Retrospective and Concurrent Predictors of The Mental Health of Children in Care

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Children and Youth Services Review 30 (2008) 1 25

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Retrospective and concurrent predictors of the mental

health of children in care
Michael Tarren-Sweeney
School of Educational Studies and Human Development, University of Canterbury,
Private Bag 4800, Christchurch 8140, New Zealand
Centre for Brain and Mental Health Research, University of Newcastle, Australia
Received 9 April 2007; received in revised form 24 May 2007; accepted 26 May 2007
Available online 22 June 2007
Abstract
The paper reports retrospective and concurrent predictors of baseline mental health estimates for 347
children recruited to an epidemiological study of children in foster and kinship care in New South Wales,
Australia. The study design addresses limitations of previous risk-related research with this population. While
a large number of potential risk and protective factors were associated with children's mental health, most
were confounded. Predictors identified in two-stage hierarchical regression models accounted for 0.31 of the
variance of continuous mental health scores. The key predictors were: age at entry into care; developmental
difficulties (intellectual disability and reading problems); three specific types of maltreatment; recent adverse
events; and factors referring to placement insecurity or lack of permanence. Mechanisms accounting for these
findings are proposed, with particular reference to cumulative exposure to adversity, attachment theory and
foster care practices. Implications for social care policy include the need to identify children who are in need of
care at younger ages, and the harmful effects of perceived impermanence for children in long-term care.
2007 Elsevier Ltd. All rights reserved.
Keywords: Out-of-home care; Foster care; Kinship care; Mental health predictors; Developmental psychopathology;
Social care policy; Placement security; Permanency planning
1. Introduction
Children residing in alternate (or out-of-home) care manifest exceptional frequency and
severity of emotional and behavioral difficulties (EUROARC, 1998; Heflinger, Simpkins, &
Combs-Orme, 2000). Indeed, the scale of these difficulties more closely resembles that of clinic Tel.: +64 3 3642987x7196; fax: +64 3 3642418.
E-mail address: Michael.Tarren-Sweeney@canterbury.ac.nz.
0190-7409/$ - see front matter 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.childyouth.2007.05.014
M. Tarren-Sweeney / Children and Youth Services Review 30 (2008) 125
referred children, than of children at large (Tarren-Sweeney & Hazell, 2006). The mechanisms that
determine developmental change and resilience among children in care are not well understood.
Information about other high-risk groups suggests they include complex, time-sensitive
interactions between genotype, pre-natal conditions, pre-care and in-care psychosocial
conditions and events, and early neurological development (Rutter, 2000). But, developmental
psychopathology models pertaining to maltreated children (Cicchetti, Toth, & Maughan, 2000)
and profoundly deprived inter-country adoptees (O'Connor, Bredenkamp, Rutter, & the English
and Romanian Adoptees Study Team, 1999; Zeanah, Boris, & Larrieu, 1997) are only partially
valid for children in care, since there is convergence and divergence of their respective
developmental pathways. Certainly however, the attachment experiences of children in care are
likely to have profound effects on their development, and especially their mental health (Cicchetti
et al., 2000; Fonagy, 2003; O'Connor & Rutter, 2000). Children in care are at very high risk of
attachment insecurity (Marcus, 1991) and of attachment disturbances (Minnis, Everett, Pelosi,
Dunn, & Knapp, 2006), given their common experience of emotional deprivation, loss, and
inconsistent caregiving. Attachment theory also predicts that the therapeutic potential of alternate
care should vary according to: 1. the characteristics of children's attachment systems at entry into
care; and 2. carer sensitivity and ability to provide a secure base (Bowlby, 1988; Schofield, 2002).
The few studies that have identified correlates and predictors of mental health problems among
children in care have largely been compromised by methodological limitations (Taussig, 2002),
specifically: lack of retrospective and/or prospective design (most are cross-sectional surveys);
small sample size; problems with sample retention; limited scope of mental health outcomes
(failure to measure problems that are specific to high-risk populations); inadequate measurement
of pre-care risk exposure; and failure to control for confounding. Despite the significance of these
children's attachment experiences, risk studies have typically aggregated mental health outcomes
without reference to their developmental histories. It is premature to identify the effects of foster
care from such aggregated data, even where changes are measured prospectively.
Among other purposes, the Children in Care Study (CICS) was designed to address some of these
limitations, with a view to identifying prospective, concurrent and retrospective predictors of mental
health. The CICS is a prospective, epidemiological study of the mental health of children in courtordered foster and kinship care in New South Wales (NSW), Australia, and of associated study factors.
The present paper identifies retrospective and concurrent predictors of children's baseline mental
health problems, from a large number of associated study factors, and proposes some likely
developmental mechanisms. Prospective predictors will be identified in a forthcoming follow-up study.
1.1. Background to alternate care in NSW
In the decade 19962006, the number of children residing in alternate care in NSW rose from about
5500 to almost 10,000 (82% increase) (Australian Institute of Health and Welfare, 2007). In that
period, the rate of NSW children residing in care rose from 3.4 to 6.2 per 1000 children. The equivalent
rate for NSW indigenous children in 2006 was 44.7 per 1000 children. Almost all pre-adolescent
children who enter court-ordered care do so following maltreatment (abuse and/or neglect) by their
parents, or because of parental inability to protect them from maltreatment. In the early 1990s the
state's large residential care facilities were closed as part of a reform of alternate care services. At the
time of the present study (20002003), less than 5% of placements were in non-family type settings
(Australian Institute of Health and Welfare, 2004). Conversely, kinship care has expanded in NSW to
the point where it is now the predominant form of alternate care (56% of all placements) (Australian
Institute of Health and Welfare, 2007). There are two distinct kinship care systems in NSW,
demarcated by custody (or parental responsibility) rights. The Children's Court may assign such
rights to kin, with the child welfare department (Department of Community Services DOCS)
providing backup support. Alternatively, custody may be assigned to DOCS, with kinship carers
having similar legal status to foster carers. Until recently, permanency planning in NSW lacked
legislative support. Adoption by foster and kinship carers is uncommon for children under 12, given
difficulties of gaining parental consent and running contested cases in the state's Supreme Court.
However, NSW made some progress in this direction, with introduction of permanency provisions to
the Children's Act in 2001.
2. Methods
The CICS baseline survey (20002003) involved collection of carer-reported mental health
estimates of children in care, as well as concurrent and retrospective measures of potential risk
and protective factors. Data were collected from a mail-out carer questionnaire, and from the
DOCS child welfare and alternate care database (the Client Information System CIS). Children
were not active participants in the survey. Special steps were taken to assure caregivers that the
child welfare agency did not know the identity of participants and non-participants.
2.1. Sampling procedure
The sampling frame for the CICS cohort was all four to nine year-old children residing in
court-ordered foster or kinship care in NSW, under the guardianship of the Minister for the
DOCS, and for whom casework responsibility rested with DOCS. The sampling frame was
differentiated from children residing in temporary care without a court order, and from children
with custody orders whose parents retained guardianship rights. The study was initially designed
to include the latter group, which would have required the consent of their birth parents. A pilot
study indicated that this was not feasible, as birth parents could not be reliably located. The
sampling frame excluded children in the care of private fostering agencies, because it was not
practical to enter into separate research agreements with each agency. A 100% sampling
procedure was employed, with the proviso that carers contact details could be confirmed via either
the electoral roll or a telephone listing. This was necessary because piloting had revealed that
carer details were not regularly updated on the CIS. Delays between drawing up the sampling
frame and completion of survey materials saw some children recruited at ages 10 and 11.
2.2. Outcome measures
Children's baseline mental health, socialization and self-esteem were estimated from carer-report
responses on the Child Behavior Checklist (CBCL) and the Assessment Checklist for Children
(ACC). These were incorporated in the mail-out survey questionnaire sent to participant carers. The
reliability of foster parent reports of children's problems remains somewhat uncertain, although there
is evidence that in respect of children in long-term care, foster parents are at least as reliable as
parents (Tarren-Sweeney, Hazell, & Carr, 2004). The CBCL measures child problem behavior across
eight empirically-derived clinical sub-scales, with two higher order scales approximating
spectrums of depressive/anxious symptoms (internalizing) and disruptive behavioral symptoms
(externalizing) (Achenbach, 1991; Achenbach & Rescorla, 2001). It was selected because of its
demonstrated validity and reliability (Doll, 1998), and the availability of comparative data for highrisk populations (Armsden, Pecora, Payne, & Szatkiewicz, 2000; Heflinger et al., 2000).
The ACC is a 120-item carer-report psychiatric rating scale, measuring behaviors, emotional
states, traits, and manners of relating to others, as manifested by children in care (Tarren-Sweeney,
2007). It was developed for the CICS to measure a range of problems not adequately covered by
other standardized instruments. The ACC includes 10 empirically-derived clinical scales, termed:
sexual behavior; pseudomature interpersonal behavior; non-reciprocal interpersonal behavior;
indiscriminate interpersonal behavior; insecure; anxiousdistrustful; abnormal pain response;
food maintenance; self-injury; and suicide discourse. Initial data indicate the ACC has good
content, construct and factorial validity, as well as internal reliability, matching or exceeding that
of other standardized checklists (Tarren-Sweeney, 2007).
2.3. Study factors
A large number of potential risk and protective factors were measured retrospectively and
concurrently in the baseline survey. Factors pertaining to children's development, education and
present status (e.g. type and makeup of present placement, recent life events) were measured from
a carer questionnaire. Historical data (e.g. maltreatment history, care history, and birth family
factors) were measured retrospectively from the CIS. Since historical events were mostly
recorded on the CIS shortly after they occurred, these data are thought to be more reliable than
those typically obtained in a retrospective design. Essentially, the study sought to measure every
factor that might be reliably obtained from the two data sources, and which might have some
influence on children's mental health. The accessibility and reliability of study factors were
examined in a 1997 pilot study, with some variables being discarded from the main study. A
summary of study factors measured in the baseline survey is listed by data source in Table 1.
Prospective exposure will be measured in the forthcoming follow-up study.
2.4. Classification of maltreatment
Maltreatment was coded using a modification of the U.S. National Center on Child Abuse and
Neglect's (NCCAN) Harm Standard (Sedlak & Broadhurst, 1996). The harm standard was
modified to account for the operationalization of maltreatment by the DOCS child protection
service. In most instances, NSW codes were readily translated (e.g. attempted strangulation
translates to physical assault). However, some were ambiguous. For example, other physical
abuse might translate to either physical assault or close confinement, while exposure to/used
for pornography can refer to quite different events. There was no classification for educational
neglect, possibly because school attendance matters are the concern of the state education
department. Although risk of harm was not defined as maltreatment in the harm standard, it was
grounds for notification in NSW. Hence, risk of sexual abuse (e.g. child's behavior is indicative of
sexual abuse) and risk of physical abuse were included in the modified classification. Finally, it
was decided that exposure to domestic violence should be included as a separate, non-aggregated
category of emotional abuse.
In the pilot study, it was noted that caseworkers' coding of child maltreatment events was often
ambiguous or incorrect, when referenced to their narrative descriptions of these events. Most events
had quite detailed narrative descriptions recorded on the CIS. While these accounts might also be
prone to error, they provided an opportunity to improve the reliability and validity of the coded
classifications. Research assistants were trained to classify maltreatment events from the narrative
reports, and to check their interpretations against the initial coding. The reliability of these classifications was checked periodically by the author.

