Young people leaving state out-of-home care are among the most disadvantaged and vulnerable young Australians (Mendes, Johnson, & Moslehuddin, Reference Mendes, Johnson and Moslehuddin2011; Stein, Reference Stein2012). Compared to their counterparts in the general population, care leavers experience higher rates of substance abuse problems, homelessness, criminal justice system involvement and early parenthood (Courtney et al., Reference Courtney, Dworsky, Brown, Cary, Love and Vorhies2011; Mendes et al., Reference Mendes, Johnson and Moslehuddin2011; Stein, Reference Stein2012). While many children and young people placed in out-of-home care fare well, a substantial proportion experience mental health issues (Blower, Addo, Hodgson, & Lamington, Reference Blower, Addo, Hodgson and Lamington2004; Ford, Vostanis, Meltzer, & Goodman, Reference Ford, Vostanis, Meltzer and Goodman2007; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Oswald, Heil, & Goldbeck, Reference Oswald, Heil and Goldbeck2010). The purpose of this article is to review the available literature relating to mental health of young people leaving care. The review adopts a broad definition of ‘mental health issues’ or ‘problems’, encompassing not just the presence of specific psychiatric diagnoses among care leavers, but also other mental health, emotional and behavioural issues, which may not have been formally diagnosed, or do not meet diagnostic criteria for a specific disorder. This more holistic approach towards mental health accords with the Victorian Chief Psychiatrist's guideline that mental health service access for the out-of-home care group should not be governed by a requirement of meeting specific diagnostic criteria (Department of Health, 2011). It also reflects the complex nature of mental health symptomatology sometimes seen among care leavers, which may be less suitably captured by traditional diagnostic criteria (Tarren-Sweeney & Vetere, Reference Tarren-Sweeney and Vetere2013). In contrast, the term ‘mental health conditions’ refers to specific diagnoses of mental illness among young people in and leaving care.
Mental Health of Out-of-home Care Populations
Local and international research indicates that children and older adolescents in state care experience mental health issues at higher rates than young people in the general community, including the most socio-economically disadvantaged households (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Pecora, White, Jackson, & Wiggins, Reference Pecora, White, Jackson and Wiggins2009; Pilowsky & Wu, Reference Pilowsky and Wu2006; Sawyer, Carbone, Searle, & Robinson, Reference Sawyer, Carbone, Searle and Robinson2007; Stein & Dumaret, Reference Stein and Dumaret2011; Tarren-Sweeney, Reference Tarren-Sweeney2008b). For example, a South Australian study of 414 children and adolescents in foster care found that the prevalence of mental health issues was two to five times higher than that of the general population (Sawyer et al., Reference Sawyer, Carbone, Searle and Robinson2007). In New South Wales, Tarren-Sweeney and Hazell (Reference Tarren-Sweeney and Hazell2006, pp. 92–93) reported that children in kinship and foster care had ‘exceptionally poor mental health and social competence relative to normative and in-care samples’. It is important to also note that studies often exclude residential care and other out-of-home care populations known to experience an even higher prevalence of mental health issues (for example, young people who are in psychiatric, secure welfare or youth justice facilities) (Akister, Owens, & Goodyer, Reference Akister, Owens and Goodyer2010; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Tarren-Sweeney, Reference Tarren-Sweeney2008a); and therefore may underestimate the overall prevalence of mental health issues. For example, a 2006 survey of 342 young people in residential care in Victoria found that 65 per cent had results indicating an abnormal risk of a diagnosable mental health disorder (Department of Education and Early Childhood Development, 2008).
