Childhood abuse and neglect can have a pernicious impact on mental health
later in life, a large volume of research has found. Moreover, a high rate of
child abuse and neglect in the United States has contributed, in part, to the
large number of youth in foster care.
Yet investigators do not appear to have conducted a controlled study on the
impact of foster care on the long-term mental health of abused or neglected
youngsters, Ronald Kessler, Ph.D., a professor of health care policy at
Harvard Medical School, and his colleagues found. So they decided to take on
the challenge themselves. (Kessler also headed the National Comorbidity Survey
Replication, which was published in 2005.)
They compared the mental health outcomes of 368 adults who had received
care as adolescents in two public-sector foster-care programs with the
outcomes of 111 adults who had received care as adolescents in a private
foster-care program called the Casey program. All subjects had been placed in
foster care primarily because of maltreatment, and all had been out of care
from one to 13 years at the time of the study.
The Casey program had provided not only more highly trained personnel and
more intense services than the public programs, but also additional funds to
foster parents and even postsecondary job training or a full college education
to all participants. Turnover of foster parents and case-workers had also been
substantially lower in the Casey program than in the public ones, resulting in
more stability for participants.
Not unexpectedly, the Casey alumni seemed to have better mental health than
public-program alumni. Specifically, in the year prior to the study, the Casey
alumni had experienced significantly less anxiety, significantly less major
depression, and significantly fewer substance-use disorders than the
public-program alumni. Casey alumni also seemed to have better physical
health—they had experienced significantly fewer ulcers and significantly
less diabetes, high blood pressure, and heart
"Public-sector investment in higher-quality foster-care services
could substantially improve the long-term mental and physical health of
foster-care alumni," Kessler and his team reported in the June
Archives of General Psychiatry.
However, before states invest in a Casey-model foster-care program, the
investigators cautioned, more analysis is needed "because we are not
sure that all of the more costly elements of the Casey package of services
contribute[d] to the greater effectiveness of the Casey program."
Also, states might want to include cognitive-behavioral therapy (CBT) in a
model foster-care program, the investigators proposed, since "CBT
designed specifically to treat the emotional scars of child abuse and
trauma" was not available in the Casey program, but has since been
developed. And states should also explore other private foster-care programs
besides the Casey one before deciding on a model foster-care program, the
researchers advised, since there are many throughout the United States.
In an accompanying editorial, Charles Nemeroff, M.D., chair of psychiatry
at Emory University, also made a novel suggestion—that researchers
should examine whether optimal foster care can improve the mental health of
maltreated youngsters who possess the SS variant of the serotonin gene. Past
research has shown that the SS variant, when combined with child abuse,
confers a particularly heightened vulnerability to depression, but
psychosocial support can reduce the risk.
The study was funded by an unrestricted grant from the Casey Family
Programs as well as by the states of Oregon and Washington, which is where the
foster-care programs that were studied were located.
An abstract of "Effects of Enhanced Foster Care on the
Long-Term Physical and Mental Health of Foster Care Alumni" is posted at