Table 1
Study factors measured in the CICS baseline survey
I. Measured from carer-report questionnaire
Type of care (foster or kinship)
Length of care order
Carer's prior training
Child's placement initially temporary or permanent
Relationship of informant to child
Number of carers
Occupational status of carers
Who lives in the home?
Carer's health
Carer's experience
Carer's prior training
Support of other carers
Carer's perceived training needs
Child's case plan
Expectations about restoration
Recent adverse and positive events for the child
Child's birth family contact
Child's physical health problems
Medications
Reported intellectual disability
History of speech problems and speech therapy
Reading difficulties
Education, special education support, tuition
In-school behavioral support, school disciplinary actions
Child's utilization of services
Perceived service needs
Provision of casework support
Sibling-related factors:
1. Number of children in foster home
2. Age difference to nearest aged child in placement
3. Sibling in shared placement is study participant
II. Measured from child welfare/alternate care database (CIS)
Maltreatment history prior to entering care:
1. Forms of reported maltreatment
2. Timing and frequency of maltreatment events
Birth parent factors related to child maltreatment
Maternal age
Reports of maltreatment in care
Child's age at entry into care
Care history (e.g. placement changes, history of temporary care, prior restoration)
Length of care order
Demographic factors (child's age, ethnicity, gender, location)
Time in care
Type of care (foster or kinship)
Child's case plan
Sibling-related factors:
1. Child's birth order
2. Any siblings ever in care
3. Current placement shared with sibling
4. Oldest sibling in shared placement
5. Biological relationship to sibling in shared placement
2.5. Statistical analysis

Associations between study factors and continuous outcome measures were calculated using
t-tests (dichotomous study variables), ANOVA (multi-category variables), and Pearson r correlations (continuous study variables). Bonferroni adjustments were calculated for ANOVA
multiple-comparison tests. In light of the large number of comparisons, the significance level was set
at = 0.01. The effect size of each significant factor was calculated as standardized differences in
group mean scores (Cohen's d), and/or as proportions of the overall variance accounted for (Olejnik
& Algina, 2000; Thompson, 2002; Trusty, Thompson, & Petrocelli, 2004). Predictors of continuous
estimates of mental health were identified from a large number of associated risk and protective
factors in two-step hierarchical linear regression models, while predictors of mental disturbance (as
indicated by clinically significant checklist scores) were identified using equivalent hierarchical
logistic regression models. The first step modeled the extent to which children's present mental
health was independently predicted by developmental characteristics and pre-care study factors. The
latter refers to exposure to social adversity and other risk factors prior to entry into court-ordered
care, as well as the history of previous care events and restoration to birth parents. The second step
modeled the extent to which various in-care experiences and events independently predict the
outcome measures.
Age and gender were included in each model, as well as factors associated with the outcome
measure at p 0.1, with the following exception. Factors that were likely to be either a
consequence of mental health, or to be correlates with common determinants, were excluded from
the models (e.g. clinical service use, school behavior problems, and being placed apart from any
other child). Factors that potentially had a bi-directional relationship with mental health
(e.g. number of placements in care) were retained. Various combinations of inter-correlated
factors, including potential confounders, were included in the models. To avoid sample attrition,
some factors had missing values replaced with values equivalent to the factor mean score, using
the coded missing values method (Orme & Reis, 1991).
3. Results
3.1. The sample
Survey questionnaires were mailed to the caregivers of 621 eligible children, for whom contact
details could be confirmed. The study sample was 347 children, aged 4 to 11 years, providing a
56% response rate. Comparisons of participant and non-participant children found the latter
entered care at a younger age, had less exposure to maltreatment, and were more likely to have
spent the larger part of their life with their present caregivers. Sixty percent of children were 6 to
8 years old, with a mean age of 7.8 years. There was an even gender mix of 176 boys and 171
girls. Half of the children (52%) resided in metropolitan locations (Sydney, Newcastle and Lower
Hunter, Central Coast, Wollongong), with the remainder living in rural and regional NSW.
Ethnicity was not reliably measured and thus is not reported.
3.1.1. Health, development, language and education
The proportions of boys and girls with at least one reported physical health problem (including
epilepsy and motor neurological conditions) were 34% and 25% respectively. About one third
(36%) of children were prescribed medications, the most common ones being psychotropic and
asthma medications (each prescribed for 17% of children). There were also significant gender
differences in prescription rates for psychotropic (boys = 26%, girls = 8%, P2 = 18.9, p b 0.001)
and asthma (boys = 23%, girls = 10%, P2 = 11.1, p = 0.001) medications. The most commonly
used psychotropic medications were stimulants (n = 49) and Clonidine (n = 16), the latter being
mostly prescribed in combination with the former. Stimulants and Clonidine are typically
prescribed for treatment of ADHD and co-morbid aggression respectively (Hazell & Stuart,
2003). About 10% of subject children (n = 33) were reported to have a physical disability.
The rate of reported intellectual disability (ID) was 22.5%. This is within the range of prior
estimates of ID among children in care (Halfon, Mendonca, & Berkowitz, 1995; Hochstadt,
Jaudes, Zimo, & Schachter, 1987; Klee, Kronstadt, & Zlotnick, 1997; Leslie, Gordon, Ganger, &
Gist, 2002; Simms, 1989; Swire & Kavaler, 1977). Nevertheless, since ID was measured solely
by carer-report, the present estimate is likely to include some false positives (such as borderline
intellectual disability, and specific learning difficulties).
A similar proportion (22%) of subject children was reported to have speech/language difficulties,
with the reported lifetime incidence being 33%. This is comparable to previous estimates of language
delay among children of this age residing in alternate care (Halfon et al., 1995). As with children at
large, speech problems among children in care were associated with gender and age, with the highest
prevalence found among younger boys. The findings do not indicate the extent to which speech
therapy influences the course of speech/language difficulties in this sample.
Thirty-six percent of children were reported to have reading difficulties. Though many children
presented with school learning and behavioral problems, just two school-age children (6+ years)
were not attending school. Most children were enrolled in mainstream classes, often with the
support of additional personnel (e.g. teacher's aide, support teacher, or volunteer). They were also
much more likely to receive additional support at school, than private tuition. Similarly, children
with learning or behavioral difficulties were more likely to be provided in-school support, than to
repeat a grade. A third of the children encountered formal disciplinary measures in the last year
(e.g. suspension, in-school suspension, discipline card, expulsion).
3.1.2. Mental health
CICS baseline mental health findings are described in detail elsewhere (Tarren-Sweeney & Hazell,
2006). Children were reported as having exceptionally poor mental health and socialization, both in
absolute terms, and relative to normative and in-care samples. Mean CBCL broadband and sub-scale
raw scores for boys and girls ranged from 0.3 to 1.9 standard deviations above Australian community
means (all differences significant at p b 0.001) (Sawyer et al., 2001). Children had particularly high
social problems, thought problems, attention problems, rule-breaking/delinquent behavior,
and aggressive behavior, with mean scores approaching those of U.S. clinic-referred groups.
(Achenbach, 1991; Achenbach & Rescorla, 2001) Fifty-three percent of girls and 57% of boys had at
least one CBCL scale score in the clinical range. Equivalent proportions of children with any score in
the borderline plus clinical ranges were 65% (girls) and 74% (boys). Levels and rates of disturbance
(as measured by CBCL continuous scores, and proportion of scores in the clinical range) exceeded all
previously reported estimates for in-care samples (Tarren-Sweeney & Hazell, 2006).
3.2. Study factor events/exposure
3.2.1. Maltreatment history
Subject children endured substantial maltreatment prior to entering care. Their mean (median)
number of confirmed notifications of maltreatment was 3.5 (3). The mean time between a child's
first confirmed maltreatment event, and their entry into court-ordered care was 1.7 (1.1) years.
Table 2
Lifetime incidence of maltreatment (confirmed notifications)
Sexual abuse
Non-contact
Contact
Intercourse
Emotional abuse
Verbal assault or threat
Classic emotional abuse
Exposure to domestic violence
Physical abuse
Physical assault
Close confinement
Any abuse
Abandonment/refuse custody
Inadequate supervision
Neglect of basic physical needs
Medical neglect
Inadequate nurturance (failure to thrive, etc)
Any neglect
Any maltreatment (abuse and/or neglect)
a
Boys (%)
Girls (%)
n = 176 a
n = 171
10.2
4.0
5.7
2.8
61.9
29.0
26.1
27.3
49.4
47.2
5.1
77.3
20.4
42.6
48.9
10.2
34.7
81.8
94.9
14.6
6.4
7.0
5.3
62.0
29.2
20.5
36.3
39.8
39.2
2.3
73.1
12.9
42.7
49.7
10.5
26.3
73.1
92.4
No gender differences achieved statistical significance.
This period provides a rough indicator of length of exposure to maltreatment. Fewer than 7% of
children entered care without a known history of maltreatment. Of these, about half left their
parents care shortly after birth, because of an assessed risk of harm. The rest were either
abandoned or surrendered to care. The lifetime incidences of confirmed exposure to various types
of maltreatment are listed for boys and girls in Table 2. The mean (median) number of
unconfirmed notifications was 1.5 (1) (n = 178, recorded for half of the sample only). Exposure to
maltreatment was directly related to the amount of time that children spent in their parents' care.
This is demonstrated in terms of the numbers of confirmed notifications (One-way ANOVA:
F = 14.9, p b 0.0001) and of categories of harm (One-way ANOVA: F = 15.3, p b 0.0001)
experienced by groups stratified according to entry into care age ranges (see Table 3).
Table 3
Age at entry into care by maltreatment exposure and reported intellectual disability
Age at entry into care
N.
Maltreatment
N. notif
Birth6 months
7 months18 months
19 months36 months
37 months60 months
Older than 60 months
a
43
39
88
88
89
1.3
2.6
3.5
3.7
4.7
N. types
1.4
2.5
2.4
2.9
3.1