Mental health conditions commonly diagnosed among adolescent out-of-home care populations include depression, anxiety, post-traumatic stress disorder, conduct disorder, oppositional defiant disorder and attention deficit hyperactivity disorder (ADHD) (Department of Human Services, 2002; Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Sawyer et al., Reference Sawyer, Carbone, Searle and Robinson2007). Furthermore, significant minorities of young people in care experience co-occurring mental health conditions (Fechter-Leggett & O’Brien, Reference Fechter-Leggett and O‘Brien2010; McCann, James, Wilson, & Dunn, Reference McCann, James, Wilson and Dunn1996; Pecora et al., Reference Pecora, White, Jackson and Wiggins2009). Mental health conditions remain prevalent in older adolescents in care; for example, McMillen et al. (Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005) determined that 37 per cent of 17-year-olds in foster care met the diagnostic criteria for a psychiatric disorder in the previous year. While studies have often investigated prevalence or risk of mental health conditions, as Ford et al. (Reference Ford, Vostanis, Meltzer and Goodman2007, p. 323) point out, ‘good psychological adjustment is more than the absence of a psychiatric disorder’. Their UK study of 1453 children and young people found that less than 10 per cent of 17-year-old care leavers demonstrated good psychological adjustment, compared to around 50 per cent of the general population (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007).
The greater presence of mental health issues seen in out-of-home care populations is understood to arise from complex interactions between genetics, prenatal conditions, pre-care and in-care experiences (McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Pecora et al., Reference Pecora, White, Jackson and Wiggins2009; Tarren-Sweeney & Vetere, Reference Tarren-Sweeney and Vetere2013). In particular, there is significant evidence linking adverse childhood events (including experiences of abuse and neglect) to specific mental health conditions, such as depression, post-traumatic stress disorder and personality disorder (Gilbert et al., Reference Gilbert, Widom, Browne, Fergusson, Webb and Janson2009). Although research examining the association between mental health issues and different maltreatment type(s), severities and at various developmental stages is still ongoing, it is understood that exposure to early and chronic stress impacts on various aspects of brain development, including structure and function, places victims at greater vulnerability for the development of mental health issues (Glaser, Reference Glaser2000; Heima & Nemeroffa, Reference Heima and Nemeroffa2001).
Tarren-Sweeney (Reference Tarren-Sweeney2008a) stresses the need to understand the differences as well as the similarities between children who have been maltreated, and those who are maltreated and later placed in care. The author argues that ‘a number of uncommon developmental events’ (Tarren-Sweeney, Reference Tarren-Sweeney2008a, p. 346) experienced by children in care, including the loss of biological parents, integration into new placements and potential placement instability, should also be taken into account in developmental psychopathology models, rather than focusing solely on experiences of abuse and neglect.
Aside from the presence and extent of child maltreatment, a number of factors associated with mental health outcomes in children and young people placed in care have been identified. Children and young people who enter care later and/or who have experienced greater maltreatment (for example, more prolonged or multiple forms of maltreatment), have been found to have a greater likelihood of experiencing mental health issues (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007; Hukkanen, Sourander, Bergroth, & Piha, Reference Hukkanen, Sourander, Bergroth and Piha1999; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Tarren-Sweeney, Reference Tarren-Sweeney2008b). Tarren-Sweeney (Reference Tarren-Sweeney2008b, p. 2) suggests that this finding ‘supports a cumulative risk model of developmental pathology wherein the more exposure to pre-care adversity, the greater the likelihood of mental health problems’. Children and young people who have been placed in care for behavioural reasons (e.g., delinquency or substance abuse) have been found to have poorer mental health outcomes than those placed due to abuse and neglect (Vinnerljung & Sallnäs, Reference Vinnerljung and Sallnäs2008); however, this does not preclude the possibility that such young people have also experienced adverse childhood events. Additionally, children and young people who experience lower placement stability (Barth et al., Reference Barth, Lloyd, Green, James, Leslie and Landsverk2007; Fechter-Leggett & O’Brien, Reference Fechter-Leggett and O‘Brien2010; Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007; Fowler, Toro, & Miles, Reference Fowler, Toro and Miles2011), those who experience residential care placements (Akister et al., Reference Akister, Owens and Goodyer2010; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005; Tarren-Sweeney, Reference Tarren-Sweeney2008a) and young people exposed to maltreatment in care (Fechter-Leggett & O’Brien, Reference Fechter-Leggett and O‘Brien2010) are also more likely to experience mental health issues. It is important to note that these are not necessarily