The experience of public care

Although psychiatrists are more likely to encounter individuals who faced adversity while going through the care system, they should bear in mind that the majority of individuals in care give a positive account of their experiences. For instance, one study found that 90% of foster children liked their foster carers (Reference Chapman, Wall and BarthChapman 2004) and another reported that 81.5% of children in out-of-home care felt ‘happy’ or ‘very happy’ with their current living arrangements (Reference Wilson and ConroyWilson 1999). Children appreciated the safety and better conditions in their foster homes (Box 2). Over half of the children participating in one survey agreed with the statement that their present foster placement was ‘definitely the right one for them’ (Reference Johnson, Yoken and VossJohnson 1995). Another study concluded that children in care felt as close to their main care giver as children living with their birth family (Reference MorganMorgan 2006).

Nevertheless, there are important disadvantages to the care system. One of its most negative characteristics is the high level of instability, transience and unpredictability. Multiple breakdowns of placements, high turnover of social workers and last-minute changes to care plans have been criticised and, as a result, placement stability is now a performance indicator for local authorities in England (HM Government 2006). During 2013, 44% of foster children experienced a change in placement (Department for Education 2013a).

A comprehensive literature review summarised qualitative research into the experiences of individuals affected by public care (Reference Dickson, Sutcliffe and GoughDickson 2009) (Box 2). It demonstrated how some children find it difficult to feel loved and at home in a foster placement. England’s highly regulated and bureaucratic Social Services apparatus cannot respond to the needs and wishes of children in the flexible, pragmatic and collaborative way of ordinary families. Despite their best efforts, social workers may struggle to give children the sense that their feelings matter and are fully considered when making important decisions (Box 2). Many children see multiple professionals stepping in and out of their lives without effecting change for the better. Clinicians should bear this in mind when individuals affected by public care are sceptical about how helpful formal services will be to them.

The mental health of young people and adults affected by public care

The literature regarding mental disorders among children and young people in public care is extensive. A comprehensive survey in England found that 45% of school-aged children in public care had a mental disorder, which represented a fivefold increase compared with children living in private households even after adjusting for deprivation (Reference Meltzer, Gatward and CorbinMeltzer 2003; Reference Ford, Vostanis and MeltzerFord 2007). For children in residential care, the figure was even higher, at 71% (Reference Ford, Vostanis and MeltzerFord 2007). Other reviews have reported similarly high levels of mental disorders in children in public care (Reference Tarren-SweeneyTarren-Sweeney 2008; Reference Pecora, White and JacksonPecora 2009; Reference Oswald, Heil and GoldbeckOswald 2010).

Less is known about the mental health of public care alumni in adulthood, although large cohort studies have recently yielded some data. Prospective studies based on the 1970 British Birth Cohort Study showed prevalence rates for psychological malaise/depression, criminality and life dissatisfaction among care alumni that were approximately twice those among the general population (Reference Viner and TaylorViner 2005; Reference Dregan, Brown and ArmstrongDregan 2011). These studies supported earlier findings based on the 1958 National Child Development Study of a link between childhood experience of public care and depressive symptoms in adulthood (Reference Cheung and BuchananCheung 1997; Reference Buchanan, Brinke and FlouriBuchanan 2000; Reference Power, Stansfeld and MatthewsPower 2002). Adult life trajectories were associated with childhood placement patterns; those with more severe emotional and behavioural difficulties were more likely to have been exposed to longer periods of care and multiple placements in both foster and residential care (Reference Dregan and GullifordDregan 2012). Overall, however, the UK data suggested that the adverse effects of public care on mental health attenuated somewhat in adult life (Reference Viner and TaylorViner 2005).

In contrast, data from US studies suggested that the adverse effects of public care on mental health became more pronounced once alumni exited care (Reference Pecora, White and JacksonPecora 2009). For instance, the Casey National Study of more than 1000 foster care alumni found that the 12-month prevalence of PTSD was 21%, exceeding that of US war veterans. The prevalence of drug dependence and bulimia nervosa among care alumni was seven times higher than in the general population. Rates of depression, panic disorder and social phobia were also increased. The Northwest Alumni Study found that lifetime prevalence of mental disorders for adults who had spent 1 year or more in foster care exceeded that in the general population on all nine mental disorders assessed. These findings have prompted calls for dedicated mental healthcare provision for young people and adults who have experienced foster care (Reference Pecora, Kessler and WilliamsPecora 2010).