b
Sex abuse
Physical abuse
2%
2%
16%
37%
42%
10%
10%
22%
31%
27%
26%
23%
22%
19%
25%
Mean number of confirmed notifications.

Mean number of categories of maltreatment child is exposed to, from the following 7 categories: sexual abuse,
emotional abuse, physical abuse, exposure to domestic violence, physical neglect, developmental neglect, and medical
neglect.
b
3.2.2. Maltreatment in care

Two thirds (68%) of subject children had no reports of maltreatment in foster or kinship care,
13% had one or more unconfirmed reports, and 19% had at least one confirmed report. The
narrative investigative reports of confirmed events suggest that maltreatment in care falls into two
broad categories. The majority of events related to carers coping poorly with children's behavioral
and relationship disturbances. Maltreatment in this context typically consisted of inappropriate
discipline or scapegoating, ranging from smacking to serious emotional or physical harm. These
carers tended to respond positively to the provision of supports such as counseling, respite or
more effective casework. A smaller group of children endured neglectful, abusive, or predatory
care, which was not attributed to poor coping by distressed carers. Descriptions of their carers'
motivations and engagement with others, suggest that they had emotional, personality, or
relationship difficulties that are incompatible with fostering.
3.2.3. Care history
The sample consisted of 297 (86%) children in foster care, and 50 (14%) children in kinship
care. Their mean and median ages at entry into care were 3.5 and 3.2 years of age respectively,
while the mean and median time that children had been in care was 4.3 and 4.1 years. Hence,
children on average had spent more than half of their lives in care.
An interesting picture emerged in regards to placement stability. At first glance, children
appear to have experienced eventful care histories. The number of placements ranged from 1 to
25, with the mean and median being 3.1 and 2 placements respectively. This excludes placements
of less than 1 week in duration (such as weekend respite care), as well as temporary care events
that pre-date their present entry into care. However, closer examination revealed that most
instability occurred in the first year of court-ordered care. The mean and median length of their
present placements was 3.3 and 3.0 years respectively, while the mean and median ratios of time
in present placement to overall time spent in care were 0.73 and 0.88 respectively. Hence,
children's placements were typically stable following their first year in care. Placement stability
did not vary according to whether children presently resided in foster or kinship care, contrary to
prior findings (Shlonsky, Webster, & Needell, 2003; Webster, Barth, & Needell, 2000). Reasons
for this are proposed elsewhere (Tarren-Sweeney & Hazell, 2005), but it is essentially because
many children entered their present kinship placement from foster care.
3.3. Associations between study factors and mental health
A large number of study factors were associated with baseline mental health scores. Factors
associated ( p 0.01) with two measures of global mental health CBCL Total Problems T score
(standardized for gender), and ACC Total Clinical Score are listed in Table 4. The effect size for
associated dichotomous factors, reported as standardized group mean differences in raw scores
(Cohen's d) ranged from 0.25 to 0.72. According to Cohen's (1988) criteria, most effect sizes were
moderate. There was similar magnitude and range of effect size for continuous and multi-category
variables, reported as accounted for variance (R2). The only non-associated factor showing a
gender-specific association was maternal age, with younger maternal age representing a risk for
girls (p 0.01).
3.3.1. Age at entry into care
Pearson r correlations of age at entry into care against various mental health raw scores
were: CBCL total problems (r = 0.20); CBCL attention problems (r = 0.18); CBCL externalizing
10
Table 4
Factors associated with global estimates of mental health ( p 0.01)
CBCLa
ACCb
c
Effect size
Continuous variables
Development risk factors
Age
Pre-care risk/protective factors
Number of temporary placements
Exposure to maltreatmente
Maternal age at birth
In-care risk/protective factors
Age at entry into care (EIC)
Time in care
Length of present placement
Time in placement/time in care
Number of permanent placements
Number of adverse events in last year
Dichotomous variables
Development risk factors
Reported speech problem
Reported reading problem
Pre-care risk/protective factors
Exposure to contact sexual abusef
Exposure to physical abuseg
Exposure to classic emotional abuseh
Any form of abuse (not neglect)
Abandonment/refuse custody
In-care risk/protective factors
Type of care (foster v kinship)
Carer has poor health
Carer resides in Sydney
Two carers employed
Care order expires before age 16
Carer anticipates restoration
Contact with mother (more/less frequent)
Multi-category variables
Mean
Placement status
1. Temporary (n = 14)
2. Short order/
restoration (n = 38)
3. Long-term
placement (n = 289)
Compare Group 1
with Group 3
Compare Group 2
with Group 3
p value
Effect size
p value
Higher scoresd
rsq
rsq
0.13
0.02 0.01
0.16
0.03 0.003
Older children
0.15
0.17
0.02 0.005
0.03 0.001
0.002
More placements
Longer exposure
Girls: younger mat age
0.007
0.31
0.22
0.17 0.03 0.001
0.30
0.23 0.05 b0.0001 0.30
0.15
0.02 0.006
0.16
0.15
0.02 0.006
0.16
d
r sq
d
b0.0001
b0.0001
b0.0001
b0.0001
0.003
0.002
0.19
0.04 0.0003
0.10
0.05
0.09
0.09
0.03
0.03
r sq
0.54
0.40
0.72
0.05 b0.0001 0.48

0.03 0.003
0.12 b0.0001 0.54
0.04 0.0002
Risk
ns
Risk
0.07 b0.0001 Risk
0.42
0.34
0.04 0.001
0.02 0.01
0.41
0.65
0.28
0.02 0.007
0.02 0.005
0.02 0.01
0.61
0.69
Later age at EIC

