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Mental Health of Foster Children Mental Health of Foster Children
Olivia Collier
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Integrated Studies
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Running head: Mental Health of Foster Children
Mental Health of Foster Children
Olivia M. Collier
BIS 437 Murray State University
Running head: Mental Health of Foster Children I
Abstract
Foster care is one of the many complex systems within the human services field.
Although foster care is usually in the best interest of the children, it still causes lasting
mental health effects and learning setbacks that the children carry into their adult lives.
Some of the negative aspects of foster care and the trauma that comes with children
being separated from their family can also be passed on through generations, if foster
children are not treated properly.
This essay will dive deeper into studies of the foster system and how it takes a
toll on the mental health and development of the children living within the system. The
foster system is made up of very complex details that shape the health of children living
within it. There are many different mental health disorders that could be linked to
childhood trauma, so there will be focus on the health of people specifically involved
with the foster care system, because, for most, it is a traumatic experience, even if they
are placed with great families. Anxiety, depression, ADHD, PTSD, and other learning
disorders are common in foster children.
Running head: Mental Health of Foster Children II
Table of Contents
Introduction……………………………………………………………………………………..4
Background Information……………………………………………………………………....4
Foster Care Demographics…………………………………………………………………...5
Becoming a Foster Parent…………………………………………………………………….5
Good Vs. Bad Foster Parents………………………………………………………………...6
Caregiver Challenges………………………………………………………………………….8
Types of Foster Care…………………………………………………………………………..9
Transition to Foster Care……………………………………………………………………...11
Family Reunification………………………………………………………………………......13
Foster Children’s Mental Health…………………………………………………………......16
Hypothalamic-Pituitary-Adrenal Axis………………………………………………………...25
Early Intervention………………………………………………………………………………25
PTSD in Foster Children……………………………………………………………………...26
ADHD in Foster Children………………………………………………………………...…...28
Poor Mental Health Leading to Risky Behavior………………………………...………….29
Self-Harm and Suicide………………………………………………………………….……..30
Medical Services for Foster Children…………... …………………………………………..33
Utilization of CAMHS………………………………………………………………………….34
Psychotropic Medication Use………………………………………………………………...35
Health Related Quality of Life………………………………………………………………...41
Foster Children Transitioning into Adulthood…………………...………………………….42
Foster Care Alumni……………………………………………………………………………48
Conclusion……………………………………………………………………………………...49
Running head: Mental Health of Foster Children 1
Introduction
Children living in the foster care system face many challenges and hurdles
regarding their mental health that often follow them into their adult lives. The vast range
of mental health disorders and learning setbacks including anxiety, depression, ADHD,
and PTSD is what makes mental health studies for foster children so complex. There
are many components that are taken into consideration when studying foster children,
including the demographics of foster care, different types of foster homes, and foster
parents.
Background Information
Foster care started in 1853, when Charles Loring Brace started the free foster
home movement (“History of foster care in the United States”). Brace started the
movement because of the alarming number of homeless children he was noticing on the
streets of New York.
Children are placed into foster care when their parents are deemed unfit to care
for them. These children are often placed with other family members, but they may also
be placed with other foster parents. The main goal of foster care is to provide children
with a safe and stable environment to live in (“History of foster care in the United
States”). The biological parents must prove that they are able to provide proper care for
their children before they can be reunited.
In the beginning of foster care, a large majority were placed in foster homes due
to the loss of parents, poverty, and illness (Racusin et al., 2005). Over 50% of foster
Running head: Mental Health of Foster Children 2
children are placed into the system due to abuse and neglect, today (Racusin et al.,
2005). Some studies even suggest that 75% of foster children had been abused and
69% neglected (Racusin et al., 2005). Racusin et al., (2005) believe that the rates of
neglect and abuse have significantly increased the number of children who suffer from
mental illness as well as worsened the symptoms of their illness.
Foster Care Demographics
There are an estimated 437,500 children in foster care, and 41% of those
children are five years old or younger (Carabez & Kim, 2019). According to Carabez &
Kim (2019) the estimation is 1 in 170 children in the United States are in foster care.
The racial and ethnic demographic is made up of the following:
“The racial, ethnic makeup of children in foster care were 43% White, 24% Black
or African-American, 21% Hispanic ethnicity (of any race), 10% other races or
multiracial, and 2% were unknown or to be determined (Carabez & Kim, 2019,
p.703).”
Becoming a Foster Parent
It is a fairly simple process to become a foster parent. According to
www.adoptuskids.org, a person must be at least twenty-one years of age in order to
become a foster parent. Marriage status does not matter when becoming a foster
parent. There are basic guidelines that must be met in order for someone to become a
registered foster parent, such as proof of financial stability and the ability to support a
child financially, physically, and emotionally. Criminal background checks are done to
ensure the safety of children, as well. Home checks are also required, to ensure that
Running head: Mental Health of Foster Children 3
adequate living conditions are available for the foster children. Lastly, there will be
some informational meetings and training required for anyone aspiring to become a
foster parent (Kentucky foster care and adoption guidelines).
Good vs. Bad Foster Parents
Affronti et al., (2015) conducted a study to find out what makes foster parents
good or bad. 18 foster care alumni were used for this study, ranging from 18 to 25
years old. These alumni gave some first hand information about their experiences with
foster parents. One thing that everyone agreed on was that good foster parents never
referred to them as “foster children” (Affronti et al., 2015). Instead they were simply
referred to as family. They were included in all family activities as if they were a
biological part of the family. Even the extended family such as grandparents, aunts and
uncles, and cousins made an impact by including them in family activities, which made
them feel less of an outcast and more like a part of the family (Affronti et al., 2015).
This is a crucial part of any foster child’s life, because they are already going through
such a traumatic experience, they do not need any added stress of feeling like a burden
or outcast with their new foster family. Several alumni mentioned that patience and
understanding from a foster parent was game changing (Affronti et al., 2015). Patience
helped them feel welcome in the home and not like a burden to the family. Another
important thing that was mentioned was that good foster parents were emotionally
supportive of their foster children, but they were never too pushy about personal
feelings (Affronti et al., 2015). This is a great way for foster parents to form a strong
bond with their children, but it could also create a barrier if they are too pushy or
overbearing. Even though it might possibly be difficult at times, good foster parents are
Running head: Mental Health of Foster Children 4
supportive of their foster children maintaining a relationship with their biological parents,
and not being judgemental about their situation (Affronti et al., 2015). Being
judgemental about the biological parents could create tension between the foster
parents and child, because they may feel that they are being judged as well. One more
quality that foster care alumni mentioned about good foster parents is being supportive
of their personal interests and activities (Affronti et al., 2015). For example, if a child is
interested in music or band, the foster parent is supportive of them being in the school
band. This may be hard at times because of the added expense of extracurricular
activities, but it is important for foster children to maintain as much of their normal life as
possible, and sometimes their extracurriculars are their only outlet and way to feel
“normal”.
On the other hand, some foster care alumni reported their bad experiences with
foster parents. One common negative aspect about foster care was that the “bad”
parents were only caring for them because they could receive payment from the state
(Affronti et al., 2015). They would only provide the bare minimum care, and the living
conditions were not kept up with (Affronti et al., 2015). Some even stated that they
were not allowed to freely eat groceries in the household, and that the refrigerator was
locked (Affronti et al., 2015). Another alumni reported that they experienced very
crowded living conditions where they were packed into a small room or closet with
several other children, so they had absolutely no personal space (Affronti et al., 2015).
Sexual abuse was also reported by the foster care alumni. They experienced sexaul
abuse from foster parents and other children who were living with them in foster care
(Affronti et al., 2015). One alumni also stated that one of the worst qualities of a foster
Running head: Mental Health of Foster Children 5
parent is judging the child by their past upbringing, or making assumptions about their
future based on their upbringing (Affronti et al., 2015). This can be very discouraging
for foster children because they cannot help how they were raised and they definitely
did not ask to be raised in a chaotic, toxic environment.