causative factors, rather that they are likely to be inter-related and reinforcing in relation to their impact on mental health. Studies have also found that social support (including the quality of relationships with biological parents) impacts upon the mental health of young people in care (Hukkanen et al., Reference Hukkanen, Sourander, Bergroth and Piha1999; Salazar, Keller, & Courtney, Reference Salazar, Keller and Courtney2011). Additionally, other socio-demographic factors associated with mental health issues in young people in out-of-home care include parental mental illness (Fechter-Leggett & O’Brien, Reference Fechter-Leggett and O‘Brien2010) and the presence of learning disabilities (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007; Hukkanen et al., Reference Hukkanen, Sourander, Bergroth and Piha1999; Taggart, Cousins, & Milner, Reference Taggart, Cousins and Milner2007). Finally, both gender and age appear to be related to the prevalence and type of mental health conditions experienced (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007; Hukkanen et al., Reference Hukkanen, Sourander, Bergroth and Piha1999; McMillen et al., Reference McMillen, Zima, Scott, Auslander, Munson, Ollie and Spitznagel2005); for example, research from the UK (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007) identified that older children in care were more likely to have anxiety disorders, post-traumatic stress disorder, depression and conduct disorder, while younger children were more likely to have oppositional defiant disorder, hyperkinetic disorder and separation anxiety disorder. This same research found that girls were more likely to have post-traumatic stress disorder, while boys were more likely to be diagnosed with hyperkinetic disorder, and conduct or oppositional defiant disorder (Ford et al., Reference Ford, Vostanis, Meltzer and Goodman2007).
Leaving Care and Mental Health
The majority of research examining the mental health of children and young people from state care backgrounds has focused on those in care (Dixon, Reference Dixon2008; Stein & Dumaret, Reference Stein and Dumaret2011). Studies concerning the mental health of care leavers indicate that prevalence rates of mental health issues within this group continue to be greater than those in the general population, and that comorbidity in mental health conditions remains a feature (Courtney & Dworsky, Reference Courtney and Dworsky2006; Pecora et al., Reference Pecora, White, Jackson and Wiggins2009). Large-scale US studies have found high rates of post-traumatic stress disorder among care leavers, which are comparable to, or exceed, the rates found among war veterans (Pecora et al., Reference Pecora, White, Jackson and Wiggins2009; Salazar, Keller, Gowen, & Courtney, Reference Salazar, Keller, Gowen and Courtney2013). Unfortunately, there is a dearth of research employing standardised instruments to examine the mental health of representative samples of Australian care leavers. In a study of 60 care leavers in Victoria, 32 per cent reported having a mental health condition, though this is likely to be an underestimate, given that the authors reported separately on certain conditions, including ADHD (Raman, Inder, & Forbes, Reference Raman, Inder and Forbes2005). Two UK studies found that approximately 40–44 per cent of care leavers in Scotland and England had mental health issues, including emotional and behavioural difficulties (Dixon, Wade, Byford, Weatherley, & Lee, Reference Dixon, Wade, Byford, Weatherley and Lee2006; Stein & Dixon, Reference Stein and Dixon2006).
There is some evidence to suggest that mental health issues may be more prevalent among young people who have recently left care compared to young people still in care (Dixon, Reference Dixon2008; Dixon & Stein, Reference Dixon and Stein2005; Pecora et al., Reference Pecora, White, Jackson and Wiggins2009; Stein & Dumaret, Reference Stein and Dumaret2011). In a representative sample of 106 care leavers in England, Dixon (Reference Dixon2008) found that the proportion self-reporting mental health issues had doubled (from 12% at baseline to 24% at follow-up) a year after the transition from care. This is understandable given that the transition from care can constitute a highly stressful time for young people. Such a non-normative, compressed and accelerated transition during a highly significant developmental period will both be impacted by, and may exacerbate, pre-existing mental, emotional and behavioural problems (Akister et al., Reference Akister, Owens and Goodyer2010; Dixon, Reference Dixon2008; Gonzalez, Cameron, & Klendo, Reference Gonzalez, Cameron and Klendo2012; Hannon, Wood, & Bazalgette, Reference Hannon, Wood and Bazalgette2010; Pecora et al., Reference Pecora, White, Jackson and Wiggins2009). From a trauma-informed perspective, poorly planned and inadequately supported transitions from care may be re-traumatising, representing a final experience of rejection and abandonment from a system upon which care leavers are dependent (Baidawi, Mendes, & Snow, Reference Baidawi, Mendes and Snow2014; Gonzalez et al., Reference Gonzalez, Cameron and Klendo2012). In addition to these factors, adolescence and young adulthood represent high-risk developmental periods for emerging mental health issues, a fact which may also partly explain these findings (Patel, Flisher, Hetrick, & McGorry, Reference Patel, Flisher, Hetrick and McGorry2007).