Shorter time
Shorter time
Smaller ratios
More placements
More adverse events
0.56
0.31
0.32
0.35
0.41
0.02
0.02
0.02
0.02
0.02
0.01
0.004
0.01
0.01
0.005
Risk
Risk
Risk
Risk
Protection
0.39
0.67
0.28
0.32
0.05 0.0001
0.68
0.06 b0.0001 0.85
0.33
0.02
0.02
0.02
0.02
0.06
0.10
0.02
0.01
0.004
0.01
0.01
b0.0001
b0.0001
0.01
Foster care
Risk
Risk
Risk
Risk
Risk
More than 4 visits/year
r sq
p valuei
0.06
b0.0001
Mean
69.0
67.7
46.0
42.2
59.1
26.9
r sq
p valuei
0.06
b0.000
0.74
0.02
0.79
0.01
0.65
0.001
0.63
0.001
Permanent is
protective
11
Table 4 (continued)
Multi-category variables
Age carer expects child
will leave
1. Before age 12 (n = 30)
2. Age 12 to 15 (n = 22)
3. Age 16 to 18 (n = 62)
4. Beyond age 18
(n = 216)
Compare Group 1
with Group 4
Compare Group 2
with Group 3
Behavior surrounding
family contact
1. Negative (n = 96)
2. Ambivalent (n = 95)
3. Positive (n = 112)
Compare Group 1
with Group 3
Compare Group 2
with Group 3
Mean
r sq
p valuei
0.09
b0.0001
68.9
70.2
60.6
58.2
Mean
r sq
p valuei
Positive is
protective
0.11
b0.0001
Older age
protective
48.2
46.3
29.0
25.0
0.81
b0.0001
0.99
b0.0001
0.71
0.02
0.67
b0.02
0.08
b0.0001
64.7
62.5
56.0
0.07
b0.0001
35.9
35.2
21.7
0.67
b0.0001
0.63
b0.0001
0.47
0.0001
0.49
b0.0001
CBCL total problems T score (standardized for gender); bACC total clinical score; cEffect size measured as correlation (r),
proportion of variance accounted for (r squared), and a standardized group mean score differences (Cohen's d); dIndicates
which children had higher scores (i.e. have poorer mental health). Either lists the higher risk group, or indicates if exposure
to a specific factor is protective or incurs risk; eTime from 1st notification to entry into care; fOne of three categories of
sexual abuse = non-penetrative genital contact; gPhysical assault or close confinement; hEmotional abuse excluding threats
of harm (e.g. scapegoating, emotional blackmail); iOverall p value for ANOVA listed in regular font, multiple-comparison
significance tests for stratified groups, with Bonferroni-adjusted p values listed in italics; jExcludes children whose
placements are no longer viable (n = 6). Placement status stratified as: children residing in temporary placements, including
children awaiting a new placement (n = 7) and carers requesting that placement become permanent (n = 8); children residing
in non-temporary placements with either a short-term order, or with a restoration plan; and children residing in long-term
placement, including children being adopted by carers (n = 7).
problems (r = 0.20); ACC total (r = 0.31); ACC sexual behavior (r = 0.28); composite ACC
attachment problems (sum of pseudomature, non-reciprocal and indiscriminate) (r = 0.31); and
ACC insecure (r = 0.31). There was a strong, linear relationship between age at entry into care
and the mental health of children who entered care beyond age 7 months (n = 204), with younger
entry being protective. Otherwise, there was a clear non-linear distinction between children who
entered care before and after age 7 months, with the former (n = 43) enjoying substantially better
mental health.
3.3.2. Associations with specific types of maltreatment
Children with a confirmed history of exposure to any form of sexual abuse (18 boys, 25 girls)
had significantly higher mean scores on the ACC sexual behavior scale (any sex abuse = 2.2, nil
sex abuse = 1.1, p = 0.02), and on all three ACC attachment difficulties scales (pseudomature,
p = 0.02; non-reciprocal, p = 0.05; and indiscriminate, p = 0.02), as well as higher mean T scores
on the CBCL social problems ( p = 0.03) scale. Sexual abuse was not associated with scores on any
other mental health scale.
12
Table 5
Predictors of global mental health (ACC total clinical score)
Correlation
Developmental factors
Age
Gender
Reported reading difficulty a
Pre-care factors
Maternal age
Exposure to maltreatment b
N. Types of maltreatment (07)
Total confirmed notifications
Contact sexual abuse c
Physical abuse d
Classic emotional abuse e
Physical neglect 1 f
Physical neglect 3 g
N. temp placements before EIC h
Prior restoration to birth parent
Age at entry into care i
Adjusted R squared = 0.19
In-care factors
Foster versus kinship care
N. placements since EIC h
Length of time in placement
Care order expires bage 16
Confirmed maltreatment in care
Placement in Sydney
Frequency of contact with mother j
N. adverse events in last year
Carer age
Carer health problems
Carer socioeconomic status k
a
b
c
d
e
f
g
h
i
j
k
Partial
correlation
Standardized beta
coefficient
Significance
( p N t)
0.16
b0.01
0.26
0.20
0.03
b0.01
0.17
0.11
0.03
b0.01
0.18
0.12
0.54
0.87
0.002
0.04
0.15
0.17
0.10
0.12
0.14
0.17
0.14
0.15
0.09
0.15
0.08
0.33
0.15
0.02
0.13
0.02
0.12
0.12
0.14
0.06
0.0
0.07
b 0.01
0.22
0.14
0.03
0.19
0.02
0.12
0.13
0.13
0.05
0.04
0.08
b 0.01
0.27
0.007
0.71
0.02
0.73
0.03
0.03
0.01
0.32
0.52
0.17
0.99
b0.001
0.13
0.16
0.30
0.29
0.25
0.31
0.12
0.13
0.12
0.16
0.07
0.16
0.04
0.08
0.03
0.01
0.11
0.10
0.23
b0.01
0.14
0.06
0.15
0.02
0.11
0.05
0.07
0.03
0.03
0.17
0.09
0.22
b 0.01
0.12
0.05
0.12
0.01
0.09
0.05
0.17
0.64
0.84
0.06
0.08
b0.001
0.95
0.01
0.31
0.01
0.79
0.06
0.35
Reported reading difficulties (Yes/No).

Length of time exposed to maltreatment: Time from 1st confirmed notification to entry into care.
One of three categories of sexual abuse = non-penetrative genital contact.
Physical assault and/or close confinement.
Emotional abuse other than threats or verbal assaults, e.g. scapegoating.
Refuse care/abandoned.
Neglect of basic physical needs, e.g. food, shelter, inadequate hygiene.
EIC = Entry into care.
Age range for entry into care: birth to 6 months; 718 months; 1936 months; 3760 months; 60 months+.
No contact versus infrequent contact versus frequent contact.
Dichotomous variable, low SES versus mediumhigh SES.
Confirmed history of physical abuse (physical assault, n = 150; or close confinement, n = 13)
was associated with two attachment problem scores (non-reciprocal, p = 0.05; and indiscriminate,
p = 0.02), and with CBCL anxious-depressed (p = 0.004), social problems (p = 0.005), attention
problems (p = 0.01), delinquent behavior (p = 0.03), and aggressive behavior (p = 0.002) scores.
13
Table 6
Predictors of global mental health (CBCL total problems raw score)
Correlation Partial correlation Standardized beta coefficient Significance (p N t)
Age
Gender
Reported reading difficulty a
Pre-care factors
Maternal age
Reported maternal schizophrenia
Exposure to maltreatment b
Contact sexual abuse c
Physical abuse d
Classic emotional abuse e
Physical neglect 1 f
Prior restoration to birth parent
Age at entry into care g
Adjusted R squared = 0.19
In-care factors
Foster versus kinship care
N. placements since EIC h
Length of time in placement
Care order expires bage 16
Sibling placement status
Confirmed maltreatment in care
Placement in Sydney
N. adverse events in last year
Carer age
Carer health
Carer socioeconomic status i
a
b
c
d
e
f
g
h
i
0.14
0.11
0.33
0.22
0.07
0.11
0.24
0.08
0.07
0.10
0.25
0.08
0.19
0.05
b0.001
0.14
0.14
0.12
0.10
0.08
0.20
0.14
0.12
0.02
0.21
0.13
0.09
0.07
0.07
0.11
0.14
0.07
0.04
0.13
0.12
0.08
0.09
0.07
0.10
0.13
0.06
0.04
0.15
0.02
0.10
0.18
0.19
0.05
0.01
0.22
0.46
0.02
0.14
0.12
0.18
0.23
0.26
0.30
0.05
0.11
0.13
0.15
0.12
0.17
0.05
0.06
0.02
0.06
0.09
0.11
0.24
0.03
0.03
0.12
0.14
0.02
0.14
0.10
0.06
0.02
0.14
0.15
0.10
0.23
0.03
0.03
0.10
0.11
0.02
0.12
0.09
0.29
0.72
0.31
0.10
0.06
b0.001
0.59
0.61
0.04
0.02
0.78
0.02
0.08

Length of time exposed to maltreatment: Time from 1st confirmed notification to entry into care.
Refuse care/abandoned.
Age ranges for entry into care: birth to 6 months; 718 months; 1936 months; 3760 months; 60 months+.
EIC = Entry into care.
Dichotomous variable, low SES versus mediumhigh SES.
Confirmed exposure to classic emotional abuse, such as scapegoating, emotional blackmail,

and overt rejection (n = 81) was associated with scores on the ACC non-reciprocal (p = 0.05),
indiscriminate, (p = 0.005), and self-injury scales (p = 0.009) scales, and the CBCL anxiousdepressed (p = 0.02), social problems (p = 0.001), attention problems (p = 0.03), and aggressive
behavior (p = 0.002) scales. Exposures to other forms of emotional abuse, namely witnessing
domestic violence, and verbal assault or threats of violence, were not associated with any mental
health score.
14
3.4. Inter-correlated factors