Caregiver Challenges
There is a lot of focus on the mental health of foster children, but that raises the
question: How does the mental health of foster care providers affect their foster
children? “Several studies show that grandparents raising grandchildren experience
increased depression compared to grandparents not caring for their grandchildren”
(Garcia et al., 2015, p. 467). This could be due to the added stress of raising
grandchildren when they most likely weren’t expecting to be doing so at that point in
their lives. Kinship foster parents who suffer from depression may have negative effects
on the children that they take in. If their mental health is not in a good state, they are
less likely to provide top quality care to their foster child. With that being said, kinship
caregivers can be very beneficial if they are in a good mental health state. Some
studies even show that children raised by their grandparents have lower rates of
depression. Nadorf (2017) found the following information pertaining to children who
are raised by their grandparents:
“Children raised by their grandparents had significantly lower levels of depressive
symptoms than those raised by foster parents. Grandparents also reported
significantly higher levels of consistent discipline practices and higher supervision
of their grandchildren. Mediation analyses found that the relation between
Running head: Mental Health of Foster Children 6
caregiver type and children’s depressive symptoms was significantly mediated by
both supervision level and consistency in discipline. These results suggest that
caregivers’ discipline and supervision are two appropriate targets for
interventions on children’s depressive symptoms.” (p.189)
This information lets us know that grandparents who are in good mental health seem to
be doing well raising their grandchildren considering the circumstances. Discipline is
one of the main reasons that these foster children are living normal and mentally stable
lives. Discipline could be easier for grandparents because they already have a personal
connection with their grandchild, and do not have to build a relationship from the ground
up when the foster child is placed into their care. Non-relative foster parents have to
start from scratch and build a relationship with the child, which could make discipline
much more difficult, because discipline could place a wedge between the parent and
child, causing the relationship to fail.
Types of Foster Care
There are two types of foster care; kinship care and nonrelative care. Kinship
care is when a family member takes over the care of a child and gains custody. In
cases where children do not have family to take over their care, they are placed in
nonrelative foster care, which would be with adults who are licensed by local child
welfare authorities (Font, 2019). According to Font (2019), “of the nearly half a million
children in out-of-home care in the United States, about one in four reside in kinship
care while slightly less than half reside in nonrelative foster care (U.S. Department of
Health and Human Services, 2012)” (Font, 2019). There are many reasons that kinship
Running head: Mental Health of Foster Children 7
care is preferred over nonrelative care, but one of the most important reasons is that it
provides some sense of normalcy to the child if they are living with someone that they
are familiar with, instead of a complete stranger. Kinship care may also allow children to
be more involved in their culture (Font, 2019). If a child is placed with someone of a
different culture, they are less likely to participate in their cultural rituals. Nonrelative
foster parents who do not come from the same cultural backgrounds might have trouble
connecting and bonding with their foster child. Font (2019) stated that “Cultural
dissimilarity between foster children and their caregivers has been linked to negative
psychosocial outcomes, particularly among minority children (Anderson & Linares,
2012; Jewell, Brown, Smith, & Thompson, 2010)”. Some studies even suggest that
children who are placed in kinship foster care have better outcomes than those that are
placed in nonrelative foster care because of the cultural connection and sense of
normalcy (Font, 2019).
Children who exhibit aggressive behavior might not be safe to place in kinship or
nonrelative care. In these cases, residential treatment centers are available
(Leloux-Opmeer et al., 2016). Residential treatment centers are not to be confused with
inpatient psychiatric institutions, which are available to children who display psychotic
and/or suicidal behavior (Leloux-Opmeer et al., 2016). Psychiatric institutions provide
around the clock care and supervision, to ensure the safety of the child.
Some children experience multiple placements or disruptions during their time in
foster care. This can be very difficult, as it is hard for them to get comfortable in their
new environments if they are unsure when their next move will be. Sometimes, these
placement disruptions can cause behavioral and emotional problems, which may lead to
Running head: Mental Health of Foster Children 8
trouble with future foster families (Leloux-Opmeer et al., 2016). If a child is experiencing
troubles with placement disruptions, they may be relocated to a residential care facility,
where they can receive more stability in their care. Each child is different, so it is the
social worker’s responsibility to identify their specific needs and place them in the care
that is best suited for their needs.
Transition to Foster Care
The transition to foster care can be a very confusing and scary experience for
children who have never experienced it before, and even for the children who have.
Racusin et al., (2015) mentions that for most children, it is not a quick process, nor do
they stay in one home for long periods of time. Some children move around for years
before they are placed with a family or reunited with their family of origin permanently.
These children experience a lot of uncertainty when it comes to their daily lives,
because they never really know where they will be living next, or how long they will stay
where they are. This causes some deep rooted insecurities, according to Racusin et
al., (2015). For example, it is hard for them to trust and make themselves comfortable
when they are placed into a permanent home, because they are so used to being
moved around so often (Racusin et al., 2015). Herrenkohl et al., (2003) studies suggest
that the frequent changes in residency causes children to feel very unstable, which
leads to serious issues in their later lives, such as negative psychosocial problems such
as teen pregnancy, substance abuse, and dropping out of school.
Because the transition to foster care can be a very traumatic experience for
children who are new to the situation. Mitchel et al., (2010) conducted a study in which
Running head: Mental Health of Foster Children 9
they held interviews with foster children where they asked for their best advice to
children who are going through the transition, foster parents, and other child welfare
professionals. These interviews gave some first hand insight as to what is helpful in
making the transition as easy and comfortable as possible.
Many of the foster children expressed the importance of letting each foster child
have their voice be heard in any situation (Mitchel et al., 2010). During the interviews,
Mitchel et al., (2010) also found that it was common for children to be unaware of what
was happening during their time of transition, which made things very scary and difficult
for them, as they did not know where they were going and oftentimes missed their
family. Some people may think that it is best to leave children unaware of their
situation, but that only makes things more confusing for them. Being open and honest
helps ease the transition to new foster children (Mitchel et al., 2010). Some advice that
was offered to new foster children was to be open-minded and understand that the new
foster family is probably just as nervous about the new placement (Mitchel et al.,2010).
The interviewees also wanted to let others know that it will be difficult and scary
in the beginning, but it gets easier with time, they just have to be patient and
understanding with their new family (Mitchel et al., 2010). Another good word of advice
was to be open with social workers and communicate, because they do not know your
feelings unless they are told (Mitchel et al., 2010). For example, if a new foster child
really hates the home that they have been placed in and feels uncomfortable, speaking
with their social worker could help them get placed into a new home, but if they do not
speak up, the social worker will not know (Mitchell et al., 2010). The children who were
interviewed also wanted transitioning children to know that sometimes it takes several
Running head: Mental Health of Foster Children
10
different placements before they find a family that they mesh well with, but not to be
discouraged if they are having trouble fitting in with new foster families (Mitchell et al.,
2010). They also advised them to be respectful and polite to their foster families as they
would want to be treated by them, even if they do not agree on certain things or get
along well (Mitchell et al., 2010). The information and advice shared by the experienced
foster children would be helpful to foster parents, social workers, and transitioning
children.
Family Reunification
The end goal of foster care is to reunite children with their biological parents after
they have proven that they are fit to care for their child properly. Many children who
become reunited with their family eventually end up reentering the foster care system
(Font et al., 2018). Sometimes it is not the safest and best option for children to be
reunited with their original caretakers. Each family has their own set of complex needs
that caseworkers have to help them resolve before reunification, and that can be a very
difficult task for some families (Font et al., 2018). According to Font et al., (2018), a
large percentage of foster children are reentered into the foster care system within one
year of reunification.
Parental substance abuse and poor mental stability is the leading cause of foster
care placement (Font et al., 2018). In fact, in 2016, more than one third of child
removals were a result of parental substance abuse, as stated by Font, et al.,(2018). It
is often difficult for parents who struggle with substance abuse and mental health to get
the help and therapy that they need because it is very expensive and at limited
Running head: Mental Health of Foster Children
11
availability (Font et al.,2018). Short-term services are more readily available for
struggling parents, but that leads to the issue of relapsation because of the lack of long
term care (Font et al. 2018). Short-term services help the parents get clean and sober
or their mental health on the right track, but it usually does not teach the parents how to
maintain a healthy lifestyle suitable for raising children. Long-term treatment options
help the parents learn coping mechanisms and other things that help them lead a
normal lifestyle. Since short-term services are the more common source of treatment, it
puts these parents at higher risk of relapsing, which would lead to their children
reentering foster care.