It appears that mental health and associated emotional and behavioural support needs are often neglected during the transition from care, which tends to focus on immediate and practical needs, such as housing, education and training (Akister et al., Reference Akister, Owens and Goodyer2010; McDowall, Reference McDowall2009). Various leaving care researchers have argued there is a need to prioritise emotional and mental health support for care leavers, given the high proportion of this population experiencing problems in this area, and their corresponding risk of poor outcomes (Broad, Reference Broad2005; Hannon et al., Reference Hannon, Wood and Bazalgette2010; Stein, Reference Stein2008).
There is little research concerning the uptake of mental health services by Australian care leavers, and the available studies generally consist of unrepresentative samples. One Australia-wide survey of care leavers found that 38 per cent had accessed counselling in the previous 6 months (McDowall 2008). In Victoria, Forbes, Inder and Raman (Reference Forbes, Inder and Raman2006) found that 50 per cent of care leavers had accessed mental health services in the previous six months, a rate approximately seven times the general population. Interestingly, this study found that young people who participated in leaving care services accessed mental health services on a less frequent basis than young people who did not participate in leaving care services. Future research should examine any differences in mental health between care leavers accessing and not accessing leaving care supports, in order to determine if those with mental health issues are adequately supported by current systems. Additionally, differences between access to mental health services while in care and following the transition from care should be investigated. While studies from the US have found that access to mental health supports decreased post-care, the findings cannot be generalised to Australia (Courtney & Dworsky, Reference Courtney and Dworsky2006).
Good leaving care preparation, suitable post-care accommodation, social support and life skills are associated with positive wellbeing post-care (Cashmore & Paxman, Reference Cashmore and Paxman2006; Dixon, Reference Dixon2008; Fechter-Leggett & O’Brien, Reference Fechter-Leggett and O‘Brien2010; Jones et al., Reference Jones, Everson-Hock, Papaioannou, Guillaume, Goyder, Chilcott and Swann2011). However, it remains unclear whether such factors contribute to wellbeing, or if those care leavers experiencing greater wellbeing are more able to access such supports and resources. Nonetheless, it is evident that care leavers with mental health, emotional and behavioural issues, in addition to having the most unstable in-care experiences (Fechter-Leggett & O’Brien, Reference Fechter-Leggett and O‘Brien2010; Fowler et al., Reference Fowler, Toro and Miles2011; Hannon et al., Reference Hannon, Wood and Bazalgette2010), tend to be vulnerable to poor post-care outcomes, particularly homelessness and lower engagement in education and employment (Brown & Wilderson, Reference Brown and Wilderson2010; Dixon, Reference Dixon2008; Dixon et al., Reference Dixon, Wade, Byford, Weatherley and Lee2006; Dumaret, Donati, & Crost, Reference Dumaret, Donati and Crost2011; Fowler et al., Reference Fowler, Toro and Miles2011; Keller, Cusick, & Courtney, Reference Keller, Cusick and Courtney2007; Stein, Reference Stein2006; White et al., Reference White, Gallegos, O’Brien, Weisberg, Pecora and Medina2011). Such findings are reflected in studies that have attempted to capture the heterogeneity of care leavers’ experiences by describing various types or classes of care leavers. Despite the differences across these studies, each identified a particular subgroup of care leavers with the most disrupted care experiences, the highest prevalence of mental health conditions, significant social isolation and the worst post-care outcomes (Fowler et al., Reference Fowler, Toro and Miles2011; Keller et al., Reference Keller, Cusick and Courtney2007; Stein, Reference Stein2006).