Several clusters of inter-correlated study factors were identified and reviewed prior to predictive
modeling. A number of time-related and pre-care exposure variables were moderately intercorrelated. The variables age and age at entry into care combined to make time in care
redundant. Time spent in present placement was confounded by age and age at entry into care,
such that the two latter variables needed to be included in the regression models. The proportion of
time in care spent in the present placement (time in present placement/time in care) was
generated as a measure of placement stability, free of such confounding.
Carer-reported intellectual disability, speech problems and reading difficulties were also
strongly inter-correlated. Children with intellectual disabilities largely constituted a subset of
those with reading difficulties. There was evidence of redundancy between reading difficulties
and speech problems. Reading difficulties was selected for predictive modeling in preference to
speech problems, because the former had a stronger association with children's mental health.
There was low to moderate correlation of factors describing the length of the child's care order,
the security of the child's placement, and the carer's perception of placement permanence. There
was some redundancy between placement status (temporary versus short order/restoration
versus permanent care) and expiry of care order before age 16. The latter variable is indicative
of a non-permanent care order, and was more closely associated with mental health than the child's
placement status. There was also some redundancy between carer expectation of restoration, and
the age carer believes child will leave their care. The former variable was more closely associated
with children's mental health, and hence is likely to be a stronger predictor. There was no evidence
of confounding between these variables.
3.5. Predictors of mental health
Hierarchical linear regression models identifying predictors of global mental health continuous
scores are listed in Table 5 (ACC total clinical score) and Table 6 (CBCL total problems raw
score). Similar sets of developmental, pre-care and in-care factors predicted the two outcomes.
Both models accounted for large proportions of the score variance (adjusted R squared = 0.31),
with developmental and pre-care factors predicting about two-thirds of the accounted for
variance. The strongest predictors of mental health problems were older age at entry into care,
reading difficulties, reported ID, younger maternal age at birth, exposure to some specific types of
maltreatment, anticipated restoration of the child to their birth parents' care, and exposure to a
higher number of adverse life events in the preceding year. Age was not an independent predictor,
while gender predicted the CBCL total problems raw score, but not the ACC total score. Male
gender also predicted higher CBCL total problems T scores (which are gender-standardized),
meaning that gender independently accounted for CBCL problems over and above the gender
effect observed among children at large.
Additional analyses identified predictors of continuous measures of attachment problems
(composite of the ACC pseudomature, non-reciprocal and indiscriminate scale scores),
externalizing problems (CBCL externalizing raw score), and attention problems (CBCL attention
problems raw score). Predictive modeling was also conducted on three clinical outcomes: CBCL
total problem scores in the clinical range; ACC total score in the clinical range; and any CBCL
broadband or sub-scale score in the clinical range. A predictor-mental health outcome matrix is
presented as Table 7. The matrix lists standardized eta coefficients (continuous outcomes), odds
ratios (categorical outcomes) and the proportion of variance accounted for by each model.
15
Table 7
Matrix of independent predictors by mental health outcomes
Linear regression models
Logistic regression models
Standardized eta coefficients
Odds ratios (95% C.I.)
CBCL
CBCL
CBCL ACC ACC
Global
Any
attention externalizing total total attachment CBCL
CBCL
problems
score score problems disorder a disorder
Gender
( = boys, + = girls)
Reported reading
difficulty c
Reported intellectual
disability
Pre-care factors
Maternal age
N. Types of
maltreatment (07)
Contact sexual
abuse d
Physical abuse e
Classic emotional
abuse f
Age at entry into
care g
In-care factors
Kinship versus foster
care ( = foster care)
Time in placement/
time in care
Care order
expires b age 16
Carer anticipates
restoration
Expected age upon
leaving care
Placement in/out of
Sydney
N. adverse events in
last year
Carer's health
0.13
0.15
0.10
0.25
0.25
0.25
0.24
0.18
0.16
0.12
0.12 0.14 0.10

0.19 0.20
0.12
0.14
0.10
0.10
0.13
0.18
0.12
0.13
0.13
0.12
0.13
0.15
0.27
0.31
0.22
c
d
e
f
g
h
0.7
(0.50.9)
3.3
(1.010.3)
2.0
(1.13.5)
0.7
0.7
(0.50.9) (0.51.0)
3.4
(1.110.9)
2.1
(1.23.8)
2.3
(1.34.2)
1.5
1.5
1.7
(1.21.9) (1.21.9) (1.32.2)
0.20
0.2
(0.00.9)
0.11
0.11
(Variance accounted for by model) h (0.31)

b
3.9
3.6
2.5
(2.27.2) (1.96.6) (1.44.6)
2.2
(1.14.4)
0.10
0.16
0.23
0.22
0.17
1.7
1.6
1.9
(1.12.6) (1.02.6) (1.22.8)
1.6
(1.02.4)
0.10
0.12
0.10
0.11
0.12
0.09
1.5
(1.22.0)
0.11
0.12
(0.22)
(0.31) (0.31) (0.29)
Two carers working
Global
ACC
disorder b
7.2
(1.339.3)
2.1
1.9
(1.13.9) (1.03.6)
(0.28)
(0.25)
(0.26)
CBCL total problems scores in the clinical range.

