Foster Care Mental Health

Close to 1 percent of children in America spend time in foster care systems annually. On average, institutionalized children tend to have higher rates of mental health disorders and conditions, including anxiety, depression, behavior disorders, and attachment disorder, among other mental health issues compared to other children (Indyk, 2015; Turney & Wilderman, 2016; Lohr & Jones, 2016). According to the National Conference of State Legislature (2019), up to 80 percent of children in the foster care system have a range of mental health issues, including depression, posttraumatic stress disorder (PTSD), anxiety, disruptive behavior disorders, and Attention deficit hyperactivity disorder (ADHD) compared to roughly 20 percent of children who have not been institutionalized. Mental health problems impact children in foster care a great deal. To mitigate these issues, timely mental assessment for children within the foster care system ought to be conducted and pertinent treatment methods procured.

Literature Review

One of the main reasons children in foster care are disproportionally affected by mental health issues stems from the fact that before these children are institutionalized, they usually come from broken homes. Many of the foster care system children have parents and relatives who have physically, sexually, or verbally abused them. These children tend to come from broken homes, maltreatment, homelessness, and dire poverty prior to being institutionalized (Lohr & Jones, 2016; Indyk, 2015; Turney & Wilderman, 2016). A supportive, nurturing, and safe environment is thus necessary if their psychological needs are to be met (National Academies of Sciences, Engineering, and Medicine, 2019; Steenbakkers et al., 2018).  Research shows that up to 48% of children within the foster care system have clinically significant mental health issues (Indyk, 2015). In Turney and Wilderman (2016), the above supposition was proven using data and logical regression.

For this reason, data from the National Survey of Children Health was utilized. The data was run through a logistic regression model to compare mental and physical health outcomes of children who had been institutionalized with those who had not spent time in foster homes, children from different types of families, children adopted form fosters systems, and children coming from underprivileged homes. The results indicated that children who had spent time in foster care homes were prone to mental health conditions. Vasileva and Petermann (2018) conducted a systematic review of literature and meta-analysis to underline mental health problems amongst children who had been institutionalized. These authors’ meta-analysis indicated that the prevalence rates for insecure attachment, mental health problem, and developmental issues were 40 percent. Overall, research shows that children from the foster care system were more likely to experience anxiety, depression, and other mental health issues than children from the general population.


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Topic Specific Information

Several types of mental health conditions affect children in foster care. They include neurological impairment, behavioral problems, attachment disorder, post-traumatic stress disorder, anxiety, depression, and other mental health issues.

Anxiety disorder

Anxiety disorder infers to a situation in which the child has an excessive, intense, and persistent worry in regards to their life. Children with an anxiety disorder will often experience intense episodes of fear, which can sometimes manifest as panic attacks. Counseling, therapy, and medication may be used to treat and/or manage anxiety disorders.


Depression is a mood disorder in which a person experiences feelings of anger, loss, or sadness. While it is normal for one to may feel sad or lonely from time to time, persistent loneliness, sadness, and loss over an extended period of time may lead to depression. Depression may interfere with the child’s school work and affect their relationship with other children, siblings, or parents.

Behavioral Problem

Behavioral problems infer to disruptive disorder among children. The behavioral problem generally affects the child’s social interaction at school and home. Examples of behavioral problems children experience include hyperactivity, criminal activity, defiant behavior and impulsivity.

Attachment Disorder

Attachment disorder is a psychiatric disorder common in children with emotional attachment issues. Most children with attachment disorders strive to forge relationships. Emotional or physical abuse is usually considered as the main cause of attachment disorder.

Applicable Theories

Several approaches and theoretical frameworks have been shown to help halt mental health problems among foster care children. Many of these approaches have been shown to have reasonably high levels of efficacy. Several of these approaches were fashioned specifically to help children in foster care deal with mental health issues. A few of these methods were not explicitly designed for children in foster care though they may be adopted for foster care settings.  Examples of these theoretical frameworks include Parent-Child Interaction Therapy (PCIT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Kids in Transition to School (KITS), Child-Parent Psychotherapy (CPP), and Keeping Foster Parents Trained and Supported (KEEP), Treatment Foster Care Oregon (TFCO), among others.