Discussion and Implications
Australia's Fourth National Mental Health Plan (Commonwealth of Australia, 2009) has identified children and young people who have experienced trauma as a key priority group for prevention and early intervention. However, as this review demonstrates, robust evidence concerning the mental health needs and service utilisation of care leavers is absent in the Australian context. This is a troubling oversight, particularly given the potential for worsening mental health during the transition from care, as well as the association between mental health and post-care outcomes. Additionally, various mental health conditions are only diagnosable, or may only emerge, beyond 18 years of age; therefore, reliance on data obtained from younger adolescents in care to understand these issues is inadequate.
One of the key factors underlying the lack of research evidence in this area is the relative invisibility of care leavers. First, there is absence of a systematic approach for tracking care leavers and monitoring outcomes in Australia (Cashmore & Mendes, Reference Cashmore, Mendes, Stein and Munro2008). This results in a reliance on costly discrete studies, often containing relatively small and unrepresentative samples of care leavers, in order to obtain data concerning post-care outcomes. In contrast, in England the government is extending national outcomes data for care leavers until the age of 21 years, an approach that we recommend Australia follows (HM Government, 2013). With respect to mental health, the limited availability of specialist services or programmes targeting the needs of the out-of-home care and leaving care populations may also result in children and young people in and leaving out-of-home care being relatively invisible within mental health research and practice (Tarren-Sweeney & Vetere, Reference Tarren-Sweeney and Vetere2013).
This review has implications for research, policy and practice in both the out-of-home care and mental health fields. There is a clear argument for more comprehensive research examining the mental health of care leavers in Australia, particularly in order to inform leaving care and post-care service provision. It is not possible to design or provide services to respond therapeutically to the needs of care leavers if these needs are unclear. At the same time, proponents of trauma-informed approaches to care and human service delivery question the utility of traditional mental health diagnoses in relation to survivors of complex developmental trauma (Bloom & Farragher, Reference Bloom and Farragher2011; Kezelman & Stavropoulos, Reference Kezelman and Stavropoulos2012; Tarren-Sweeney, Reference Tarren-Sweeney2008a; Tarren-Sweeney & Vetere, Reference Tarren-Sweeney and Vetere2013). Rather, these researchers assert that a trauma-informed approach to care and practice moves away from prioritising the search for traditional diagnoses, and instead seeks to understand and address holistically the impact of complex trauma and attachment-related difficulties (Kezelman & Stavropoulos, Reference Kezelman and Stavropoulos2012; Tarren-Sweeney & Vetere, Reference Tarren-Sweeney and Vetere2013). Research that examines the mental health needs of care leavers in Australia, as well as mental health service utilisation (including the identification of good practice in service design and therapeutic interventions), would be beneficial from the perspectives of both mental health and leaving care services.
Stemming from such research, there is a subsequent need for the National Child Protection Framework to establish post-care benchmarks on mental health against which outcomes can be compared. To be sure, the Commonwealth government introduced national out-of-home care standards in December 2010 requiring the development of a detailed support plan covering key areas such as housing, health and financial security for all young people transitioning from out-of-home care. The standards specifically refer to the need to provide additional services to better address the mental health needs of children and young people in, and transitioning from, out-of-home care (Department of Families, Housing, Community Services and Indigenous Affairs, 2012); however, these mental health supports are only prescribed up to 18 years of age. Outcomes data and benchmarking would enable development and evaluation of policies and practices that can best meet the mental health needs of care leavers.
Overall, the evidence demonstrates that a substantial proportion of young people transitioning from care will experience significant mental health, emotional and behavioural issues. Such problems may be exacerbated by the stress of the premature transition to independence, but also impact on care leavers’ capacity to negotiate the everyday tasks expected of them. Trauma-informed leaving care systems would have the capacity to respond to the individual needs of care leavers, including the capacity to delay the transition from care or to provide a safety net, enabling access to supports at a later period if required (Gonzalez et al., Reference Gonzalez, Cameron and Klendo2012; Mendes et al., Reference Mendes, Johnson and Moslehuddin2011). In light of current understanding regarding the mental health of care leavers, these systems should afford, at a minimum, access to resources – in terms of both capacity and expertise – to meet the needs of those care leavers who may present with complex mental health issues.