Another factor that could play a role in foster care reentry is the effort to limit the
amount of time that a child spends in foster care (Font et al., 2018). Ideally, parents
who have lost custody of their child would maintain the therapy or other qualifications
required for them to prove that they are fit to regain custody. This might be done with
short-term services, as previously mentioned, which would help the children get
reunited quicker. The problem with that is that sometimes the parents are not ready.
The reasoning behind the rush to get families reunited is because after children are in
foster care for fifteen of the past twenty-two months, the parents lose all parental rights
to their children (Font et al., 2018). Because of this, things could be rushed in order to
avoid the loss of parental rights. In some cases, parents have not yet resolved the
issues that had their children placed into foster care in the first place.
Each state can make their own decision on whether or not there is a timeline for
foster children. Some states choose to revoke parental rights after a certain period of
time and others give parents unlimited amounts of time to complete the process of
Running head: Mental Health of Foster Children
12
regaining custody of their children. This could be a negative or positive thing, because
if there is a time limit, it would encourage parents to get the ball rolling in completing
requirements to regain custody, but that also puts a rush on things and children could
be reunited before their parents are fully ready for the responsibility. On the other
hand, if there is no time limit, parents might take years before they are ready to
complete the steps to regain custody, and by this time the children have settled into
their new life and routine, so that could be hard on the children and cause some issues
with their mental health and learning.
“In 1986, Maluccio et al. (1986) defined permanency planning as a movement that
established the need to shorten as much as possible the time children spend in
temporary care by a return to their birth family, as the preferable solution, by adoption or
even by permanent foster care” (Lopez et al, 2013, p. 226). The goal for this was to
minimize the amount of time children were placed in temporary care in order to provide
the most stable lifestyle.
“In the USA, according to the data provided by the Children’s Bureau in 2008, 52% of
children leaving the child protection system that year returned home with one or both
parents. Other studies in the US context indicate that half of cases returned home within
a year of being fostered.” (Lopez et al., 2013, p. 227)
There are several reasons as to why some children have a better chance at
being reunited with their birth parents. One study found that children with disabilities
are more likely to stay in foster care or return to foster care after reunification (Lopez et
al., 2013). This could be because of the expenses related to their disabilities. Some
Running head: Mental Health of Foster Children
13
disabilities require extra healthcare and equipment in order for the child to live their life
as normal as possible, and considering the vast majority of foster children come from
families who live in poverty, it may not be an option for them to receive the healthcare or
equipment due to the lack of funds. Children who are placed into foster homes that are
distant from their biological family are also at a higher risk of remaining in foster care
because of the added inconvenience (Lopez et al., 2013). Lopez et al., (2013) also
found the following information pertaining to foster care reunification:
“Biological families are less likely to be reunited with their children when they are
economically disadvantaged (Westat, Inc. 1995; Thomlison et al. 1996), when
they are one-parent families (McDonald et al. 2007; Rockhill et al. 2007) and,
particularly, when they have problems of alcohol or other drug abuse (Fein 1993;
Harris 1999; Brook & McDonald 2007; Mapp & Steinberg 2007; Wade et al.
2010)” ( Lopez et al., 2013, p.227)
Lopez et al., (2013) also found that children who are fostered by relatives tend to stay
with them longer or even permanently. This could be because biological parents have
easier access to their children and they can even co-parent with their relatives (Lopez et
al., 2013).
Foster Children’s Mental Health
Oswald et al. (2010) suggests that foster children often face neglect, physical,
sexual, and mental abuse at home before they are placed into foster care. This
childhood trauma commonly leads to mental health disorders, including, but not limited
to, substance abuse and addiction. Racusin et al., (2005) found that because of the
Running head: Mental Health of Foster Children
14
experiences foster children go through, they are “16 times more likely to have
psychiatric diagnoses, eight times more likely to be taking psychotropic medications and
utilize psychiatric services at a rate eight times greater compared with children from
similar socioeconomic backgrounds and living with their families.” (p.203) One of the
most prevalent issues leading to foster care placement is the parents’ substance abuse.
According to the National Center on Addiction and Substance Abuse of Columbia
University, seven out of ten children who are placed into foster care come from a home
where their parents suffer from some type of addiction (Oswald et al., 2010).
Stevens et al., (2011) study suggests that certain kinds of abuse lead to different
types of mental health issues. The following information was reported in the study
conducted by Stevens et al., (2011):
“A variety of studies have examined the impact of childhood abuse and neglect
on psychological and physical functioning in later childhood and adulthood.
MacMillan et al. (2001) examined a large probability sample in Canada and found
that individuals who had experienced physical abuse in childhood reported higher
rates of anxiety disorders, alcohol and substance abuse, and major depression
than those who did not report abuse. Sexual abuse in childhood was related to
higher levels of anxiety disorders, depression, substance use, and antisocial
behaviors. Sexual abuse and physical abuse in childhood have been shown to
affect virtually every facet of life and contribute to many types of
psychopathology, including posttraumatic stress disorder (PTSD; Kessler,
Sonnega, Brommel, & Nelson, 1995; McLeer, Deblinger, Atkins, Foa, Ralphe,
1988; K. M. Thompson et al., 2003; Widom, 1999), difficulties in social and
Running head: Mental Health of Foster Children
15
interpersonal behavior (Abdulrehman & De Luca, 2001; Mullen, Martin,
Anderson, Romans, & Herbison, 1994; Noll, Trickett, & Putnam, 2003; Tong,
Oates, & McDowell, 1987), eating disorders (Dansky, Brewerton, Kilpatrick, &
O’Neill, 1997; Hund & Espelage, 2005; Wonderlich et al., 2001), depression
(Beitchman et al.,1992; Finkelhor, Hotaling, Lewis, & Smith, 1990; McHolm,
MacMillan, & Jamieson, 2003), anxiety (Briere & Runtz, 1987; Finkelhor et al.;
Kendall-Tackett, Williams, & Finkelhor, 1993; M. B. Stein et al., 1996), personality
disorders (McLean, & Gallop, 2003; Sabo, 1997; Saunders & Arnold, 1993), and
substance use (Acierno et al., 2000; Caviola & Schiff, 1988; Giacona et al., 2000;
Kilpatrick et al., 2003).” (p.541)
When comparing foster children to children who were raised in loving homes with
their biological parents, foster children are more likely to have undergone prenatal
exposure to nicotine, alcohol, and psychotropic drugs (Oswald et al., 2010). Prenatal
exposure to the previously listed toxins can lead to developmental setbacks, including,
but not limited to, physical growth and learning disorders. It is not uncommon for these
children to go without proper healthcare, which prevents them from receiving any
therapy or medication that they might need in order to function properly in their daily
lives. Improper healthcare for children who have experienced trauma could lead to
severe learning disorders and mental disorders. If proper healthcare is provided, the
children can learn how to cope with their trauma in a healthy way that will help them
thrive.
Oswald et al., (2010) conducted a study to find the correlation between
maltreatment and developmental delays. In this study, the researchers narrowed their
Running head: Mental Health of Foster Children
16
focus onto 32 articles that had extensive data regarding the mental health of foster
children. In this study, they found that it is extremely common for foster children,
especially those who experienced trauma and abuse before placement, to suffer mental
illness. Of the 32 articles that the researchers used, only twelve reported the rates of
maltreatment, Oswald et al.,(2010) found the following statistics:
“The highest rates were found for neglect (18–78%), physical abuse (6–48%)
and sexual abuse (4–35%). Other placement reasons were emotional abuse
(8–77%), no available caretaker (21–30%).” (pp. 463-465)
Minnis et al., (2006) conducted a study by sending out questionnaires and holding
in-home interviews to gauge the number of foster children with mental disorders. The
study consisted of 182 children, whose foster families and teachers were interviewed.
In this study, they found that children who were placed in foster care often had
behavioral issues before their placement. This could be from the neglect and abuse
that they were experiencing. After extensive research and interviews, Minnis et al.,
(2006) came up with the following statistics:
“93 % of the children in the sample had suffered some form of abuse or neglect
in the past: 39 % of the children in the sample had been physically abused, 28 %
sexually abused, 77 % emotionally abused and 75 % neglected. More than two
thirds of the children (72 %) had been in previous placements, 28 % were
described as having a learning disability, 69 % came into care because of abuse
or neglect and 16 % because of parental mental illness (p.66)”
Running head: Mental Health of Foster Children
17
It is also not uncommon for these children to carry these behavioral issues into their
adult life, which could possibly become a cycle for their own children. That being said, it
is likely that they had fallen victim to the cycle in their own childhood. Proper healthcare
and therapy can help to end these cycles.
