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Adult Health and Social Outcomes of Children Who Have Been in Public Care: Population-Based Study
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     the Department of Paediatrics and Child Health, Royal Free and University College Medical School, Royal Free Campus, Royal Free Hospital, London, United Kingdom

    ABSTRACT

    Objective. To examine adult socioeconomic, educational, social, and health outcomes of being in public care in childhood.

    Methods. The 1970 British birth cohort was followed up at 5 (N = 13135), 10 (14875), 16 (11622), and 30 years (11261). Cases were defined as those ever in statutory or voluntary public care at 5, 10, and 16 years. Self-reported adult outcomes were occupation, educational achievement, general health, psychological morbidity, history of homelessness, school exclusion, and convictions.

    Results. A total of 343 (3.6%) of 9557 had been in public care <17 years. Nonwhite children were more likely to have been in care (odds ratio [OR]: 3.3; 95% confidence interval [CI]: 2.1–5.4). Controlling for socioeconomic status, men with a history of public care were less likely to attain high social class (OR: 0.6; 95% CI: 0.4–0.9) and more likely to have been homeless (OR: 2.0; 95% CI: 1.1–3.8), have a conviction (OR: 2.3; 95% CI: 1.5–3.4), have psychological morbidity (OR: 1.8; 95% CI: 1.1–3.0), and be in poor general health (OR: 1.6; 95% CI: 1.1–2.6). Similar associations were found in women. Men but not women with a history of care were more likely to be unemployed (OR: 2.6; 95% CI: 1.4–5.0) and less likely to attain a higher degree (OR: 0.4; 95% CI: 0.2–0.7). Nonwhite ethnicity was associated with poorer adult outcomes of being in care.

    Conclusions. Public care in childhood is associated with adverse adult socioeconomic, educational, legal, and health outcomes in excess of that associated with childhood or adult disadvantage.

    Key Words: foster care population health psychiatric disorders public health public policy

    Abbreviations: BCS70, 1970 British Birth Cohort Study OR, odds ratio CI, confidence interval

    Children in public care, whether voluntary or subject to a statutory care order, seem to be among those most at risk from the adverse effects of social inequalities.1 Numbers of children in public care increased in the United States during the 1990s, and it is estimated that >750000 children are currently in public care in the United States.2 Public care in the United Kingdom includes all children in the care of local state authorities, whether voluntarily or enforced by statute (this does not include families who are in state-supported accommodation as a result of poverty). Such children may be looked after either in private homes by related or unrelated foster parents (foster care) or in a variety of residential group settings, including children's homes (large residential institutions that care for large numbers of children) and family group homes (small institutions that care for small numbers of children in a simulated family environment). In England and Wales, 49 per 10000 children who are younger than 18 years are cared for by local authorities in such settings each year.3

    Such children have poorer physical and mental health and educational attainments during childhood.4–7 It is likely that children enter care with poorer health related to social disadvantage2,5,8,9 and that physical and psychological problems may worsen during care,2,7 as a result of problems with access to and continuity of health care,2,8 yet few data are available on adult outcomes of public care in childhood.2

    Uncontrolled studies of small groups of children who were in care and tracked into adult life suggest that they experience poor educational attainments10 and health and social function.11,12 Studies of socially excluded young adults suggest that those with a history of public care are overrepresented among homeless young people and the prison population and that young people who leave care at 16 years face unemployment rates of up to 50% to 80%.13 However, population-based longitudinal data on outcomes in adult life are not available. We used longitudinal data from the 1970 British Birth Cohort Study (BCS70) to examine outcomes of public care in childhood within multiple domains related to adult social exclusion.