Treatment Foster Care Oregon for Preschoolers (TFCO-P)

Treatment Foster Care Oregon was developed in the 50s to help children who had been institutionalized to transition between foster care and return to their original family. Today TFCO is used as an alternative to group care. This framework aims to meet the needs of children with serious mental health and behavioral problems (Åström et al., 2020). TFCO-P is one of the best approaches for alleviating mental health issues affecting institutionalized children owing to its many advantages. Specifically, it can be used to increase increased placement permanency and improve cortisol levels. It can also help be used to prevent HPA axis dysregulation and reduce avoidant attachment behavior among several other advantages (Hambrick et al., 2016). These advantages invariably help decrease anxiety, depression and other mental health issues affecting children in the foster care system.

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Child Parent Psychotherapy (CPP)

Child Parent Psychotherapy is a theoretical framework designed for children between the ages of 0-5 years who have experienced a traumatic event such as sexual abuse, maltreatment, a serious accident, or traumatic death of a loved one. Also, it is applicable for children experiencing mental health issues such as post-traumatic stress disorder. For the most part, CPP relies on attachment theory though it also uses cognitive-behavioral theories, social learning, and psychodynamics (National Child Traumatic Stress Network, n.d.). Therapeutic sessions involving the parent or the primary caregiver and the child are conducted to strengthen the parent and the child’s relationship. CPP research shows can drastically improve institutionalized children’s mental health (Hambrick et al., 2016). Specifically, CPP have been shown to help alleviate posttraumatic stress in children. It also enhances behavioral functioning and the strengths of the child.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy is basically an evidence-based counseling approach whose objective is to address mental health issues such as PTSD among children. Typically psychoeducation is offered to the child and the parent or the carer with the view that they will improve behavior and cope with thoughts and emotions (Bermudez, 2018). This theoretical framework research shows that it has many advantages for children with mental health issues within the foster care system. Some of its advantages include help improving behavioral functioning, decreasing posttraumatic stress, decreasing risk behaviors, and decreasing internalizing and externalizing of problems by children in the foster care sy,stem among other advantages (Hambrick et al., 2016). All these advantages tend to decrease the likelihood of depression and anxiety among institutionalized children.

Parent-Child Interaction Therapy (PCIT)

Parent-Child Interaction Therapy is a behavioral intervention approach dyadic in nature involving parents or primary caregivers and their children. The goal of PCIT is decrease child behavior such as aggression and defiance and increase behaviors such as social skills. It also improves the child-parent attachment. Traditional play therapy skills are also taught to the parent. This theoretical framework arrest several mental health problems among children. Behaviors such as aggression and defiance are decreased while the child’s social skills improved. Through PCIT, the abuse of foster children could be decreased. Forster parent distress could also be decreased (Hambrick et al., 2016). These directly reduced the likelihood of anxiety and depression among children within the foster care system.

Kids in Transition to School (KITS)

The objective of KITS is to boost children’s social skills, literacy and self-regulation. This theoretical framework is evidence-based and makes use of behavioral change strategies and positive teaching. KITS had many advantages linked to better mental health. Specifically, this theoretical framework was able to decrease aggressive and oppositional behavior among kids in foster care. KITS was also shown to increase emotional self-regulation. These interventions likely decreased the probability of depression and anxiety in institutionalized children.

Keeping Foster Parents Trained and Supported (KEEP)

KEEP is a group based16 week session involving kinship and foster carers to help children between 5 and 12 years deal with behavioral difficulty. Accordingly, carers learn practical approaches useful for managing challenging behavior in the child and improving their relationship with them. Hambrick and colleagues (2016) were able to show that KEEP had several benefits for children within the foster care system. Specifically, this theoretical framework decreased behavior problems, and increased positive exit from care.

Attachment Behavioral Catch-Up (ABC)

Attachment behavioral catch-up is a theoretical framework that may be adopted to foster care setting to alleviate mental health issues affecting children within the foster care system. Essentially, ABC is a ten-session home visiting program in which the parent or child caregiver is coached so as to increase their sensitivity, attachment security, and regulatory capabilities are also augmented using ABC (Dozier & Bernard, 2017). Hambrick and colleagues (2016) were able to show that ABC decreased avoidance behavior, improved cortisol levels, and foster parents’ sensitivity, among other benefits, which are linked to reduced anxiety and depression.