Leve et al., (2012) states that it is important to use early intervention with foster
children to check for any signs of mental illness. Because most of these children have
faced significant trauma, on top of being placed into a new home, they are at a very
high risk of developing problems with their mental health, if they have not already had
them. If mental healthcare is implemented early on, it could be possible for these
children to live normal lives without struggling with their mental health into their adult
lives.
Nearly half of the over 6,200 children who were investigated by the United States
child welfare system showed signs of behavioral problems, according to research done
by Leve et al., (2012). Those who were eventually placed in foster care had even
higher rates of behavioral issues. Leve et al.,(2012) also stated that the rates of mental
disorders were exceptionally higher in children whose parents were abusive “49% of the
children in such families were diagnosed with a psychiatric disorder (vs. 17% of the full
sample)” (p. 1198). These psychiatric disorders may also lead to other hurdles for the
child to cross, such as difficulty finding placement (Leve et al., 2012, p. 1198). These
problems could carry on into adolescence and young adulthood, as the National Survey
of Child and Adolescent Well-Being found that 17% of adolescents had been arrested,
making the arrest rates almost four times the national average for arrests in 18-24 year
olds (Leve et al., 2012, p. 1198).
Running head: Mental Health of Foster Children
18
Brain development is also a concern for foster children. “children and comparison
children reared in low income, non maltreating biological families, the foster children
experienced deficits in a variety of neurocognitive functions, including poorer
visuospatial processing, poorer memory skills, lower scores on intelligence tests, and
less developed language capacities” (Leve et al., 2012, p. 1198).
The deficits in neurocognitive functions cause major issues for children who are going to
school, because they often fall behind other kids their age. According to Leve et al.,
(2012), more than half of children who are on welfare assistance fall behind in basic
education such as language and alphabet knowledge.
Foster children face many challenges, and their mental health is one of the main
hurdles that they must cross throughout their lives. Clausen et al., (1998) found the
following when studying the mental health of foster children:
“Two major factors lead one to expect that children in foster care would exhibit
significantly higher risk for mental health problems than children who are not in
foster care. First, most of these children have experienced one or more forms of
maltreatment sufficiently severe to bring them to the attention of Child Protective
Services. For example, of the 93,294 children who received public social services
in the state of California from January to March of 1987, 87% had experienced
some form of documented child maltreatment (California State Department of
Social Services, 1988). The short term (Browne & Finkelhor, 1986; Downs, 1993;
Friedrich, 1993) and long term traumatic effects (e.g. Briere & Runtz, 1993;
Finkelhor, Hotaling, Lewis, & Smith, 1990; Saunders, Villeponteaux, Lipovsky,
Running head: Mental Health of Foster Children
19
Kilpatrick, & Veronen, 1992) of child maltreatment are well documented. Second,
children in foster care are at heightened risk for mental health problems due to
the negative effect of separation from their family. When an abused child, who
has likely experienced difficulty developing appropriate attachment to his abusing
caretakers, is removed from home and placed in foster care, he/she suffers
further due to an inability to separate in a healthy way (Charles & Matheson,
1990; Kadushin, 1980). Indeed, the movement from his own home to the foster
home engenders feelings of rejection, guilt, hostility, anger, abandonment, shame
and dissociative reactions in response to the loss of a familiar environment and
the separation from family and community (e.g., Katz, 1987). Clearly, a child who
is abused or neglected and is subsequently removed from home is at great risk
for the development of mental health problems.” (Clausen et al., 1998 p. 284)
Woods et al., (2013) conducted a study to determine whether or not children in
long term foster care have higher rates of chronic illness and delinquency. They also
studied whether or not depression has any significant links to child delinquency. In this
study, they learned that on average, foster children have much worse health than
children who are raised in traditional families (Woods et al., 2013). Children with health
issues have a harder time finding foster placements, as well (Woods et al., 2013).
Behavior issues are 2.5-3.5 times more likely to occur in foster children (Woods et al.,
2013). This makes things even more difficult for them, as their behavioral issues create
a barrier between them and the people who are trying to help them, such as foster
parents, teachers, and law enforcement. Another thing that Woods et al., (2013) found
is that foster children with mental health disorders often end up abusing substances
Running head: Mental Health of Foster Children
20
such as drugs and alcohol, making them more susceptible to committing crime (Woods
et al., 2013).
30% of foster children suffer from a chronic illness (Woods et al., 2013). This high
rate of illness could be related to the inconsistency in preventative healthcare and
vaccinations, according to Woods et al., (2013). Chronic illness and disabilities
inevitably place a strain on families' physical, mental, and financial well-being. This
could also be a reason that the rate of chronic illness is so high in the foster child
population, because their parents could not handle the added stress and responsibilities
that are associated with the illness. “Rubin, Halfon, Raghavan, and Rosenbaum (2005)
found that an estimated one in every two children in foster care has chronic medical
problems unrelated to behavioral concerns” (Pecora et al., 2009, p.6). Chronic medical
problems may be linked to the development of mental and emotional issues (Pecora et
al., 2009). Giving these children easy access to quality healthcare is key in helping
them maintain good physical and mental well-being. According to Pecora et al., (2009),
there are not enough mental health screenings for the mental health of foster kids, and
there needs to be more training on how to identify mental illness in adolescents. The
American Academy of Child and Adolescent Psychiatry (AACAP) and the Child Welfare
League of America (CWLA) took action and created some guidelines to follow in order
to help prevent and identify mental illness in the children.
When studying homeless adults, Patterson et al., (2015) found that “One of the
earliest identifiable precursors to homelessness may be placement in out-of-home or
foster care.” (Patterson et al., 2015, p.2) Youth who age out of foster care often find
themselves homeless, living either on the streets or with friends and family (Patterson et
Running head: Mental Health of Foster Children
21
al., 2015). Patterson et al., (2015) states that childhood trauma, including sexual,
mental, physical, and emotional abuse, along with other traumatic experiences, lead to
severe psychological abnormalities that may affect their adult lives in many ways, such
as difficulty finding employment, homelessness, and even social issues.
Bruskas (2010) wrote about the importance of treatment for children experiencing
mental and physical health issues. It is important that things get taken care of early on
because she has found that it is not uncommon for untreated illness to cause major
health issues in adulthood, such as heart disease and premature death (Bruskas,
2010). Bruskas, (2010) states the importance of healthcare workers being able to
identify developmental problems, because they could potentially save the child from
having long term effects from their trauma. Also, Bruskas (2010) brings up the fact that
most children who enter foster care are infants, and are nonverbal. A lot of these
infants go untreated because they are too young to understand the situation, so people
assume their mental and developmental health is unaffected. Infanthood is a time of
extensive brain development, and if they have been living in neglectful or abusive
environments, their brain development suffers (Bruskas, 2010). Proper treatment and
therapy may allow the infant to get back on track for their brain development, so it is
important that they are assessed in a timely manner after being removed from their
family of origin. If taken care of soon enough, these infants may not have any long-term
effects, because they will not remember the trauma of being separated from their family
like older children do.
Running head: Mental Health of Foster Children
22
Hypothalamic-Pituitary-Adrenal Axis
One reason Leve et al., (2012) found for neurocognitive setbacks is the
neuroendocrine stress response system, which is the job of the
hypothalamic-pituitary-adrenal (HPA) axis, is different when compared with foster
children and children who are not in foster care. Neglect and abuse causes a hormonal
imbalance, which takes a toll on the HPA. HPA is activated when an infants’ needs are
met (Laurent et al., 2014). When an infant is being nurtured and his or her needs are
being met, the HPA releases a hormone called Cortisol, which helps with brain
development. When foster children experience neglect, especially as infants, their brain
is being deprived of Cortisol, which results in learning delays and mental health
disorders (Laurent et al., 2014).
Early intervention
Foster children are at a higher risk for learning disorders, as previously stated.
Because of this, it is imperative that foster parents know about early intervention. Early
intervention is crucial in helping these children learn to the best of their ability.
