leads a clinical service for children in
foster and kinship care at Texas Children’s Hospital in the Section of
Public Health and Child Abuse Pediatrics. She is the cochair of the
Texas Pediatric Society Committee on Foster Care.
10 TRAUMA, VIOLENCE, & ABUSE XX(X)