Systematic UK mapping data show that 9% of individuals accessing child and adolescent mental health services (CAMHS) have been accommodated in public care (Reference Barnes, Devanney and UglebjergBarnes 2010). Comparable data for adult care alumni in UK adult mental health services are not available. Researchers in the USA examined adults receiving treatment for schizophrenia and severe mood disorders within public mental health systems. They found that about 40% of patients had been in public care (Reference Rosenberg, Lu and MueserRosenberg 2007; Reference Lu, Mueser and RosenbergLu 2008). Services working with vulnerable groups such as substance misusers, homeless people and offenders were the most likely to encounter individuals affected by public care (Reference Pecora, Kessler and WilliamsPecora 2010). Homeless adults with a history of public care were 70% more likely than those without such histories to report any psychiatric disorder (Reference Thompson and HasinThompson 2012). Although these data come from the USA, they suggest that screening for public care history among clinical populations in the UK could aid the planning and provision of mental health services for these vulnerable groups.

The experience of adoption

Adoption services in England and Wales have undergone even more radical changes than the care system over recent decades and the experiences of an individual who was adopted will depend on the era during which they were placed with their new family (Reference ThomasThomas 2013). The Children Act 1975 helped to transform adoption by strangers from a service providing ‘the perfect baby’ to infertile couples to a service designed to find homes for vulnerable children (Reference QuintonQuinton 2012); however, it was not until 2002 that the welfare of the child was made first and paramount in legislation (Reference LewisLewis 2004). More recently, adoption has been viewed as a way of helping children overcome the negative effects of early deprivation and maltreatment within a reparative family environment (Reference QuintonQuinton 2012).

This section focuses mainly on domestic adoptees, since the number of international adoptions is still relatively low in England.

Most adult adoptees report positive experiences of adoption (Box 3). A study of self-reported outcomes and experiences of adults who experienced domestic adoption by strangers indicated that around 70% did well or very well, while 15–20% expressed dissatisfaction, with the rest falling somewhere in between (Reference Triseliotis, Feast and KyleTriseliotis 2005). The majority reported feeling a sense of belonging to their adoptive family and of being loved by their adoptive parents, and these feelings have been linked to emotional health. Adoptees who reported emotional difficulties as a result of adoption attributed their problems to the upbringing in an adoptive home, including emotional distancing from adoptive parents, being treated differently from birth children and being from a different ethnic background than their adoptive parents (Reference Triseliotis, Feast and KyleTriseliotis 2005). A poorer quality of experience within the adoptive family and a negative view of the adoption were also associated with mid-life mental health problems among international adoptees (Reference Rushton, Grant and FeastRushton 2013).

Although adoptive placements tend to be more stable than foster placements, one should not assume that all adopted individuals experienced permanence whereas those who were fostered did not. Delays in placing children for adoption have been highlighted regularly over the past 40 years, and many adopted children will have had multiple carers prior to placement (Reference Rowe and LambertRowe 1973; Reference Monck, Reynolds and WigfallMonck 2004). For example, in 1998–1999, 38% of children had one placement prior to adoption, but 29% had four or more (Reference IvaldiIvaldi 2000).

The first comprehensive study of adoption breakdown in England found lower than expected rates and indicated that only about 3 in 100 legalised adoptions broke down over a 12-year period (Reference Selwyn, Wijedasa and MeakingsSelwyn 2014). Breakdown rates were higher once adoptees had reached their teenage years. Other risk factors for disruption included older age at placement, longer waiting period between placement and granting of an adoption order, and poor mental health. Thus, 97% of young people whose adoptions had broken down showed significant social, emotional or behavioural difficulties compared with 22% of adoptees whose parents reported that the adoption went well.

Over the past three decades, there has been a move towards greater openness in adoption, and young people today are more likely to have more information about their birth parents. These young people’s experiences of adoption are therefore different from those of the adult adoptees that dominate adoption research. However, there is also considerable heterogeneity of experience and adjustment in the open adoption group. Reference Selwyn, Sturgess and QuintonSelwyn (2006) found that, although some adoptive parents rated contact with birth parents as beneficial, a significant proportion (45%) were concerned about its negative emotional and behavioural effects on children. Two-thirds of children had indirect (‘letterbox’) contact with their birth parents, but very few adoptive parents spoke positively about this.