Attachment and Biobehavioral Catch-up for Toddlers (ABC-T) is an early intervention
method that helps children improve their vocabulary (Raby et al., 2019). A study was
done for children aged 24-36 months where foster parents were given a number at
random which would determine if they received the ABC-T (n=45) or (n=43) (Raby et
al., 2019). N=45 was the intervention method that was produced to help children learn,
and n=43 was the control group. After each child completed intervention, it was clear
Running head: Mental Health of Foster Children
23
that the ABC-T (n=45) had great results and had helped tremendously with the
children's vocabulary (Raby et al., 2019).
The Ages and Stages Questionnaire: Social Emotional (ASQ-SE) and the Ages
and Stages Questionnaire (ASQ) are two tools that help with early intervention.
ASQ-SE helps identify emotional problems that foster children might have, and the ASQ
helps find other developmental delays that include communication disorders, gross
motor delay, fine motor delay, problem solving, and personal-social problems (Jee et al.,
2010). The ASQ and ASQ-SE are non-diagnostic tools, but they do help physicians
determine their next steps in helping children get on the right path (Jee et al., 2010).
These two screenings are now routine for well- child visits of foster children and help
doctors detect learning and mental disorders early on, so that they can begin early
intervention techniques for the child.
PTSD in Foster Children
Haselgruber et al., (2020) performed a study that dived into the details of PTSD
and CPTSD in foster children. They state that PTSD (Post Traumatic Stress Disorder)
is different than CPTSD (Complex Post Traumatic Stress Disorder). These two
disorders are made up of three common symptoms: “re-experiencing the trauma here
and now (Re), avoidance of traumatic reminders (Av) and persistent sense of current
threat, manifesting in startle and hypervigilance (Th) (Haselgruber et al., 2020, p. 61).
The difference between PTSD and CPTSD is that CPTSD also accompanies
disturbances in self-organization, which includes the following symptoms: “affective
Running head: Mental Health of Foster Children
24
dysregulation (AD), negative self-concept (NSC) and disturbances in relationships (DR)
(Haselgruber et al., 2020, p. 61).
Due to foster children undergoing childhood trauma, they have high rates of
PTSD, and their chances of developing CPTSD are also high. Solva et al., (2020),
raised the question, are there different categories of abuse and trauma that are more
likely to lead to PTSD and CPTSD? Their studies suggest that there are different
classes and subcategories of maltreatment, characterized by physical, emotional, and
sexual abuse, along with physical and emotional neglect (Solva et al., 2020). Their
study aims to find if different combinations of maltreatment cause higher risk of PTSD.
For example, does a child who experienced physical and sexual abuse, but not neglect,
have a higher or lower chance of developing serious mental disorders?
Using the Childhood Trauma Questionnaire (CTQ) and the International Trauma
Questionnaire- Child and Adolescent Version (ITQ- CA), Solva et al., (2020), assessed
147 children for the different types of maltreatment and their relation to PTSD and
CPTSD. These studies concluded with the following data:
“23.1% reported no maltreatment, 20.1% reported having experienced one
subtype of maltreatment, 23.1% reported two different types of maltreatment,
12.7% reported the experience of three subtypes, 12.7% reported having
experienced four subtypes and 8.2% reported the experience of all five subtypes
of childhood maltreatment. In total, 56.7% of children and adolescents reported
having experienced more than one experience of maltreatment according to the
CTQ” (Solva et al., 2020, p. 5).
Running head: Mental Health of Foster Children
25
These screenings also came to the conclusion that 8.7% of the children were highly
likely to suffer PTSD, and 8.2% CPTSD. In regards to the question whether or not
different types of maltreatment lead to higher risk for mental disorders, the study
conducted by Solva et al., (2020) reported the following information:
“The cumulative maltreatment class showed the highest PTSD, DSO, and
CPTSD symptom severity and functional impairment. The high neglect class
showed the lowest post-traumatic symptom severity in PTSD, DSO, and CPTSD.
The limited maltreatment class showed medium symptom severity in PTSD,
DSO, and CPTSD and the lowest values for functional impairment.” (pp. 5-6).
Solva et al., (2020) came to the conclusion that different categories and combinations of
maltreatment do lead to different severity risk for children developing PTSD and
CPTSD.
ADHD in Foster Children
Attention deficit and hyperactivity disorder (ADHD) is a common
neurodevelopmental disorder (CDC). Childhood trauma is linked to the development of
ADHD, according to Vrijsen et al., (2017). Though ADHD is most commonly found in
children, it even follows up to 60% of diagnosed people into their adult life (Vrijsen et al.,
2017). The main and most common symptom of ADHD is the inability to hold attention
on something for periods of time, which can be very detrimental to children who are in
school, as it is hard for them to stay focused and learn. Vrijsen et al., (2017) states that
ADHD links to other psychosocial disorders, such as issues with memory. The
childhood trauma that foster children undergo creates a higher risk of ADHD lasting into
Running head: Mental Health of Foster Children
26
adulthood, and it is often accompanied by severe anxiety and depression (Vrijsen et al.,
2017). ADHD in adults may even lead to more serious issues, such as unemployment,
which then causes more potential issues, such as homelessness.
Poor Mental Health Leading to Risky Behavior
Stevens et al., (2011) conducted a study that researched the correlation between
the poor mental health of foster children with risky behavior, such as unprotected sexual
activity at a young age and substance abuse. In this research, 56 children ages 12 to
17 years old were studied. Some of the children were living in traditional family settings,
which would be used as the “control” group and others living in foster care settings, to
determine if the adverse effects had any relation to poor decision making (Stevens et
al., 2011). Adolescents go through rapid changes in multiple aspects of their lives,
including emotionally, physically, socially, and cognitively (Stevens et al., 2011).
According to Stevens et al., (2011), they also begin to make decisions for themselves
and become more independent than they were as young children. Their friends and
peers also become a bigger part of their life, whereas before they were mainly
surrounded by either their biological family or foster family. Stevens et al., (2011) also
stated that these changes are accompanied by “increased risk for developing emotional
and behavioral disorders, such as depression, anxiety, conduct problems (such as
aggression and oppositionality), and substance use” (p. 539). Stevens et al., (2011)
study found the following statistics about mental health in teens:
“Rates of depression in adolescents between 15% and 20% (Kessler, Avenevoli,
& Merikangas, 2001; Lewinsohn & Essau, 2002), while anxiety disorders such as
Running head: Mental Health of Foster Children
27
social anxiety and generalized anxiety disorder have rates of 0.5% to 3% and
0.4% to 4%, respectively (Beidel, Turner, & Morris, 1995; Chorpita &
Southam-Gerow,2006). Conduct problems (and disorders like
oppositional-defiant disorder and conduct disorder) have a prevalence rate
between 1% and 10% and are frequently seen comorbidly with anxiety and
depression (Angold & Costello, 2001; Loeber & Keenan, 1994). Finally, rates of
adolescent substance use and abuse are also quite high, with more than half of
high school seniors reporting having used at least one illicit drug in their lifetime
and close to 11% of 12- to 18-year olds meeting current criteria for substance
abuse or dependence (Johnston, O’Malley, Bachman, & Schulenberg, 2005;
Winters, Leitten, Wagner, & O’Leary-Tevyaw, 2007)” (pp. 539-540)
Ideally, these adolescents that are experiencing poor mental health would receive
support and guidance from their family. That is not the case for many children,
especially those in foster care, because in most cases, their family played a huge role in
their trauma to begin with (Stevens et al., 2011). This makes things more difficult for
foster children, leading them to be at higher risk to make poor decisions, especially
self-medicating that leads to substance abuse (Stevens et al., 2011).
