Mental Disorders in Foster Children: A Study of Prevalence, Comorbidity, and Risk Factors

Abstract

Children in foster care have often experienced multiple adverse childhood experiences, including maltreatment and the rupture of attachment bonds. Maltreatment and the rupture of attachment bonds make foster children vulnerable to later mental health problems. Register-based studies in Norway indicate that a history of out-of-home care is associated with marginalization in several areas of life, including school dropout, low income, the receipt of disability benefits, and early death. The overall aim of the present thesis was to extend the knowledge on the mental health problems of children placed in foster care. First, the point-prevalence and patterns of comorbidity of mental disorders in school-aged foster children were examined. Second, a standardized questionnaire frequently used for mental health assessment in child populations was validated as a screening tool to identify foster children with mental disorders. Third, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classify reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) as two separate disorders. We examined the validity of the conceptual structure of RAD and DSED as two separate dimensions for foster children. Finally, the associations between exposure to maltreatment prior to placement and placement history, on the one hand, and psychopathology, on the other hand, were examined. Child mental health was assessed using the web-based diagnostic interview the Developmental and Well-Being Assessment (DAWBA), eliciting DSM-IV diagnoses, and eliciting dimensions of children’s mental health through the Strengths and Difficulties Questionnaire (SDQ). Both measures were completed online by foster parents and teachers of foster children 6-12 years of age. Data on exposure to maltreatment prior to placement and placement history were derived from a custom-made questionnaire completed by the child’s caseworker at child protective services. Of 395 eligible children, 279 had the DAWBA completed by at least one informant. The results in Paper I indicated that 50.9% of the participating children met the criteria for one or more DSM-IV disorders at the time of assessment. The comorbidity rate was very high. In Paper II, support for the screening properties of the SDQ Total Difficulties and Impact scales was reported. There was an additive effect of combining the scores for these two scales for screening purposes. In Paper III, confirmatory factor analyses (CFA) supported the conceptualization of RAD and DSED as two distinct dimensions, congruent with the DSM-5 definition. The risk for mental disorders increased with exposure to serious neglect, increasing numbers of types of violence, and increasing numbers of prior placements (Paper I). The associations between external risk factors and RAD and DSED were somewhat different depending on whether they were combined into a single diagnostic category (Paper I), or treated as separate dimensional scales (Paper III). Whereas more exposure to violence in the family of origin and more prior out-of-home placements were associated with having RAD according to the DSM-IV (Paper I), these findings were not replicated for the dimensional measures of RAD and DSED according to the DSM-5 (Paper III). Instead, male gender and mental disorder in biological parents were associated with higher scores on the RAD scale. These findings show that foster children have a high prevalence of mental disorders, including ADHD, behavioural disorders, emotional disorders, and trauma- and stress-related disorders. The results support the use of the SDQ Total Difficulties and Impact scales when screening foster children for mental disorders. The high prevalence and comorbidity of mental disorders, including attachment disorders, indicate a need for further development of diagnostic and therapeutic competence for foster children and their families.