The mental health of young people and adults affected by adoption

Research comparing adjustment in fostered and adopted children has tended to favour adoption, although these differences are diminishing because fewer infants and greater numbers of older children with prolonged exposure to maltreatment are being adopted (Reference TriseliotisTriseliotis 2002). A meta-analysis of 35 case–control studies found that rates of externalising and internalising difficulties were mildly elevated among adoptees aged 4–18 years compared with the general population (Reference Juffer and van IjzendoornJuffer 2005). Prevalence rates were higher in domestic adoptees than in international adoptees. The meta-analysis did not consider late adoptions, i.e. school-aged children who were adopted from public care. A study focusing on late adoptions found a high prevalence of behavioural problems, with about one-third of adoptees showing considerable disturbance after a substantial amount of time in their placements (Reference Rushton and DanceRushton 2006). Pre-adoption experiences, such as maltreatment or highly depriving institutional care, were also associated with outcome, with the latter particularly affecting physical growth and attachment (Reference Juffer and van IjzendoornJuffer 2005; Reference van Ijzendoorn and Juffervan Ijzendoorn 2006).

Increased rates of suicidal behaviour, completed suicide, psychiatric admissions, schizophrenia, depression and substance misuse have been described for adults who had been part of national and international adoptions (Reference Hjern, Lindblad and VinnerljungHjern 2002; Reference Tieman, van der Ende and VerhulstTieman 2005; Reference von Borczyskowski, Hjern and Lindbladvon Borczyskowski 2006; Reference Cantor-Graae and PedersenCantor-Graae 2007; Reference Laubjerg, Christensen and PeterssonLaubjerg 2009; Reference Van den Dries, Juffer and van IJzendoornvan der Vegt 2009; Reference Yoon, Westermeyer and WarwickYoon 2012), but a meta-analysis of these data is not yet available. Recent data on mental health service usage by adopted individuals are not available. A study conducted over 20 years ago in the USA showed that between 10 and 17% of psychiatric inpatients, and 5% of psychotherapy patients, were adopted by non-relatives (Reference Brodzinsky, Schechter and MarantzBrodzinsky 1992).

Relational functioning and intergenerational patterns

The impact of separation from birth parents on children’s ability to form attachments with alternative caregivers is not yet fully understood. Studies of young infants in foster care (Reference Dozier, Stoval and AlbusDozier 2001) and after adoption (Reference Singer, Brodzinsky and RamsaySinger 1985) found that levels of secure attachment towards alternative caregivers did not differ from those in biologically intact dyads. Similar results have recently been found in a study of adolescents in foster care (Reference Joseph, O'Connor and BriskmanJoseph 2014). However, other studies indicated that negative attachment experiences prior to removal may be carried over into subsequent placements. A meta-analysis found that children adopted after their first birthday showed significantly less attachment security and more attachment disorganisation than their peers (Reference Van den Dries, Juffer and van IJzendoornvan den Dries 2009).

Relational difficulties may persist into adulthood. For example, care alumni in the USA reported higher levels of psychological aggression, physical assault and sexual coercion in their intimate relationships than the general population (Reference Courtney, Dworsky and LeeCourtney 2009). Higher divorce rates have been observed in adults in England who had been placed in foster care because of the Second World War, and this was mediated by attachment style (Reference RusbyRusby 2010).

The vast majority of individuals who experience maltreatment do not mistreat their own children (Reference Kaufman and ZiglerKaufman 1987; Reference WidomWidom 1989; Reference Dixon, Hamilton-Giachritsis and BrowneDixon 2005). The intergenerational transmission of maltreatment has been widely explored in the literature, but many studies supporting this hypothesis have suffered from weak study designs (Reference Thornberry, Knight and LovegroveThornberry 2012). A prospective study of 4351 newborns in England found that in the first 13 months 6.7% of parents with a history of physical and/or sexual abuse were referred to Social Services for maltreating their own children, compared with 0.4% of non-maltreated parents (Reference Dixon, Hamilton-Giachritsis and BrowneDixon 2005). Poor parenting styles, young parenthood, mental illness and domestic violence were associated with the intergenerational transmission of abuse.