Self-Harm and Suicide
Children and adolescents experiencing mental health crisis are at risk to self-
harm or even attempt suicide (Gabrielli et al., 2014). A study conducted by Gabrielli et
al., (2014) found that out of 135 children, ages 8-11 years old, 24% of them stated that
they wanted to die or hurt themselves. In another study pertaining to children in foster
Running head: Mental Health of Foster Children
28
care found that 25% of the children had frequent suicidal thoughts and thoughts of
harming themselves (Gabrielli et al., 2014). Though some children have thoughts of
suicide and self harm at a young age, it is most common in adolescents and teens who
are closer to entering adulthood (Gabrielle et al., 2014). This could be caused by the
stress of becoming an adult and having to provide for themselves, without help from
family. Most teens who live in a traditional family setting have plenty of support as they
enter adulthood, but foster children often do not, especially those who age out of foster
care before being placed with a permanent family for adoption. Teens are also at a
different developmental stage that causes them to act on impulse, and not take future
consequences into consideration before making decisions (Gabrielle et al., 2014). This
also sheds light on why young adults and teens fall into addiction, because they are
only acting on impulse and seeking immediate relief, instead of weighing the benefits
and risks involved for their future self.
Gabrielle et al., (2014) also note that suicidal behavior is often brought on by
some type of conflict, usually with someone they love, such as family or friends.
Another common trigger that causes young people to have thoughts of self-harm and
suicide is having stuggles with academics (Gabrielle et al., 2014). For some of these
children, their academic performance is the only thing that they can control and feel
proud of, so if they are struggling to meet academic standards and milestones, it could
be very detrimental to their mental well-being, causing them to feel worthless.
Foster placement may also play a role in suicidal tendencies, according to
Gabrielle et al., (2014). Their studies suggest that children who are placed in family
setting foster homes are less likely to have thoughts of suicide, because of the sense of
Running head: Mental Health of Foster Children
29
stability (Gabrielle et al., 2014). Children who are placed into a family setting are able to
get more one on one attention, rather than group homes where it is harder for children
to get individual attention and care. In some cases, placement setting is determined by
the child’s mental well-being, for example, if they are in a very poor mental state, it is
preferred that they are placed with a family so that they can receive more one on one
attention, but if they are seemingly healthy, they may be placed into a group home.
In an attempt to find out whether or not other factors, such as age and gender,
play a role in the rates of suicidal thoughts, Gabrielle et al., (2014) created a study to
find some answers. They chose to study a group of 135 foster children, ranging from
ages eight to eleven years old, with the following characteristics:
“The majority of the youth were African American (54 %), followed by Caucasian
(33 %), Multiracial (11 %), and Other (2 %). Of the youth participants,
approximately 79 % lived in home-based settings, and the remaining 21 %
resided in residential facilities. The gender distribution of youth approached
equality (54 % female). Caregiver reporters were foster mothers (44 %), foster
fathers (13 %), staff at residential facilities (16 %), or other reporters (e.g.,
therapist at residential facility or kinship provider; 27 %). Finally, at baseline
assessment, based on caregiver reports, roughly 54 % of the children had
received a mental health diagnosis and 54 % had been treated for an emotional
or psychological problem” (Gabrielle et al., 2014, pp. 895-896).
To complete the study, caregivers were to answer questions about their child regarding
their behavioral and mental health. The questionnaire asked multiple questions
Running head: Mental Health of Foster Children
30
pertaining to thoughts of self-harm and suicide, and the caregiver/child could answer on
a scale of “often”, “sometimes”, and “never” (Gabrielle et al., 2014). The following data
was collected from the finished questionnaires:
“29 (22 %) caregiver reporters indicated that the youth participant had said, ‘‘I
want to kill myself’’ and 28 (21 %) indicated that the youth participant had said,‘‘I
want to die.’’ A combination of these two variables revealed that 32 (24 %) of
caregivers endorsed at least one of these two items” (Gabrielle et al., 2014, pp.
897-898).
Medical Services for Foster Children
It is known that foster children are at a higher risk for mental illness, so that
raises the question, are they receiving the appropriate health care? Larsen et al.,
(2018) dove into research to find the answer to this question and found the following:
“Generally, children and youths in foster care have a high use of mental health
services, also compared to the general youth-population. However, relative to
their high rate of mental disorders, the service utilization by foster youth seems
low, and findings indicate that a considerable part of this population does not
receive services according to need (p.1)”
Teens and their caregivers were given questionnaires that asked basic questions about
their mental health and also how often they had utilized health care services within the
past two years. After assessing the questionnaires, the following statistics were found:
Running head: Mental Health of Foster Children
31
“Overall, 74.5% of carers and 68.7% of youths reported contact with any service”
(Larsen et al., 2018). Further, 61.2% of carers and 58.5% of youth reported
Contact with Primary Health Care Services. CPS stands out as the single service
most used by carers and youths; 92.1 and 85.3%, respectively, reported having
any contact. The second most used service was special education (41.7%),
reported by carers, and the school health service (30.8%), reported by youth.
(Larsen et al. 2018, p. 5)”
Even though there is a massive need for mental health resources for foster
children, there are barriers that prevent some children from obtaining the care that they
need (Carabez & Kim, 2019). The foster system is overrun with children who are in dire
need of medical attention, particularly pertaining to their mental health. This makes it
harder for medical agencies to keep up with the overload of patients. This is a problem
because this could mean that some children are being prioritized over others due to the
severity of their mental health. With that being said, children with severe mental health
issues should be prioritized, but that just makes the process longer for other children,
which could potentially lead to their mental health worsening if they are not provided
with proper health care and therapy.
Utilization of CAMHS
Child and Adolescents Mental Health Services (CAMHS) provides mental health
care services to children in foster care. Studies have found that even though all foster
children are provided with CAMHS, the utilization rates are rather low (York & Jones,
2017). York & Jones (2019) state that a study found that only 25% of United States
Running head: Mental Health of Foster Children
32
foster children received mental health services within the past twelve months. Children
who go untreated are at a high risk of mental health disorders carrying on into their adult
lives, and even worsening as they get older. “For example, it is well established that
looked after children will often leave care with poor levels of academic achievement,
higher rates of unemployment, homelessness, high rates of teenage pregnancy and
drug use” (York & Jones, 2019, p.144). Untreated mental illness can have a severely
negative impact on the adult lives of foster children. This could potentially create
cycles, if they are not dealt with in a healthy way early on. For example, if the untreated
foster child grows up into an adult with addiction problems, it is likely that they will lose
custody of their children, if they have them, which creates the cycle. It is crucial that
foster parents are making sure that their foster children are utilizing the care that is
provided by CAMHS.
Psychotropic Medication for Foster Children
According to Davis et al., (2021), there has been a rise in the use of antipsychotic
medication in children over the past two decades. Davis et al., (2021) also states that
children who are insured by government assistance programs, such as medicaid, are
especially likely to be prescribed antipsychotic medications, along with psychotropic
medications. Foster children have an even higher rate of psychotropic and
antipsychotic medication use, as much as 30-60% higher than other children (Davis et
al., 2021). Considering foster children are at higher risk of experiencing traumatic
events in their lifetime, these medications may be absolutely necessary in order for
them to remain in a positive and healthy mental state (Davis et al., 2021).
Running head: Mental Health of Foster Children
33
There is a question about whether or not psychotropic medication is worth taking,
as it is rather expensive and may also create many different side effects, which could
cause long-term issues for the individuals who take it, according to Davis et al., (2021).
Some of the side effects mentioned by Davis et al., (2021) are: increases in body mass
indexes, obesity, glucose dysregulation, hyperlipidemia, type 2 diabetes mellitus, and
fatigue/somnolence (p. 2). Since foster children are already at risk for long-term mental
and physical health disorders, this could be an added risk. If a child must have these
medications, it is important that they are kept under supervision to ensure that they are
not developing any of the side effects listed above (Davis et al., 2021). Foster children
should be watched even closer, as they have an even higher chance of experiencing
side effects, since most of them are or have experienced toxic situations that create a
rocky foundation for their mental and physical well-being (Davis et al., 2021).
Because of the concern about the adverse side effects of psychotropic and
antipsychotic medications, states have put monitoring mechanisms into place to ensure
the health and safety of foster children who are prescribed these medications (Mackie et
al., 2016). Mackie et al., (2016) found the following information pertaining to the efforts
to monitor children who are consuming medications that could potentially result in
negative side effects:
“First, the Children’s Health Insurance Program Reauthorization Act of 2009
(CHIPRA) included provisions to improve health outcomes of children in
Medicaid and the Children’s Health Insurance Program (CHIP) by developing
quality measures for voluntary use by State Medicaid and CHIP programs
(Center for Medicare and Medicaid Services 2013). Second, accreditation bodies
Running head: Mental Health of Foster Children
34
like the National Committee for Quality Assurance (NCQA) also have endorsed
monitoring measures; NCQA has proposed measures related to antipsychotic
use among children in its 2015 Healthcare Effectiveness Data and Information
Set (HEDIS; NCQA, 2014). Third, federal legislation is prompting state agencies
to develop psychotropic medication monitoring programs to address quality and
safety issues among vulnerable pediatric subpopulations, specifically, children in
foster care (Child and Family Services Improvement and Innovation Act 2011;
Fostering Connections to Success and Increasing Adoptions Act of 2008).” (p.
