What factors predict long-term mental health for children in out-of-home care?

Introduction

In Australia around 46,000 children and young people live in out-of-home care which, in 2020, equated to approximately eight in every 1,000 children (Australian Institute of Health and Welfare [AIHW], 2021). The rate of children in care is much higher for Aboriginal and Torres Strait Islander children – one in 18 (AIHW, 2021) – due to historical and ongoing impacts of colonisation, intergenerational trauma and systems of forced child removal (Blackstock et al., 2020; Human Rights and Equal Opportunity Commission, 1997; Yoorrook Justice Commission, 2023).

Children in care are at greater risk of negative life outcomes, including poor long-term mental health (Cashmore & Paxman, 2007; Meltzer et al., 2013). But not all children fare poorly; for some their wellbeing improves over their time living in care (e.g. Fernandez, 2006). Protective factors are likely to play a role here. Certain pre-existing child characteristics or living conditions may help to reduce the risk of negative long-term outcomes.

Nonetheless, the ways in which individual characteristics and early life circumstances impact on longer-term wellbeing for children in care are not well understood. In an analysis of data from 962 children who entered care in New South Wales between May 2010 and October 2011, researchers sought to understand how characteristics of children and families prior to a child’s entry into care were related to patterns of change over time for child mental health (and other outcomes).

First, the analyses looked at how children could be meaningfully ‘clustered’ or grouped together, by looking for children with similar pre-care profiles on key characteristics that have been identified in past research as being associated with out-of-home care outcomes. These key characteristics were: age on entry into care; Aboriginality; disability; and socioeconomic status (SES).

Then, growth curve modelling was used to explore whether there were differences between clusters in the patterns of change in children’s mental health (and other outcomes) over a six-year period.

Results

Cluster analysis identified three distinct clusters of children in the sample:

1. The largest cluster (n = 379, 39.4% of the sample) were on average more likely to have a disability and have a lower SES when entering care. They also tended to be younger at entry into care (an average age of one year old), and were more likely to identify as Aboriginal or Torres Strait Islander.
2. A cluster of 372 children (38.7%) also tended to be younger at entry (an average age of one and a half years), but had a higher SES at the time they entered care, compared to other clusters.
3. A cluster of 211 children (21.9%) tended to have entered out-of-home care after the early childhood period (entering care at an average age of seven and a half years).

There were different trajectories for children’s mental health and cognitive functioning, depending on how children clustered on indicators of early life circumstances and family factors.

In relation to child mental health, children who entered care at an older age (average 7.5 years) showed improvement in mental health over time, despite having poorer mental health on care entry, compared to high SES children who entered care when they were under two years old (on average).

On the other hand, children with multiple risks on care entry demonstrated the poorest mental health six years after their entry into care. Both the multiple risk and the young at care entry/higher SES clusters showed similar trends towards decreasing mental health over time.

Implications

With greater knowledge about the interactions between different combinations of pre-care factors, agencies will be better equipped to make informed decisions about care placement, restoration, and permanency planning for children exposed to abuse or neglect.

For instance, this study found the mental health of children with multiple risk factors at care entry worsened over time. This could indicate a need for greater investment in out-of-home care prevention through targeted early intervention for young children with two or more risk factors.

Efforts to support the family to keep the child at home, through parenting support or temporary placement while safety is addressed, may be indicated for children for whom a range of risk factors are present. This has implications for Aboriginal and Torres Strait Islander children, for whom the importance of connections to family, community, culture and Country is enshrined in child and family welfare legislation and policy (e.g., through the Child Placement Principal). Accordingly, kinship care is a common placement choice for Aboriginal and Torres Strait Islander children.

However, kin carers must be appropriately resourced to take on the care of the child. Other researchers have speculated that kinship carers are potentially more poorly trained than other foster and adoptive parents, and that children placed with kin may be moved to locations some geographic distance from their original community (Arney et al., 2015; Walsh et al., 2018). Additional investment would aide in equipping kin carers with the skills and resources they need to provide care for often highly vulnerable children.

The findings about improving mental health for children entering care at school age are interesting as they challenge the assumption and some past research (e.g. Dubowitz et al., 1993; Pritchett et al., 2013) that placing children into care at an older age is risky, and that decisions about child placement and the achievement of permanency need to occur when the child is young. Children who enter care after the age of six years do show improvements in their mental health and wellbeing, sometimes with results that are indistinguishable from children placed in care much earlier in their lives.

This research emphasises the importance of considering how risk and protective factors may be associated with children’s longer-term wellbeing. Findings help inform out-of-home care placement and support decision-making for cohorts of children with different presentations at entry into care.

How was this resource developed?

This short article summarises the findings of analyses conducted by Catherine Wade titled, , published in the journal Child Abuse and Neglect in August 2023.

References

Arney, F., Iannos, M., Chong, A., McDougall, S., & Parkinson, S. (2015). Enhancing the implementation of the Aboriginal and Torres Strait Islander Child Placement Principle: Policy and practice considerations. CFCA Paper No. 34. Melbourne: Australian Institute of Family Studies.

Australian Institute of Health and Welfare (AIHW). (2021). Data tables: Child protection Australia 2019–20. Child Welfare series no. 74. Cat no. CWS 78. Canberra: AIHW.

Blackstock, C., Bamblett, M., & Black, C. (2020). Indigenous ontology, international law and the application of the Convention to the over-representation of Indigenous children in out of home care in Canada and Australia. Child Abuse & Neglect, 110.

Cashmore, J. & Paxman, M. (2007). Longitudinal study of wards leaving care: Four to five years on. Report commissioned by NSW Department of Community Services.

Dubowitz, H., Zuravin, S., Starr, R. H., Feigelman, S., & Harrington, D. (1993). Behavior problems of children in kinship care. Journal of Developmental and Behavioral Pediatrics, 14(6), 386–393.

Fernandez, E. (2006). Growing up in care: Resilience and care outcomes. In R. J. Flynn,  P. M. Dudding & J. G. Barber (Eds.) Promoting Resilience in Child Welfare (first ed.), pp. 131–156. Canada: Ottawa Press.

Human Rights and Equal Opportunity Commission. (1997). Bringing them home: Report of the national inquiry into the separation of Aboriginal and Torres Strait Islander children from their families. Human Rights and Equal Opportunity Commission: Sydney.

Meltzer, H., Gatward, R., Corbin, T., Goodman, R., & Ford, T. (2003). The mental health of young people looked-after by local authorities in England. London: HM Stationery Office.

Pritchett, R., Gillberg, C., & Minnis, H. (2013). What do child characteristics contribute to outcomes from care: A PRISMA review. Children and Youth Services Review, 35(9), 1333–1341.

Wade, C. (2023). Trajectories for children and young people who experience out of home care: Examining the influences of pre-care characteristics on later wellbeing and placement stability. Child Abuse & Neglect, 106398.

Walsh, P., McHugh, M., Blunden, H., & Katz, I. (2018). Pathways of care longitudinal study: Outcomes of children and young people in out-of-home care. Literature review: Factors influencing the outcomes of children and young people in out-of-home care. Research report number 6. Sydney: NSW Department of Family and Community Services.

Yoorrook Justice Commission. (2023). Yoorrook for Justice: Report into Victoria’s child protection and criminal justice systems. Melbourne: Yoorrook Justice Commission.