    METHODS

    Participants

    The BCS70 is a continuing longitudinal study of infants who were born between April 5 and 11, 1970, in England, Scotland and Wales, and Northern Ireland. A total of 16567 infants were enrolled,14 with followed up at 5 years (N = 13135), 10 years (N = 14875), 16 years (N = 11622) and 30 years (N = 11261).15 Data were obtained electronically from the United Kingdom Data Archive, University of Essex, United Kingdom. Loss to follow-up was highest in disadvantaged groups: children who lived with 1 parent and children of teenage mothers were underrepresented at 5 and 10 years.14 At 30 years, marked efforts were made to recruit difficult-to-reach subjects; between the birth and 30-year surveys, there was a loss of 17% for those with parents who were born outside Britain, 9.2% for children of teenage mothers, and 14.6% for children of single mothers.15

    Outcome Measures

    Information on whether a child had ever been placed "in care," whether voluntary or statutory, was obtained from parental interview in the 5-, 10-, and 16-year surveys. At 5 and 10 years, the parent or caregiver was asked, "Has the child ever been in care (voluntary or statutory), now or in the past" At 5 years, the type of care accommodation was noted, whether with foster parent in a private home or in public residential accommodation including children's home (orphanage or large residential institution that cares for large numbers of children) and family group home (small numbers of children cared for by staff in a simulated family environment). At 10 years, parents were asked the age and duration of each episode of care. At 16 years, parents were asked whether parental responsibility had ever been taken from them since 10 years. A composite variable was constructed from these responses to indicate whether a subject had a history of public care and the age at which the child was first in care. At 30 years, subjects were asked whether they had ever been in care before their 17th birthday; these data were not used to define care status, as episodes of public care may not have been known to adult respondents. A "case" of having been in public care was defined as any child reported to have been in care in any of the 5-, 10-, or 16-year surveys. When children were reported in the 5-year survey as having been in public care but reported as never having been in public care in the 10-year survey, we used data from the 30-year survey to help assign subjects; those with a positive self-report history of being in public care were assigned as in care at 5 years. Those with a negative self-report history were assigned as likely to have been in public care by 5 years. We conducted all analyses with this likely group included to increase our sample size; however, we repeated all analyses with these subjects excluded to assess whether their inclusion significantly biased results.

    Socioeconomic status in childhood was defined by father's social class and mother's educational status at 10 years. Adult outcome data at 30 years were derived from confidential interview or self-report, including ethnicity, occupation, current income, educational and vocational achievements, marital history and age at first pregnancy, drug and alcohol use, accidents, school exclusion, crime, and self-rated general health. Problems with alcohol were assessed using the CAGE questionnaire (includes questions on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers), a validated screening tool in which a score of 2 indicates potential alcohol dependence or abuse.16,17 Mental health was assessed by confidential self-report, including the Rutter Malaise Inventory,18 a 24-item self-completion scale designed to assess psychological morbidity; a score 7 indicates likely psychological morbidity.19,20 Data on annual net income, drug and alcohol use, educational attainments, and pregnancy were derived using code provided by the Centre for Longitudinal Studies, Institute of Education, London.

    Analysis

    Data were analyzed using Stata 8. Differences in adult outcomes between those with a history of public care and those without were assessed using 2 after initial tabulation. Logistic regression then was used to assess the relationship between care history and each adult outcome. Odds ratios (ORs) were calculated without adjustment and then after adjusting for factors that were likely to confound the association with adult outcomes: father's social class in childhood, mother's educational status, and adult social class.

    RESULTS

    A total of 343 (3.6%) subjects had been in public care before 17 years, 224 (65%) of whom were in care at or before 5 years (including likely cases). There were no gender differences in likelihood of being in care or in age first in care. Data on self-assigned ethnicity was available from the 30-year survey on 335 (98%) subjects who had been in care, 25 of whom (7.5%; 6.6% of male subjects, 8.2% of female subjects) were nonwhite (9 black, 5 South Asian, 6 of mixed ethnicity, and 5 of other ethnicity). Nonwhite children were significantly more likely to have a history of public care (adjusted OR: 3.3; 95% CI: 2.1–5.4; P < .0001).