244)
Foster children are at a disadvantage because they may not have the consistent
care that other children who are living in traditional families receive (Mackie et al.,
2016). For example, they may be moved around often to different foster placements,
which makes it hard for foster parents to pick up on any adverse side effects that the
child is experiencing from their medications (Mackie et al., 2016). Also, they may
struggle with having access to their medications because of the high cost. Having
issues accessing these medications could be harmful to their health if they are not
taking them as prescribed.
State Medicaid questions the excessive use of psychotropic and antipsychotic
medications, and argues the possibility of the medications being used instead of therapy
treatments (Mackie et al., 2016). There is no doubt that some children must be
prescribed medications in order to balance their mental health, but in some cases,
personalized therapy could be very useful and prevent the need for prescriptions
(Mackie et al., 2016). Personalized therapy allows the therapists to analyze each aspect
Running head: Mental Health of Foster Children
35
of the child’s trauma, and provide therapy that is specifically helpful for their personal
experiences. Medicaid is concerned about this because of the alarming contrast
between the rates of psychotropic medication prescriptions that are given to children in
foster care and children who are not in foster care (Mackie et al., 2016). The rates are
21-52% of children in foster care consuming these medications, and only 4% for the rest
of the child population (Mackie et al., 2016). Some data even shows that some foster
children are even being prescribed more than one psychotropic medication (Mackie et
al., 2016). With the data that has been found about the high rates of psychotropic
medication usage in foster children, it raises question about whether or not foster
children are receiving the same level of care as the rest of the population, or if they are
being given “quick fixes'' in places of personalized therapy that could result in long-term
success (Mackie et al., 2016).
With the questionable rates of psychotropic medication being given to foster
children specifically, the federal government had to intervene (Mackie et al., 2016).
They are making the extra effort to ensure that every child who is prescribed these
potentially dangerous medications, is legitimately in need of them, and not just being
given a quick fix (Mackie et al., 2016). Multi-step protocols were put into place,
requiring physicians to take every step to ensure that the child is being rightfully
prescribed psychotropic medications (Mackie et al., 2016). If the steps are taken and a
physician decides that it is in the best interest of the child to take these medications,
they are required to provide continuous close monitoring to ensure that the child is both
taking the medication as directed and also experiencing the results that were hoped for.
Running head: Mental Health of Foster Children
36
Larsen et al., (2018) studied whether or not foster children are utilizing the mental
health services that are available to them. Their findings show that the rates of service
utilization is low in comparison to the rates of diagnosed mental health disorders
(Larsen et al., 2018). The low utilization of services may be linked to the high rates of
psychotropic medication prescriptions, because if children are prescribed medication to
quickly fix their problem, they are less likely to attend therapy or other services, because
it takes up more of their time and is more of an inconvenience.
Lohr et al., (2019) also studied the overuse of psychotropic medication in foster
children, and the use of polypharmacy, which is when someone is prescribed multiple
medications at one time. Lohr et al., (2019) theorize that foster children, specifically, are
not receiving behavioral interventions that could prevent the use of psychotropic
medications. There are also concerns and questions about whether or not foster
children receive the quality of care that other children do. Lohr et al., (2019) mention
how important the role of a child welfare professional is in terms of treatment. They can
help make the change and advocate for their children to receive the same level of care
that all other people do.
The state of Kentucky has particularly high rates of psychotropic medication and
polypharmacy use (Lohr et al., 2019). In an attempt to understand the reasoning behind
these high rates, Lohr et al., (2019) conducted interviews with child welfare
professionals, because they are the people who approve and monitor the usage of
psychotropic medications and polypharmacy. The goal of these interviews was to
understand why psychotropic medications are seemingly overused, and also find out if
there are problems that prevent children from receiving psychosocial treatment instead
Running head: Mental Health of Foster Children
37
of prescription medications (Lohr et al., 2019). After finding the answers to their
questions, it is hoped that they can help come to a conclusion to provide better quality
healthcare to foster children, and hopefully lower the use of potentially dangerous
medications.
After completing the interviewing process, Lohr et al.,(2019) came to the
conclusion that there are four major factors contributing to the usage of psychotropic
medications: “access to health records, access to mental health services, consent and
decision-making about PM use, and training related to PM use” (Lohr et al., 2019, p.
88). The most common issue for child welfare professionals was the difficulty securing
access of their clients medical records, followed by the difficulty keeping in contact with
medical professionals (Lohr et al., 2019). Another issue, pertaining specifically to
mental health, was that child welfare professionals commonly experience difficulty
obtaining information about a child’s mental health from their primary care provider, due
to the misunderstanding of the professionals rights to the child (Lohr et al., 2019). As
the child welfare professional that is assigned to a specific child, they have the right to
obtain information regarding their mental health, as it helps them make informed
decisions regarding their placement options and treatment (Lohr et al., 2019). If the
biological parents are still legally responsible for the child, they may need to sign off on
their child’s medical information being released to the child welfare professional, and it
is not always easy to convince the parents to cooperate (Lohr et al., 2019). These
issues can cause problems for the foster children because their social worker is unable
to choose placement based on their mental health, if they do not have access to their
medical records. If social workers are informed about their child’s health, they are able
Running head: Mental Health of Foster Children
38
to place them in homes that are equipped and prepared to provide the highest level of
care.
Health Related Quality of Life
Carbone et al., (2007) conducted a study to gather information about the health
related quality of life (HRQL) of foster children. 326 children participated in this study.
Children aged 13-17 years old were about to complete the survey themselves, and
children younger than 13 had to have their caregivers complete the questionnaire.
More specifically, the Child Health Questionnaire (CHQ) was filled out by the
participants. The CHQ contains the following:
“The CHQ is a multi-domain generic health-related quality of life questionnaire,
which assesses children’s physical, psychological and social functioning over a
4-week period. The 50- item parent-version of the CHQ (CHQ-PF50) assesses
13 domains of children’s functioning, including children’s physical functioning,
mental health, school and social limitations arising from children’s health
problems, and the impact of the children’s physical and psychosocial health on
caregivers/parent.” (Carbone et al., 2007 pp. 1158-1159)
The results of this study showed that children who had experienced three or more
placements in foster care had lower health related quality of life (Carbone et al., 2007).
Altogether, the study found that children living in foster care have a lower HRQL than
the general population of children who are being raised in a traditional family setting.
When comparing foster children to those raised in traditional family settings, foster
children had worse overall health, higher aggressive tendencies, and some showed
Running head: Mental Health of Foster Children
39
signs of immature behavior for their age (Carbone et al., 2007 p. 1164). Anxiety and
depression was also higher in foster children, and the authors found that they even had
lower self- esteem than other children (Carbone at al., 2007, p. 1164). These results
are alarming because they play a role in how these children live their daily lives. The
mental and physical effects that foster care has on children takes a toll on their social
lives, schooling, and extracurricular activities.
Foster children are commonly raised in severe poverty and experience family
dysfunction (Carbone et al., 2007). Not only are they at risk for mental illness, but
studies show that they are also experiencing physical health issues, such as problems
with their skin, vision, and teeth (Carbone et al., 2007). The following data was reported
after retrieving information from 224 foster children: “37% had skin problems, 27% had
dental caries, 15% had vision problems, 14% had abnormal neurological exams, and
11% had short stature” (Carbone et al., 2007, p. 1158).
Foster Children Transitioning into Adulthood
Some studies suggest that older children should have some say in the
court-ordered decisions about their future, such as where they will be housed
(Shdaimah et al., 2021). The argument is that as children get older, they eventually
reach cognitive maturity and are less likely to be influenced by their peers, and more
likely to make decisions based on what they feel is best for them (Shdaimah et al.,
2021). Letting the youth make decisions for themselves leads to better relationships
and a healthier mental state, as they do not feel as controlled by everyone else, and
Running head: Mental Health of Foster Children
40
they can take some control of their own lives. This is empowering to the young adults,
and may lead to higher confidence.