Applicable Legislation

A number of legislations are applicable to the mental health of institutionalized children. This section will highlight a few federal and state and legislatures pertinent to mental health issues affecting institutionalized children.


In California, the 2014 Assembly Bill1790 mandates that different stakeholders within the foster care continuum will be summoned with the object of identifying barriers to the provision of mental health services for institutionalized children.


In Connecticut, the 2013 Senate Bill 972 and 2013 Conn Acts, P.A. 178 requires that a plan for arresting mental health issues amongst institutionalized children be developed.  Early interventions, training of school resource officer, among other approaches, are some of the strategies this legislation mandates to be developed.


In Michigan the House bill 4694 of 2014 mandates that family division of the district and circuit courts institute a juvenile mental health court. Further, the Mich. Pub Acts, Act 63 Section 58 underlines that child placing agencies will be involved in mental health issues affecting institutionalized children. The legislation highlights several measurement and treatment approaches to be use in all mental health cases supervised by the different child placing agencies.

Federal Legislation

The Health Oversight Provisions in the Fostering Connections to Success Act of 2008 is a core piece of federal legislation on mental health issues affecting children in foster care. Accordingly, this piece of legislature mandates that every state must consult experts in regards to medical and mental health issue affecting youth in foster care and develop plans on its mitigation (National conference of State Legislature, 2019).  The other piece of federal legislation that directly addresses institutionalized children’s mental health is

The Child and Family Services Improvement Act. This piece of legislature categorically includes issue on the mental and social-emotional health of children who have experienced maltreatment. According to this piece of legislation, Child and Family Service Plans must underline details on how it addresses mental issues associated with maltreatment and trauma and the psychotropic mediation procured to help mitigate pertinent mental health issues.

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Practical Considerations

Stigma plays a significant role in increasing the potency of mental problems. Stigma affecting individuals with mental health issues often originates from family, friends, and even healthcare professionals. Stigmatized individuals generally tend to record poor health outcomes compared to those in a supportive environment devoid of stigma. Based on this prelude, providing institutionalized children with an environment devoid of stigma ultimately help reduce the potency of mental health problems such as anxiety and depression. In general, siblings are often separated in most foster care arrangements. Children in foster care are often separated from their siblings; such siblings often lose contact with their kin. Keeping siblings together even as they become institutionalized may alleviate mental health issues. Relationships between siblings are generally quite strong.  Such relationships can be quite fulfilling to children within the foster system and naturally helps them cope with their new reality. By placing siblings together, their relationships with siblings have a chance to flourish, and mental health issues such as depression and anxiety are, to an extent, calmed via such arrangement. Familial contact is the other practical arrangement that can significantly impact institutionalized children’s mental health. Children are happy to have contact with their uncles, aunties, grandparents, cousins among other relatives. Regular familial visits from their kin are thus advantageous and may positively impact the child’s mental health issues. In the end, alleviating stigma in the child’s environment, keeping siblings together within the same foster family and ensuring consistent contact with their kin are some of the best practical approaches that can be used to alleviate mental health issues affecting institutionalized children.


While mental health issues are a major problem amongst children living in foster care, these issues can be remedied or their potency lessened via several theoretical frameworks and practical arrangements. Several federal and state legislations also attempt to tackle mental health issues affecting institutionalized children. Mental health problem is particularly prevalent among children living in foster care. Generally, these children are usually coming from broken homes, homelessness, poverty, neglect, and abuse. Research highlight that up to 40% of institutionalized children suffer from mental health issues such as depression, anxiety, and attachment disorder, among other mental health issues. Theoretical frameworks including Treatment Foster Care Oregon (TFCO), Child Parent Psychotherapy (CPP), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Parent-Child Interaction Therapy (PCIT), Kids in Transition to School (KITS) and Keeping Foster Parents Trained and Supported (KEEP) among others research shows have a lot of efficacy in treating mental health issues affecting children who have been institutionalized. Practical arrangements such as ensuring that the environment in which the child lives is devoid of stigma, keeping siblings within the same foster family and ensuring the institutionalized children have regular contact with their extended relatives can impact their mental health issues positively.

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