ACC total score in the clinical range.
Age ranges for entry into care: birth to 6 months; 718 months; 1936 months; 3760 months; 60 months+.
Adjusted R squared for linear regression, Pseudo R squared for logistic regression (Statacorp, 2003).
16
In separate analyses reported elsewhere, it was found that maltreatment in care predicted a pattern
of excessive eating and food acquisition and maintenance behaviors without concurrent obesity
(termed Food maintenance syndrome), resembling the behavioral correlates of Hyperphagic Short
Stature (Psychosocial Dwarfism) (Tarren-Sweeney, 2006).
4. Discussion
4.1. The significance of intellectual disability
Despite the likely role of deprivation as determinant of both cognitive impairments and
mental health problems in this population (Kreppner et al., 2001), the present study found that
ID predicted mental health problems independent of children's prior exposure to adversity. It is
also known that children with intellectual disability in the general population present with much
higher rates of mental disorders than other children (Tonge & Einfeld, 2003). The question
arises as to what mechanisms account for the link between ID and mental health problems
among children in care. These are difficult to interpret without prospective and psychometric
test data. Among some children there are likely to be direct effects, as in the case of autism and
some genetic syndromes. Alternatively, lower IQ may render children less able to respond
adaptively to severe adversity. Another pathway observed among children at large, sees
children who perform poorly at school developing a negative self-image, placing them at higher
risk of emotional and behavioral difficulties. ID and mental health problems might also be codetermined by biological, pre-natal or psychosocial factors.
4.2. Differential prediction of inattention and attachment problems
Early attachment experiences and the development of self-regulation are intricately related
(Sroufe, 1996). There is an element of impulsivity to the indiscriminate affection and attention
seeking of children with disinhibited attachment disorder behaviors. Among profoundly deprived
children in institutional care, attention-deficit/hyperactivity presents as a deprivation syndrome
against a background of genetic risk (Kreppner et al., 2001; Roy, Rutter, & Pickles, 2000). Yet, the
present data suggest that attention problems are less sensitive to social adversity than other mental
health problems. The strongest predictors of inattention were male gender, reported reading
difficulties, and reported intellectual disability, while factors measuring early social adversity
(including age at entry into care) were non-predictors. Conversely, the problems most strongly
predicted by pre-care social adversity were attachment difficulties, aggression, defiance, and ageinappropriate sexual behavior. This does not suggest an absence of genetic vulnerability for
attachment difficulties, or that social factors do not have some bearing on inattention. Indeed,
children who entered care at older ages had somewhat higher attention problems than children placed
in infancy. Rather, the findings assert that inattention is less sensitive to the effects of caregiving and
deprivation, than are attachment difficulties.
4.3. Influence of parental difficulties
Children who enter care have a higher likelihood of one or both parents having mental health
problems (Quinton & Rutter, 1984) and/or substance use problems (Besinger, Garland, Litrownik, &
Landsverk, 1999). Parental psychopathology (Rutter & Quinton, 1984; Zeanah et al., 1997) and
parental substance abuse (Dore, Kauffman, Nelson-Zlupko, & Granfort, 1996; Velleman, 1996) are
17
associated with mental health problems and attachment difficulties among children at large. With the
exception of conditions with strong heritability, parentchild transmission of psychiatric disturbance
appears to be largely mediated via the child's experience of psychosocial adversity (Rutter &
Quinton, 1984). Indeed, the severity and duration of the parents symptoms are stronger predictors of
child outcomes than the type of disorder (Seifer & Dickstein, 1993). Yet in the present study, various
parental difficulties (as reported by caseworkers) were not associated with the development of
children's mental health, with the exception of maternal schizophrenia. What might account for this?
Some analyses lacked statistical power, that is, for difficulties that were reported for small numbers
of parents. Second, the distribution of proximal risk factors (e.g. emotional deprivation, physical
abuse) did not co-vary with types of parental difficulty. Third, few difficulties were reported for
fathers, since they mostly resided elsewhere, and hence were not discussed in the investigative
reports. Lastly, caseworkers' references to parental psychopathology are dependent on parental or
agency reports of clinical diagnoses. It is likely that personality disorders among parents in this
population are under-diagnosed. Whereas caseworkers readily identified mental illness (such as
schizophrenia or depression) as a contributor to child neglect or abuse, a parent's affective instability,
impulsivity, lack of empathy, or poor bonding were rarely constructed in diagnostic terms.
4.4. Specific versus cumulative effects of early adversity
The present findings provide partial support for a cumulative risk model of developmental
psychopathology. The strongest and least ambiguous pre-care predictors of children's mental health
were age at entry into care and the inversely correlated time in care, which are indicators of overall
exposure to pre-care adversity. Furthermore, encountering more types of maltreatment was less
influential than the estimated length of exposure to maltreatment. Whereas a single harmful event may
have life-altering developmental consequences for children at large, the impact of individual events is
tempered among children exposed to chronic and multiple adversities. A number of researchers have
reported that broad indicators of exposure to adversity and to other risk factors account for a greater
proportion of the variance in children's mental health, than exposure to specific types or single
instances of harm (Fergusson & Lynskey, 1996; Rutter, 1999). For instance, it has previously been
shown that length of exposure to maltreatment and the number of maltreatment events are stronger
predictors than the type of harm encountered by children (Zeanah et al., 1997). Similarly, among
children with multiple genetic vulnerabilities, individual genetic risks account for small proportions of
the variance in their mental health (Plomin, DeFries, & McClearn, 1997). Nonetheless, three types of
maltreatment accounted for mental health problems, independent of other influences, namely
physical abuse, classic emotional abuse (which excludes verbal threats and exposure to domestic
violence), and contact sexual abuse. These findings are particularly revealing, given that the effects
were located among children who, by-and-large experienced multiple forms of abuse and deprivation.
While exposure to single forms of psychosocial adversity accounts for a small proportion of
the variance in the mental health of children at large, the univariate effect size is usually high
(Rutter, 1999). This is because experiencing serious adversity of any form (especially if linked to
parental functioning) is likely to be a marker for other social and biological risks. However, in the
present sample, quite small effect sizes were calculated for some known risk factors, such as
exposure to domestic violence. Why might this be so? The simplest explanation is that the vast
majority of subject children have at some time encountered chronic and severe adversity.
Consequently, in such a high-risk sample, we see a dilution of the effect sizes for exposures that
are relatively less harmful for their development (although this does not infer that their exposure
to domestic violence is trivial or non-harmful).
18
4.5. Age
A univariate age effect was detected, consistent with prior evidence that older children in care
have poorer mental health (Armsden et al., 2000; Dubowitz et al., 1993; Heflinger et al., 2000).
This flags the possibility that more children than not manifest some deterioration in mental health
whilst in care (i.e. that foster care is not therapeutic). For some children this is clearly so,
especially in response to maltreatment in care (Tarren-Sweeney, 2006), placement breakdowns
(Barber, Delfabbro, & Cooper, 2001), and insensitive caregiving (Schofield & Beek, 2005). But,
among the present sample the age effect seems illusory, confounded by age at entry into care.
The greater mental health problems of older children were largely accounted for by their later
entry into care. There were two exceptions to this, namely that older age predicted sexual
behavior problems, and younger age predicted inattention/hyperactivity.
4.6. Age at entry into care
The age at which children entered care was the strongest predictor of their mental health, with
entry at younger age being protective. This is consistent with prior findings for children in
residential care (Hukkanen, Sourander, Bergroth, & Piha, 1999), children in foster care (Fanshel &
Shinn, 1978; Halfon et al., 1995), those formerly in care (Lambert, Essen, & Head, 1977) and those
adopted from foster care (Dumaret, Duyme, & Tomkiewicz, 1997). Since this finding has profound
implications for social care policy and practice, likely mechanisms accounting for it need to be
considered. One possibility is some older children are selected into care because of their parents'
responses to pre-existing temperamental or behavioral difficulties. However, previously reported
analyses suggest that child-related factors had little bearing on the maltreatment histories of subject
children (Tarren-Sweeney & Hazell, 2005).
For chronically deprived and maltreated children, their age at entry into care provides a broad
approximation of their length of exposure to adversity. This does not imply that all children endure
chronic maltreatment and deprivation from birth. However, the child protection histories of subject
children suggest the vast majority resided in dysfunctional family environments for most of their
pre-care lives. It should be remembered that these children represent the most seriously and
chronically maltreated children in this state. It is also notable that age at entry into care was a
stronger predictor of developmental outcomes, than was time between the child's first notification
and entry into care.
A child's age at entry into care also has significance in terms of the development of their
attachment system, and the influence of attachment experiences on their emotional and
neurological development. Children who are emotionally deprived and/or abused, are likely to
develop insecure or disorganized attachments to their caregivers, or worse, manifest attachment
disorder behaviors (Howe & Fearnley, 2003; O'Connor & Zeanah, 2003). Such difficulties are in
turn moderately correlated with the presence of behavioral and emotional problems (Marcus,
1991). The situation is perhaps different for infants. Dozier et al. (2001) found that the attachment
styles of 1224 month-old infants in foster care (n = 50) were concordant with the attachment
styles of their foster mothers, regardless of their age at entry into care. This suggests that, at least
until age 20 months, infant attachment systems are flexible to changes in parenting style.
While a number of studies have articulated differences in the attachment behaviors of abused
versus neglected children (Crittenden & Ainsworth, 1989), this is an artificial distinction for
children in care. In addition to abuse and neglect, other pre-care experiences account for the
development of attachment difficulties among such children. Some children are cared for by a
19
succession of strangers for lengthy periods (sometimes extending to weeks or months). Some
endure successive losses, both prior to and following entry into care, resulting in grief, confusion
and insecurity. For example, a child might reside with her birth mother to age 18 months, then with
her grandmother to age 30 months, then back to her mother, and so on. In this scenario, the child
resides long enough with her mother, and thence with her grandmother, to become successively
attached to each caregiver. But, her relationships are rendered insecure upon losing them.
Our knowledge of attachment development suggests that children who enter care as infants are
more likely than later-placed children to develop secure attachments to their foster or kinship
carers (Bowlby, 1988). This is notwithstanding genetic or temperamental risks, the intensity of
caregiver bonding, or other aspects of the quality of alternate care. The findings from the present
study are consistent with this expectation. Beyond the initial risk threshold of 7 months, there was
linear deterioration in the mental health of children entering care at progressively older ages. This
includes their manifestation of attachment disorder behaviors. A similar linear relationship
between length of exposure to deprivation and attachment difficulties was reported for Romanian
adoptees, who had experienced profound early deprivation prior to adoption (O'Connor et al.,
1999). The attachment difficulties of late-placed children may also be more enduring (or resistant
to change) in response to markedly improved care. If so, a likely mechanism is the older child's