These youth do need to have a good understanding of what types of decisions
they will be making, so that they can have legitimate opinions and input on their
decisions. To help with this, the Emancipation Checklist (EC) was created to help guide
social workers and other child welfare officers through the decision making process with
the child that they are working with (Shdaimah et al., 2021). The EC helps the
professionals ask the right questions without leaving anything out, in order to help the
children fully understand what is going on in their case and to keep everyone on the
same page (Shdaimah et al., 2021). The checklist makes it easier for children to have
their own voice about what happens in their life. The EC includes the following
questions, according to Shdaimah et al., (2021) (p.63):
● Does the youth have adequate housing?
● Is the youth employed or have other income?
● Is the youth currently attending an educational or vocational program?
● Does the youth have a GED or high school diploma?
● Does the youth have medical insurance?
● Does the youth have permanent family and/or adult connections?
● Is the youth connected to desired community activities?
Running head: Mental Health of Foster Children
41
● Does the youth have all identifying documents, i.e. birth certificate, Social
Security card, driver’s license, or state ID?
● Are there any outstanding criminal or delinquency cases for the youth?
● Does the youth have a bank account?
● Did the youth complete a credit score check?
● Can the youth identify their core values?
This list also helps the professional adult recognize if the youth is mature enough to
make decisions on their own. If some of the questions were answered with
questionable answers, it might raise some red flags and let the professionals know that
the young adult is not ready to make their own decisions yet.
Some children stay in the foster system long enough that they “age out”. This
means that they turn 18, a legal adult, while in foster care. When a foster child ages
out, they are responsible for themselves, meaning that they are no longer under the
care of a foster parent. This does not mean that they are thrown out onto the streets,
but they are usually sent to a group-home type setting that teaches them how to live as
a functioning adult in society (Affronti et al., 2015). Some of the things they learn are
employment skills, money management, and how to take care of their basic human
needs (Affronti et al., 2015).
“Researchers estimate that foster children who are eight years or older are more
likely to age out of foster care than to be adopted” (Ahmann, 2017, p.43). In 2015,
20,289 teenagers were emancipated from foster care (Ahmann, 2017). Emancipated
Running head: Mental Health of Foster Children
42
teens face many challenges, since they do not have the help from family at home.
Reilly (2003) completed a study that focused on 100 emancipated teens who had aged
out of foster care to find what the most common struggles are, and found the following
information:
● “Limited education (50% of youth left foster care without a high school
degree).
● Failure to obtain and/or maintain regular employment (although 63% were
employed at the time of the study, 26% had not had steady employment; 24%
had dealt drugs at some time since leaving care; 11% had used sexual
intercourse for money; and 55% had been terminated from employment at least
once).
● Lack of funds to meet basic needs (41% of respondents).
● Early pregnancies (38% of youth had children; over 70 pregnancies had
occurred, some miscarried, and some aborted).
● Inability to obtain healthcare services (only 54% of youth rated their
health as very good or excellent; 30% reported a serious health problem since
leaving care; 32% reported needing health care but being unable to obtain it).
(These numbers may have improved in recent years due to the extension of
Medicaid to this population in some states [S. Punnett, personal communication,
November 11, 2016].)
Running head: Mental Health of Foster Children
43
● Homelessness (almost 33% of young people left foster care without a
place to live; since leaving foster care, 36% had experienced periods of
homelessness).
● Involvement with the criminal justice system (41% had spent time in jail
since leaving foster care)” (Ahmann, 2015 pp. 43-44)
Even though foster teens are put through training to learn how to function as an adult,
the outcomes that are listed above are still common.
The statistics prove that no matter the amount of training and preparation that a
child has, having a supportive adult relationship can have a major impact on the
well-being and success of young adults (Ahmann, 2015). This could be simply because
they have someone to go to for advice on day to day things such as how to apply for
jobs, or how to pay bills, or even having someone to help out in other ways such as
giving them a ride to work or helping out with childcare. A supportive adult can be a
game changer for young adults who have aged out of the foster system, as they can
help guide them through all of the new experiences that adulthood entails.
It can be a challenge for teens and young adults to establish relationships with
supportive adults. They may have social workers that are there to help them on a
professional level, but they cannot be there as a friend to guide them through their
struggles. To help make establishing supportive relationships a bit easier, there is a
program called the Family and Youth Initiative, which is a program that helps foster care
youth aged 12-21 form relationships with adults who are willing to support them
(Ahmann, 2015). This program hosts events that bring together the teens and adults so
Running head: Mental Health of Foster Children
44
that they are able to bond and create a stable relationship (Ahmann, 2015). These
events are also great for families who are interested in adopting an older child, as it
gives them a chance to get to know several different children and find who they bond
with the most. Some of the events are educational for the youth, such as learning adult
life skills like budgeting, but others involve more fun activities such as sports or crafts
that just give everyone a chance to get to know each other (Ahmann, 2015). This can
make things feel more natural and not like forced relationships. Forming relationships
slowly and on their own terms is great for foster youth, as they have most likely been
through unstable relationships with past family and friends (Ahmann, 2015). If an adult
finds themselves having a strong relationship with one of the youth, they are able to
speak with the program director about being a mentor for that child (Ahmann, 2015).
When an adult becomes a mentor, they are expected to meet with their child on a
regular basis in order to keep the bond strong. In some cases, the volunteers and
mentors even end up adopting the teens after getting to know them and forming strong
connections (Ahmann, 2015).
Stockdale (2019) discusses the importance of education for foster children,
because it lays a foundation for successful work ethic. They state that allowing youth to
leave the foster system with low levels of education is like setting them up for failure,
because they are more likely to experience unemployment (Stockdale, 2019). Because
these young adults who are starting out on their own do not have family to go home to
for support, it is imperative that they are able to provide for themselves, and they will not
be able to provide for themselves without employment.
Running head: Mental Health of Foster Children
45
Transitional housing is a major benefit if aged-out foster children are able to live
in one. Transitional housing offers young adults a place to live while they figure out how
to support themselves as an adult in society (Stockdale, 2019). Transitional housing
may also give these young adults a chance to go to college, while still having a stable
place to live. People who have aged out of foster care without transitional housing may
be at a disadvantage, because they will have to provide for themselves on their own,
meaning they will most likely need to work a full time job, leaving little time for higher
education. Transitional housing softens the transition, as they have more room to be
flexible in their finances, and may have the extra time to complete some schooling.
Alumni of Foster Care
Jackson, et al. (2015) states that foster care alumni are likely to pass their
psychological baggage onto their own children. Their studies found the following
statistics:
“Approximately 1.1% of children in the USA enter foster care each year, the
Casey Family Programs (Casey) Northwest Foster Care Alumni Study found that
8% of alumni with children had a child placed in foster care” (Jackson, et al.,
2015, p.72)
For this study, 1582 foster care alumni were interviewed. The alumni ranged
from age 20 to age 51, and they must have spent at least one year in foster care as
children, and have been out of foster care for at least one year prior to the interview
(Jackson et al., 2015). Eight percent of the alumni that were eligible for the study were
unable to participate due to death, imprisonment, or mental institutionalization (Jackson
Running head: Mental Health of Foster Children
46
et al., 2015). Interviewees were asked to recall what their living conditions were like
before being placed in foster care. This included questions about their biological
parents, such as if they had substance abuse problems, psychological illness, and if
they experienced poverty. There was also emphasis on the study of father involvement,
as it has been proven that a fathers’ bond with his children has a huge impact on the
child’s long-term well-being (Jackson et al., 2015).
The results of this study showed that most alumni recalled their biological parents
to struggle with addiction and mental health disorders. It was also common for the
alumni to live in poverty before their placement into foster care (Jackson et al., 2015).
Conclusion
This essay dove into the complex details pertaining to foster children and their
struggles with mental health disorders. Research concludes that there are many factors
that play a role in the mental and physical well-being of foster children, including
placement, foster parents, forms of abuse, and much more. Child welfare specialists
play a huge role in ensuring the health and safety of foster children.
Running head: Mental Health of Foster Children
47
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