    The associations of care history with adult socioeconomic status are shown in Table 2. Public care in childhood was associated with significantly poorer social class outcomes and a history of homelessness in both genders and a >2-fold risk of current unemployment in men but not women.

    Legal and educational outcomes of public care are shown in Table 3. Men but not women with a history of public care were significantly less likely to achieve high educational outcomes, and women with a history of care were >3-fold more likely to be permanently excluded from school. Both genders were more than twice as likely to have a conviction by 30 years of age.

    Physical and mental health outcomes of public care are shown in Table 4. In both genders, those with a history of care were more likely to be high scorers on the Malaise Inventory, indicative of current psychological morbidity. Men but not women were more likely to have seen a mental health specialist for a mental health disorder since age 16. Among both men and women, those with a history of care were more likely to have fair or poor perceived general health but were not more likely to have a history of accidents or alcohol problems or to have used illicit drugs. Public care was not associated with higher risk for teenage pregnancy. These findings were not materially changed when analyses were repeated excluding cases that were considered only likely to have been in care at 5 years (data not shown).

    Age First in Public Care

    The 5-year period in which children were first in care was available in 331 (97%) subjects (Table 1). The integer age first in care was available from parental responses in the 10-year survey in 128 (37%) subjects. Those who were first in care at older ages were more likely to be lost to follow-up (adjusted OR for integer age: 1.13; 95% CI: 1.03–1.24; P = .01) Age first in care was not associated with any adult outcomes studied using either the integer year or age-group data.

    Placement

    Data on care placement were available in 304 subjects at 5 years, 165 (54%) of whom were looked after by foster parents and 139 (46%) of whom were looked after in group residential accommodation. Placement was not related to any adult outcomes measured.

    Ethnicity and Adult Outcomes

    Nonwhite children in care were significantly more likely to have a later history of homelessness than white subjects (adjusted OR: 3.0; 95% CI: 1.1–8.1; P = .03) yet were significantly less likely to leave school without any qualifications (adjusted OR: 0.2; 95% CI: 0.1–0.7; P = .01). Other outcomes were not significantly different between children of white and nonwhite ethnic groups.

    DISCUSSION

    In a large population-based sample, we found that those with a history of public care were significantly less likely to achieve high social status and significantly more likely to have been homeless, have a conviction, have psychological morbidity, and have poor general health. Men with a history of care were also more likely to be unemployed and have a history of mental health problems and less likely to attain higher education, whereas women with a history of care were more likely to be permanently expelled from school. These findings persisted when adjusted for childhood and adult social class and maternal education, suggesting that they reflect adversity related to being in public care per se, rather than to wider aspects of childhood and then adult disadvantage.

    Strengths and Limitations

    This study used data from a large national birth cohort and defined those with a history of public care using data obtained from early childhood to the end of possible statutory care. We controlled analyses for childhood social class, mother's educational status, and adult social class to segregate the effects of being in care from those of childhood and adult socioeconomic disadvantage.

    Weaknesses of this study arise from the high rate of dropout from adult follow-up among those with a history of care, the use of parental or caregiver report to define care history, and the use of self-report to define outcome at 30 years. Those with a history of care were more than twice as likely to be lost to follow-up, which will bias our findings toward underestimation of adverse outcomes. However, those who were followed up at 30 years were representative of the birth cohort, with minimal loss of those from lower socioeconomic groups. Bias in parent or self-report of public care is likely to manifest as denial. We sought to minimize this by defining care history using data from 3 childhood surveys and using adult self-report only for validation. Our findings regarding the impact of ethnicity on adult outcomes must be treated with caution because of the very small numbers of nonwhite subjects in this cohort. Similarly, our findings with regard to type of placement are limited by lack of detail regarding placements, eg, quality of parenting, whether kinship or nonrelative placements.

    The use of self-report to define adult outcomes may provide a source of bias; however, it is unclear whether those in care in childhood are more likely to overreport or underreport adult adversity. Given that ours is a secondary analysis of the cohort data set, participants were unaware of the hypotheses of our study at the time of follow-up.