more finalized internal representations of self and others. A small study of children placed in
foster care between the age of 9 and 13 (n = 32) found that internal representations as well as birth
maternal representations were associated with the severity of maltreatment in their mothers' care
(Milan & Pinderhughes, 2000). This in turn predicted their mental health, as well as their internal
representations of their foster mothers (the finding also reveals a dilemma for how we should
interpret the accounts of late-placed children in qualitative research).
Late-placed children also experience alternate care differently to other children. Might some of
these differences harm their development, or hamper their recovery? The perceived transition
from one's immediate birth family to a surrogate family or residential placement is colored by the
child's attachments, identity, world view, and pre-existing beliefs about the care system. We can
speculate that late-placed children are more prone to feel aggrieved at being separated from their
families, even if their family relationships are ambivalent or insecure. These children often report
in clinical assessments that they feel alone, abandoned, and forcibly separated from their families.
Another risk encountered by late-placed children is placement instability. Although the link
between poor mental health and placement stability is well established, the mechanisms
accounting for this relationship remain speculative (Barber et al., 2001). Certainly, placements
break down because carers are unable or unwilling to manage severely disruptive behavior. But,
two prospective studies have found that placement instability accounts for further deterioration in
children's mental health, suggesting these events are psychologically harmful (Delfabbro &
Barber, 2003; Newton, Litrownik, & Landsverk, 2000). Among the present sample, placement
instability did not independently predict mental health, and longer time in care was protective.
This will be reexamined in the CICS follow-up study.
4.7. Are placement security and relationship security linked?
Several indicators of placement security or longevity were associated with the mental health of
children in the present study. The effect sizes were largely substantial, but were partially confounded
by age at entry into care. This is because children who entered care at older ages were more likely
to have a restoration plan, or a short-term order. Importantly however, most of these factors
independently predicted children's mental health (although given some redundancy, not all of these
20
terms could be modeled simultaneously). The strongest predictor was carer anticipates restoration.
This is probably because it measures two separate mechanisms: 1. placement insecurity; and 2.
anticipation of placement breakdown. Although it seems counterintuitive that children with mental
health problems are more likely to be restored to their parents' care, it does occur as an unplanned
consequence of placement breakdown. Hence, NSW carers may in some instances anticipate
restoration because their child's placement is breaking down. Further predictive modeling was
conducted with and without the carer anticipates restoration term, with a view to isolating these
two influences. The analyses confirmed that placement security was a strong predictor of mental
health, after controlling for age at entry into care, and anticipated placement breakdown.
It can be argued that the alternate care environment at the time of the present study engendered
placement insecurity. Foster parents of children in so-called permanent care had no substantive
guardianship or custody rights. Permanency plans endorsed by DOCS were effectively statements
of intent, since they had no legal status. This applied also to about half of the state's kinship carers,
including all those recruited to the present study (the sampling frame excluded kinship carers who
held custody rights). The Children's Court often made short-term care orders (typically 2 to
5 years) for infants and young children, with the belief that these timeframes were needed for
parents to address their difficulties. This is despite these timeframes being developmentally
inappropriate for very young children. Children sometimes languished for years on either shortterm or permanent orders with restoration plans that were not enacted, or that were inadequately
case-worked.
The idea that placement security might influence the development and well being of children in
care is not new. Related findings have been reported before, although the direction of effects
remains unknown. Emotional and behavioral problems among a sample of US children in kinship
care (n = 346) were predicted by caregiver expectations of placement security, with permanency
being protective (Dubowitz et al., 1993). The mental health, relationship security and well being of
a sample of youths leaving court-ordered care in NSW (with mixed histories of residential and
foster care) were related to self and carer perceptions of permanence and placement security
(Cashmore & Paxman, 1996). It has also been suggested that the greater sense of belonging and
permanence enjoyed by children adopted by their foster parents may account in part for their better
functioning relative to children in long-term foster care (Rushton, 2004).
What then might be the underlying mechanisms that link placement security and permanency
(both real and perceived) to children's mental health? An attachment hypothesis is proposed, namely
that placement security and permanency directly affect the attachment security of children in longterm care, via their perceptions of permanence, as well as indirectly, via the influence of placement
security on their carers attachment systems. There is evidence that the attachment security of infants
in care is more strongly predicted by their carers' attachment style, than that of their parents (Dozier
et al., 2001). Conversely, children who enter care at older ages are likely to arrive with existing
insecurity, following early deprivation and trauma. In clinical practice we observe that in some
instances, carers with secure relationships and apparent capacity to nurture (as evidenced by their
care of other children), sometimes hold back from engaging emotionally with a young child. They
admit to actively forestalling bonding, to spare themselves future grief! Often, this decision follows
on from a previous painful loss. This phenomenon was reported in a recent qualitative study of UK
foster parents, who recounted similar uncertainty and insecurity (Nutt, 2006). Securely attached
children may also become insecure if they perceive that there is a possibility of losing their carers.
Children who enter care as infants reach an age (typically around six or seven) when they begin to
understand the meaning of not being born to the people they are primarily attached to, as well as their
placement status. This realization invites a range of emotions, and engenders some insecurity.
21
Whereas the adopted child can be reassured of his or her permanence, the fostered children may be
denied this if their legal status suggests other possibilities.
The situation for children who enter care beyond age 5 is more complex. The present study
didn't measure children's relationships or views. However, the author's clinical involvement with
children placed at older ages suggests there are many contextual variations in how they view
restoration. Some may feel the loss of their parents acutely and thus be heartened by the knowledge
that they are to return to them (though they may hide such feelings from their present carers).
Others may have serious reservations about returning to an abusive family environment, but
remain hopeful that their parents might someday get better. Yet others are so seriously
traumatized by the abuse of their parents that they literally live in fear of restoration. The converse
is also true, that is, some children pine to return to their birth parents after being abused in care.
Others have multiple attachments to birth and foster families, and a degree of ambivalence where
they wish to reside. And some children are quite mercenary in regards to where they wish to reside,
because they are not attached to anyone.
4.8. Strengths and limitations
The study accessed retrospective data recorded close to the time of the events, which are less
prone to recall bias than self-reported data (such as that obtained in case-control studies).
Furthermore, the study accessed comprehensive child welfare and alternate care records for each
child (the study pre-dates the present practice of screening out less serious events). A wealth of
qualitative information was obtained from caseworkers' narrative reports, which accompanied
each notification investigation. The study was designed so that caregivers' participation and
responses were not known to DOCS, given the fractious relationships that sometimes exist
between caregivers and caseworkers.
Predictive modeling was limited by the absence of genetic and pre-natal risk exposure.
Similarly, the study lacked measures of infant temperament. These limitations could possibly be
addressed in a more ambitious study e.g. by recruiting the parents of children in care to a cohort
study, and measuring the pre-natal care and development of subsequently born children. Other key
variables not measured include indicators of the quality of care provided to children in their present
placements. Ideally, the study would have measured carer motivations, parenting stress and burden
of care, carer attachment style, and the carers' feelings about the subject child. It is likely that these
quality of care factors account for a reasonable proportion of the variance in children's mental
health, and that they are also partly determined by children's pre-existing problems.
Several measures of risk exposure appeared to have suspect validity. First, number of
confirmed notifications is probably not a good indicator of exposure to chronic sub-critical
adversity, particularly neglect. Second, it is unclear whether time from first notification to entry
into care is a reliable measure of length of exposure to maltreatment, especially for children who
experience transient or occasional harm. Third, the high number of unconfirmed reports of
maltreatment of subject children (amidst a succession of confirmed reports) questions the validity
of a dichotomous assessment of harm.
5. Implications
A major challenge for this field is developing social care policy and practices that are
cognizant of the time-sensitive development of children in care, particularly regarding their
attachment and regulatory systems. There is need for greater understanding of the developmental
22
significance of court orders and case-plans among child welfare courts and agencies. The present
findings also highlight the particular vulnerabilities of children with developmental delays. More
than any other group, children who enter care with intellectual, language and specific learning
difficulties require early assessment, support and intervention.
The present study identified retrospective and concurrent predictors of children's mental health
from a large number of potential risk and protective factors. The principal finding was that entry
into care at younger ages protects chronically maltreated children who are in need of care from
developing mental health problems. The main implication of this is that psychological ill health
can be prevented if child welfare agencies can identify such children at younger ages. The
obvious challenges of earlier identification are: 1. avoiding false positive identifications that result
in children being improperly removed from their parents; and 2. predicting which parents can
attain substantive and lasting improvements in their caregiving within reasonable timeframes.
There is a need for research on how children who are in need of long-term care can be
differentiated from other at-risk children in infancy, and what barriers there are to early entry into
care.
In the present study, lack of placement security and/or permanency predicted mental health
problems among pre-adolescent children in care. These children were mostly placed in care
before age 5. It is hypothesized that children's insecurity and fear of loss and separation escalate
over time via two related mechanisms: 1. increased understanding of their birth and legal status,
and the status of their carers (linked to their level of cognitive development); and 2. in response to
their carers' expressed insecurity. These findings support policies that ensure permanency for
children in long-term care, with timeframes being dependent on children's developmental age
(younger children require quicker resolution). Regardless of whether permanency planning leads
to permanent alternate care, adoption or restoration to one's birth family, it should be as much
influenced by children's attachments, as their need for care and protection. Children's perceptions
of permanence are also important for their security. To this end, permanency requires legal status
(i.e. transfer of parental responsibility rights) if children are to grow up feeling secure.
Acknowledgement
This study was funded and supported by the NSW Department of Community Services.
References
Achenbach, T. (1991). Manual for the child behavior checklist/4-18, and 1991 profile. Burlington, VT: University of
Vermont.
