In the first controlled follow-up study ever to examine the long-term health effects of foster care programs, researchers from Harvard Medical School showed that the extremely high rates of mental and physical disorders typically found among adult alumni of public foster care programs were significantly reduced among alumni of a private foster care program staffed by highly trained social workers with low caseloads and good access to quality services.
The study followed 659 foster care alumni into adulthood more than a decade after they left foster care. To make the comparisons meaningful, a control group of state-run public system alumni was created consisting exclusively of those eligible for, but not selected for, the private program because of limited openings. The most dramatic differences were approximately 50 percent reductions in rates of adult major depression and substance use disorders among private program alumni compared to the control group of public program alumni.
According to Ronald Kessler, Professor of Health Care Policy at Harvard Medical School and lead author on the study, "Concerns have been raised by many child welfare advocates that the $24 billon per year US child welfare system is at a crossroads for reform. The system has expanded dramatically in the past two decades, with nearly 800,000 children currently in foster care each year, more than 1 percent of all US children, over twice the number served two decades ago."
Calls for system redesign to improve care have resulted in a number of public and private agencies developing foster care programs that offer higher quality services, lower caseloads, and higher salaries for workers. Until now, however, researchers have never systematically evaluated whether these program quality improvements make a difference to youth outcomes. "The results of this study show clearly that they make an enormous difference," says Kessler.
The study was carried out among alumni of foster care programs in the states of Oregon and Washington in collaboration with state agencies in Oregon (i.e., the Department of Human Services; Children, Adults and Families; Community Human Services) and Washington (i.e., the Department of Social and Health Services, Children's Administration, Division of Children and Family Services) and Casey Family Programs (a private operating foundation providing foster care services).
Case record files were used to select adolescents (14 to18 years of age) who were in either the public or private programs in Oregon and Washington between 1988 and 1998. Over 80 percent of alumni were traced up to 13 years after leaving care and 92.2 percent of those traced were interviewed. Post hoc matching of public program alumni to private program alumni, and of follow-up survey respondents to non-respondents was done based on information abstracted from case record files.
Although there were many similarities in program experience and alumni outcomes, significant differences were found in key areas. Alumni from the program with enhanced services:
- Had significantly more stable placements in terms of mean duration of placement than public program alumni--both in Oregon (32.7 vs. 13.3 months) and Washington (26.4 vs. 19.2 months).
- Were substantially less likely to experience adverse events such as a reunification failure during comparable periods of time in foster care.
- Were also at consistently lower risk of foster parent neglect, physical abuse, and sexual abuse.
The study team also found that alumni from the program with enhanced services had significantly better outcomes than alumni from the other programs in all measures of mental health and in some, but not all, measures of physical health. Specifically, after adjusting for several program differences, alumni from the higher quality program had a significantly lower 12-month prevalence than alumni from the other programs in all three classes of mental disorder studied, including major depression (11.3 percent vs. 24.3 percent), anxiety disorders (28.8 percent vs. 43.0 percent), and substance use disorders (5.1 percent vs. 11.1 percent). In addition:
- When combined across classes of mental disorders, alumni from the program with enhanced services had 44.7 percent fewer 12-month disorders per 100 respondents than alumni from the other programs.
- Alumni from the program with enhanced services also had a significantly lower 12-month prevalence of ulcers (7.4 percent vs. 13.0 percent) and cardio metabolic conditions (including diabetes, hypertension, or heart disease: 14.9 percent vs. 22.6 percent)
"These findings provide a wake-up call for the nation that the well-being of hundreds of thousands of our most vulnerable children needs to become a national priority," said Dr. Carol Spigner, Kenneth L.M. Pray Professor in the School of Social Policy & Practice at the University of Pennsylvania. "These children enter the child welfare system through no fault of their own because of traumatic family circumstances. We have a responsibility as a nation to provide them with high-quality services to help them succeed in life."
"We shortchange children in foster care when we deny them the essential services that ultimately would enable them to function in society as adults," said Dr. Carl Bell, President and C.E.O. of the Community Mental Health Council in Chicago. "This research deepens our understanding of the direct connection between investments and results. When our child welfare systems fail to provide resources at an early age, we miss opportunities to change individual lives and society pays health and mental health costs that we have the power to prevent."
Bob Butterworth, Secretary of the Florida Department of Children and Families, added: "This study shows the tremendous benefits possible for the children and families we serve if we can improve the care we give them. The best way to do this in the face of flat budgets might be to reduce the number of children in care and reinvest those savings into improving programs for the children who remain in care."
- Ronald C. Kessler, Ph.D., Peter J. Pecora, Ph.D., Jason Williams, M.S., Eva Hiripi, M.A., Kirk O'Brien, Ph.D., Diana English, Ph.D., James White, Ph.D., Richard Zerbe, Ph.D., A. Chris Downs, Ph.D., Robert Plotnick, Ph.D., Irving Hwang, M.A., Nancy A. Sampson, B.S. Effects of Enhanced Foster Care on the Long-Term Physical and Mental Health of Foster Care Alumni. Archives of General Psychiatry, Vol. 65: No. 6, June 2008
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