    Comparison With the Literature

    Our finding of poorer socioeconomic outcome in both genders confirms reports that being in public care is linked with later social exclusion.21,22 It is likely that the development of inequalities is at least partly mediated by unemployment and by homelessness,13 given that nearly one fifth of women and one eighth of men who were previously in public care reported periods of homeless since age 16. However, many avoid significant disadvantage; we found that those who were previously in care were not overrepresented in the lowest income quartile, and the proportions who were currently unemployed and seeking work were significantly lower than reports of 50% to 80% unemployment in the years after leaving care.13

    We found that men but not women who had a history of care were less likely to achieve higher academic qualifications. However, contrary to previous reports from unrepresentative samples,10 those with a history of care were not more likely to leave school with no qualifications, and a higher risk for school exclusion was only found among women, suggesting that school failure in this group reflects childhood socioeconomic disadvantage as well as the effects of local authority care.

    A recent cross-sectional study of 142 children in public care found that they were significantly more likely than matched control subjects to be involved with the police and use illicit drugs.4 Our findings confirm that those with a history of care have a >2-fold higher risk for having a conviction by 30 years. However, participants were not more likely to report illicit drug use, alcohol problems, and accidents or being victims of personal crime.

    Reports from the United Kingdom National Child Development Study suggested that men but not women who were born in 1958 and were in public care in childhood had higher Malaise scores at age 33 than those who were not.23,24 We found a similar gender difference in history of mental health problems since age 16 but found that women as well as men with a history of care were nearly twice as likely to be high scorers on the Malaise Inventory. These differences may reflect social change or changes in treatment of children in public care between the 2 birth cohorts. The proportions of those with a history of care with adult psychological morbidity in our study were significantly less than suggested by a case-control study of 88 adolescents, which reported that 67% had a psychiatric disorder compared with 15% of matched control subjects.25 This may reflect methodologic differences but may also suggest that the adverse effects of care on mental health attenuate somewhat in adult life.

    Our data did not confirm previous reports suggesting that nearly half of young women who leave care at 16 years were mothers within 18 to 24 months.22 Indeed, in our sample, only 1 of 39 women who had been first in care between 10 and 16 years reported a pregnancy at <18 years. Given that teenage pregnancy rates in this cohort were comparable to contemporary national data,26 this suggests that studies of care-leavers may identify higher levels of adversity such as teenage pregnancy, reflecting longer duration of care among those who leave care at 16 years. It is also likely that, in our cohort, loss to follow-up was higher among teenage mothers.

    Few comparative data are available on the effects of age first in public care or the duration of care on adult outcomes. We found that adult outcomes varied little by age first in care, which does not support suggestions that being in public care in early childhood is particularly damaging. We found no evidence of difference in adult outcomes between foster placements and residential group homes. These findings should be regarded with caution, as data on placement were available only for a minority, and we have no data on the quality or number of placements.

    CONCLUSIONS

    Public care in childhood is associated with adverse adult socioeconomic, educational, legal, and health outcomes in excess of that associated with childhood or adult disadvantage. We did not confirm previous reports of high rates of mental health problems, unemployment, and teenage pregnancy. This suggests that disadvantage associated with public care is substantially less than is reported by studies of those who leave care at 16 to 17 years and by cross-sectional studies during adolescence that fail to account adequately for other causes of disadvantage. It is estimated that the majority of children spend <6 months in care in the United Kingdom,27 and our data, although likely to underestimate adversity, suggest that the great majority do not experience significant long-term health or social adversity. Additional research is needed to examine whether timing or placement of care affects long-term outcomes and whether enriched care interventions can reduce adult disadvantage in those groups most at risk, such as children from nonwhite ethnicities.

    ACKNOWLEDGMENTS

    Dr Viner is funded by a fellowship from the Health Foundation.

    FOOTNOTES

    Accepted Aug 2, 2004.

    No conflict of interest declared.

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