Effective interventions to improve parenting skills have been developed and they can help break unhelpful intergenerational cycles (Reference Dretzke, Frew and DavenportDretzke 2005). Adult mental health services play a role in supporting parents who have a mental illness and struggle with their parenting even though models of practice are not yet well established (Reference CraigCraig 2003). Protective factors should be considered in assessments, alongside risk factors and parenting styles (Reference Dixon, Browne and Hamilton-GiachritsisDixon 2009).

Stigma, devaluation and bullying

The media and general public often see individuals affected by public care or adoption in a negative light (Reference Kline, Karel and ChatterjeeKline 2006). As children, they often faced a devalued status in a society that defined kinship in genetic terms and viewed alternative family constitutions as second best (Reference WegarWegar 2000; Reference FisherFisher 2003). Many had to endure bullying before and after they were removed from their birth families. Bullies may have targeted them because they were ‘different’, found it hard to stand up for themselves and had fewer people to speak out on their behalf (Reference Dickson, Sutcliffe and GoughDickson 2009). The additional stigma attached to mental health services may lead to denial and non-engagement (Reference CallaghanCallaghan 2003). Being mindful of these factors might help clinicians when dealing with individuals affected by public care or adoption who are reluctant to accept another role that may be associated with a devalued status, such as that of the mental health patient.

Social disadvantage into adulthood

During the critical stage of transition from adolescence into adulthood, young people affected by public care or adoption may have less support at their disposal than the general population. This applies particularly to those who have come through the public care system, as many adopted young people can draw on the ongoing support of their adoptive families (Reference WadeWade 2008). In England, care alumni must become independent at the age of 18 years, while most of their peers in the general and adopted population remain living at home into their twenties (Reference SteinStein 2006).

Young people exiting the English care system are referred to as care leavers and are entitled to extra support until the age of 25 years. However, this support can rarely match that of a caring family. As a consequence, care leavers are at risk of social exclusion and they are overrepresented in the most disadvantaged groups (Reference Wade and DixonWade 2006) (Box 4). It has been suggested that the comparative disadvantages faced by care leavers become less pronounced by middle adulthood (Reference Viner and TaylorViner 2005).

Importance of resilience

Levels of psychological adjustment, self-esteem and educational success in non-clinical samples affected by public care or adoption are similar to those in the general population (Reference HaugaardHaugaard 1998; Reference FisherFisher 2003; Reference Merdinger, Hines and OsterlingMerdinger 2005; Reference Juffer and van IjzendoornJuffer 2007). The concept of resilience is used to explain why individuals manage to function competently despite living or having lived in adversity. Research into resilience has demonstrated that the ability to overcome adversity is not something extraordinary found in a few people, but is a common consequence of basic human adaptive systems, the functioning of which can be jeopardised by multiple stressors (Reference MastenMasten 2001).

A study of Romanian orphans has provided evidence for a catch-up in the cognitive and social development of children who move from an extremely neglectful to a supportive environment (Reference RutterRutter 1998). A review of UK outcome studies concluded that children who were adopted from or looked after by the English care system generally demonstrated improvements in their emotional and behavioural presentation over time, despite entering their placements with significant difficulties (Reference Forrester, Goodman and CockerForrester 2009).

Reference SteinStein (2005) reviewed studies of care leavers and suggested that they fall into three groups: those who were ‘moving on’ successfully, who had gained resilience through their experiences in and after care; those who had experienced more disruption and instability in the care system, but nevertheless viewed themselves as survivors and were able to make use of support networks on leaving care; and those whose damaging pre-care experiences and associated behavioural difficulties had led to and were compounded by disrupted placements in care and education, whose life chances appeared bleak. Quality of care experience, positive (gradual) transition and after-care support were key factors in resilient outcomes. In line with the ‘recovery approach’, clinicians can promote the resilience of individuals affected by public care or adoption through therapeutic interventions aimed at enhancing their self-efficacy, improving their problem-solving skills and helping them to find a niche where they can develop their potential (Reference MastenMasten 2001; HM Government 2011).