Achenbach, T., & Rescorla, L. (2001). Manual for ASEBA school-age forms and profiles. Burlington, VT: University of
Vermont, Research Center for Children, Youth, & Families.
Armsden, G., Pecora, P. J., Payne, V. H., & Szatkiewicz, J. P. (2000). Children placed in long-term foster care: An intake
profile using the child behavior checklist/4-18. Journal of Emotional and Behavioral Disorders, 8(1), 4964.
Australian Institute of Health and Welfare. (2004). Child protection Australia 20022003. Child Welfare Series, Vol. 34
Canberra: AIHW.
Australian Institute of Health and Welfare. (2007). Child protection Australia 20052006. Child Welfare Series, Vol. 40
Canberra: AIHW.
Barber, J. G., Delfabbro, P. H., & Cooper, L. L. (2001). The predictors of unsuccessful transition to foster care. Journal of
Child Psychology and Psychiatry and Allied Disciplines, 42(6), 785790.
Besinger, B. A., Garland, A. F., Litrownik, A. J., & Landsverk, J. A. (1999). Caregiver substance abuse among maltreated
children placed in out-come-home care. Child Welfare, 78(2), 221239.
Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London: Routledge.
23
Cashmore, J., & Paxman, M. (1996). Longitudinal study of wards leaving care: Final report. Sydney: Commissioned by
the N.S.W. Department of Community Services.
Cicchetti, D., Toth, S. L., & Maughan, A. (2000). An ecological-transactional model of child maltreatment. In A. Sameroff
& M. Lewis (Eds.), Handbook of developmental psychopathology (pp. 689722)., (2nd Ed.). Dordrecht, Netherlands:
Kluwer Academic Publishers.
Cohen, J. (1988). Statistical power analysis of the behavioral sciences, (2nd Ed.). New York: Academic Press.
Crittenden, P. M., & Ainsworth, M. D. S. (1989). Child maltreatment and attachment theory. In D. Cicchetti & V. Carlson (Eds.),
Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 432463). New
York, NY: Cambridge University Press.
Delfabbro, P. H., & Barber, J. G. (2003). Before it's too late: Enhancing the early detection and prevention of long-term
placement disruption. Children Australia, 28(2), 1418.
Doll, B. (1998). Test review of the Child Behavior Checklist. In J. Impara & B. Plake (Eds.), Thirteenth mental measurements
yearbook. Lincoln, Nebraska: Buros Institute of Mental Measurements.
Dore, M., Kauffman, E., Nelson-Zlupko, L., & Granfort, E. (1996). Psychosocial functioning and treatment needs of
latency-age children from drug-involved families. Families in Society, 77(10), 595604.
Dozier, M., Stovall, K. C., Albus, K. E., & Bates, B. (2001). Attachment for infants in foster care: The role of caregiver
state of mind. Child Development, 72(5), 14671477.
Dubowitz, H., Zuravin, S., Starr, R. H., Feigelman, S., & Harrington, D. (1993). Behavior problems of children in kinship
care. Journal of Developmental and Behavioral Pediatrics, 14(6), 386393.
Dumaret, A. C., Duyme, M., & Tomkiewicz, S. (1997). Foster children: Risk factors and development at a preschool age.
Early Child Development and Care, 134, 2342.
EUROARC. (1998). Care to listen: A report of residential child care in four European countries. : EUROARC- European
Association for Research into Residential Childcare.
Fanshel, D., & Shinn, E. (1978). Children in foster care: A longitudinal investigation. New York: Columbia University Press.
Fergusson, D., & Lynskey, M. (1996). Adolescent resiliency to family adversity. Journal of Child Psychology and
Psychiatry, 33, 10591075.
Fonagy, P. (2003). The development of psychopathology from infancy to adulthood: The mysterious unfolding of
disturbance in time. Infant Mental Health Journal, 24(3), 212239.
Halfon, N., Mendonca, A., & Berkowitz, G. (1995). Health status of children in foster care. The experience of the Center
for the Vulnerable Child. Archives of Pediatrics & Adolescent Medicine, 149(4), 386392.
Hazell, P., & Stuart, J. (2003). A randomized controlled trial of Clonidine added to psychostimulant medication for hyperactive
and aggressive children. Journal of the American Academy of Child and Adolescent Psychiatry, 42(8), 886894.
Heflinger, C. A., Simpkins, C. G., & Combs-Orme, T. (2000). Using the CBCL to determine the clinical status of children
in state custody. Children and Youth Services Review, 22(1), 5573.
Hochstadt, N. J., Jaudes, P. K., Zimo, D. A., & Schachter, J. (1987). The medical and psychosocial needs of children
entering foster care. Child Abuse & Neglect, 11(1), 5362.
Howe, D., & Fearnley, S. (2003). Disorders of attachment in adopted and fostered children: Recognition and treatment.
Clinical Child Psychology and Psychiatry, 8, 369387.
Hukkanen, R., Sourander, A., Bergroth, L., & Piha, J. (1999). Follow-up of children and adolescents in residential care in
children's homes. Nordic Journal of Psychiatry, 53(3), 185189.
Klee, L., Kronstadt, D., & Zlotnick, C. (1997). Foster care's youngest: A preliminary report. American Journal of
Orthopsychiatry, 67(2), 290299.
Kreppner, J., O'Connor, T., Rutter, M., Beckett, C., Castle, J., Croft, C., et al. (2001). Can inattention/overactivity be an
institutional deprivation syndrome? Journal of Abnormal Child Psychology, 29(6), 513528.
Lambert, L., Essen, J., & Head, J. (1977). Variations in behaviour ratings of children who have been in care. Journal of
Leslie, L. K., Gordon, J., Ganger, W., & Gist, K. (2002). Developmental delay in young children in child welfare by initial
placement type. Infant Mental Health Journal, 23(5), 496516.
Marcus, R. F. (1991). The attachments of children in foster care. Genetic, Social, and General Psychology Monographs,
117(4), 365394.
Milan, S. E., & Pinderhughes, E. E. (2000). Factors influencing maltreated children's early adjustment in foster care.
Development and Psychopathology, 12(1), 6381.
Minnis, H., Everett, K., Pelosi, A., Dunn, J., & Knapp, M. (2006). Children in foster care: Mental health, service use and
costs. European Child and Adolescent Psychiatry, 15, 6370.
Newton, R. R., Litrownik, A. J., & Landsverk, J. A. (2000). Children and youth in foster care: Disentangling the
relationship between problem behaviors and number of placements. Child Abuse & Neglect, 24(10), 13631374.
24
Nutt, L. (2006). The lives of foster farers: Private sacrifices, public restrictions. Abingdon Oxon: Routledge.
O'Connor, T., Bredenkamp, D., Rutter, M., & the English and Romanian Adoptees Study Team. (1999). Attachment
disturbances and disorders in children exposed to early severe deprivation. Infant Mental Health Journal, 20(1), 1029.
O'Connor, T., & Rutter, M. (2000). Attachment disorder behavior following early severe deprivation: Extension
and longitudinal follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 39(6),
703712.
O'Connor, T., & Zeanah, C. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment &
Human Development, 5(3), 223244.
Olejnik, S., & Algina, J. (2000). Measures of effect size for comparative studies: Applications, interpretations, and
limitations. Contemporary Educational Psychology, 25, 241286.
Orme, J., & Reis, J. (1991). Multiple regression with missing data. Journal of Social Service Research, 15(1-2), 6191.
Plomin, R., DeFries, J., & McClearn, G. (1997). Behavioral genetics, (3rd Ed.). New York: W.H. Freeman.
Quinton, D., & Rutter, M. (1984). Parents with children in care: II. Intergenerational continuities. Journal of Child
Psychology and Psychiatry and Allied Disciplines, 25(2), 231250.
Roy, P., Rutter, M., & Pickles, A. (2000). Institutional care: Risk from family background or pattern of rearing? Journal of
Rushton, A. (2004). A scoping and scanning review of research on the adoption of children placed from foster care.
Clinical Child Psychology and Psychiatry, 9(1), 89106.
Rutter, M. (1999). Psychosocial adversity and child psychopathology. British Journal of Psychiatry, 174, 480493.
Rutter, M. (2000). Children in substitute care: Some conceptual considerations and research implications. Children and
Youth Services Review, 22(9-10), 685703.
Rutter, M., & Quinton, D. (1984). Parental psychiatric disorder: Effects on children. Psychological Medicine, 14(4),
853880.
Sawyer, M. G., Arney, F. M., Baghurst, P. A., Clark, J. J., Graetz, B. W., Kosky, R. J., et al. (2001). The mental health of
young people in Australia: Key findings from the Child and Adolescent Component of the National Survey of Mental
Health and Well-Being. Australian & New Zealand Journal of Psychiatry, 35(6), 806814.
Schofield, G. (2002). The significance of a secure base: A psychosocial model of long-term foster care. Child & Family
Social Work, 7, 259272.
Schofield, G., & Beek, M. (2005). Risk and resilience in long-term foster-care. British Journal of Social Work, 35(8),
12831301.
Sedlak, A., & Broadhurst, D. (1996). The third national incidence study of child abuse and neglect (NIS-3). Washington,
DC: U.S. Department of Health and Human Services.
Seifer, R., & Dickstein, S. (1993). Parental mental illness and infant development. In C. Zeanah (Ed.), Handbook of infant
mental health. New York: Guilford.
Shlonsky, A., Webster, D., & Needell, B. (2003). The ties that bind: A cross-sectional analysis of siblings in foster care.
Journal of Social Service Research, 29(3), 2752.
Simms, M. D. (1989). The foster care clinic: A community program to identify treatment needs of children in foster care.
Journal of Developmental and Behavioral Pediatrics, 10(3), 121128.
Sroufe, L. A. (1996). Emotional development: The organization of emotional life in the early years. New York: Cambridge
University Press.
Statacorp (2003). Stata statistical software (Version 8.0) [Statistical software]. College Station, Texas: Stata Corporation.
Swire, M., & Kavaler, F. (1977). The health status of foster children. Child Welfare, 56, 635653.
Tarren-Sweeney, M. (2006). Patterns of aberrant eating among pre-adolescent children in foster care. Journal of Abnormal
Child Psychology, 34, 623634.
Tarren-Sweeney, M. (2007). The Assessment Checklist for Children ACC: A behavioral rating scale for children in
foster, kinship and residential care. Children and Youth Services Review, 29, 672691.
Tarren-Sweeney, M., & Hazell, P. (2005). The mental health and socialization of siblings in care. Children and Youth
Services Review, 27, 821843.
Tarren-Sweeney, M., & Hazell, P. (2006). The mental health of children in foster and kinship care in New South Wales,
Australia. Journal of Paediatrics and Child Health, 42, 9199.
Tarren-Sweeney, M., Hazell, P., & Carr, V. (2004). Are foster parents reliable informants of children's behaviour
problems? Child: Care, Health and Development, 30(2), 167175.
Taussig, H. N. (2002). Risk behaviors in maltreated youth placed in foster care: A longitudinal study of protective and
vulnerability factors. Child Abuse & Neglect, 26, 11791199.
Thompson, B. (2002). Statistical, practical, and clinical: How many kinds of significance do counselors need to
consider? Journal of Counseling & Development, 80, 6471.
25
Tonge, B., & Einfeld, S. (2003). Psychopathology and intellectual disability: The Australian child to adult longitudinal
study. In L. Glidden (Ed.), International review of research in mental retardation, Vol. 26 (pp. 6191). San Diego:
Academic Press.
Trusty, J., Thompson, B., & Petrocelli, J. (2004). Practical guide for reporting effect size in quantitative research in the
Journal of Counseling and Development. Journal of Counseling & Development, 82, 107110.
Velleman, R. (1996). Alcohol and drug problems in parents: An overview of the impact on children and the implications
for practice. In M. Gopfert, J. Webster, & M. V. Seeman (Eds.), Parental psychiatric disorder: Distressed parents and
their families (pp. 233243).
Webster, D., Barth, R. P., & Needell, B. (2000). Placement stability for children in out-of-home care: A longitudinal
analysis. Child Welfare, 79(5), 614632.
Zeanah, C., Boris, N. W., & Larrieu, J. A. (1997). Infant development and developmental risk: A review of the past
10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36(2), 165178.

Retrospective and Concurrent Predictors of The Mental Health of Children in Care

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Children and Youth Services Review 30 (2008) 1 25

Retrospective and concurrent predictors of the mental

M. Tarren-Sweeney / Children and Youth Services Review 30 (2008) 125

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2.5. Statistical analysis

M. Tarren-Sweeney / Children and Youth Services Review 30 (2008) 125

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No gender differences achieved statistical significance.

Reported intellectual disability

Mean number of confirmed notifications.

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3.2.2. Maltreatment in care

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0.05 b0.0001 0.48

Later age at EIC

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Reported reading difficulties (Yes/No).

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Reported reading difficulties (Yes/No).

Confirmed exposure to classic emotional abuse, such as scapegoating, emotional blackmail,

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3.4. Inter-correlated factors

M. Tarren-Sweeney / Children and Youth Services Review 30 (2008) 125

Logistic regression models

Standardized eta coefficients

Odds ratios (95% C.I.)

0.12 0.14 0.10

(Variance accounted for by model) h (0.31)

(0.31) (0.31) (0.29)

Two carers working

CBCL total problems scores in the clinical range.

M. Tarren-Sweeney / Children and Youth Services Review 30 (2008) 125

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