Those who suffer from psychiatric disturbances, whether psychoneurotic, sociopathic, or psychotic, always show impairment of the capacity for affectional bonding, an impairment that is often both severe and long lasting…Antecedent conditions of significantly high incidence [of mental disorders] are either an absence of opportunity to make affectional bonds or else long and perhaps repeated disruptions of bonds once made.[1]
When a foster child first enters care, a critical attachment or bond has already been disrupted. He is placed in a temporary parking spot where he is physically safer until a permanent and stable home can be found. This is an emergency placement. If he were in a burning building, our first step would be to get him out fast. The situation itself is a serious problem. Being in temporary care after having been removed from his home is an emergency. The best therapy for a newly removed foster child is to return him to his rehabilitated family or to find him a new and stable home, and to do so within the year prescribed by law.
Instead, in an alleged attempt to “get it right,” the child welfare system compounds the problem with bureaucratic delays. Worse still, the child may be moved from one foster home to another and eventually leave the system with no permanent home. For many, this disruption of attachments or bonds will become internalized and lead to mental illness in childhood or later in adulthood.
What is mental illness? In simple terms, mental illness is a disorder of thought or behavior that significantly interferes with functioning in a major life area such as home, work or leisure time. Both the research and common sense affirm what Bowlby reports: disrupted “affectional bonding” is a strong antecedent for many serious mental disorders. Psychiatric problems of childhood set the stage for adult illnesses that include post-traumatic stress disorder, anxiety disorders, depression and thought disorders like paranoia and schizophrenia. Even among seemingly normal adults, failure to form healthy emotional attachments makes stable and joyful family life difficult if not impossible.
A common regression
Many foster children will typically move through five emotional stages as they wait for society to find them permanence.
- Hope. At first the child has hope. “Maybe this family will be the one. If only…” But in time, hope fades.
- Fear. As hope declines, fear takes over. “What if it will always be like this? What if no one really wants me? What if I never have a home? What if…” Fear hurts.
- Anger. After fear comes anger. The child gets mad and often expresses feelings by acting out, temper tantrums, foot-dragging, stealing, destroying property, and failing deliberately in school to frustrate the foster parents.
- Depression. The anger may dissipate into darkness. The child becomes quiet and sad.
- Indifference. In time, the depression may be replaced by a coldness, a lack of caring. “It doesn’t matter! What’s the use? Who cares anymore? I don’t.”
The destructive cycle has run its course. The abused child has learned not to hope for or trust relationships. Attachment and bonding are regarded as hurtful and dangerous. The child has chosen detachment.
Childhood mental illness
Trauma begins when a young child is removed from a situation of abuse or neglect. Frightened, bewildered, upset, he comes to a new and totally unknown home. In time he becomes accustomed to this new home, grows to like it, and attaches to the people in the home. Suddenly his case manager moves him to another home. These people are also kind to him. He likes his room, he likes the food. But he is cautious about growing attached to them. Sure enough, six months later, he moves to yet a third foster home. This time he may greet the new people warmly and smile at the right time, He may get used to the food and the bed and the new school. But he no longer feels any attachment to the family. On the outside he wears the mask of compliance. On the inside he remains apart and alone. He has learned how painful broken attachments are, and he will no longer expose himself to that kind of pain. Intermittent placement and the resultant non-attachment can result in mental illness.
“Two psychiatric syndromes and two sorts of associated symptoms are consistently found to be preceded by a high incidence of disrupted affectional bonds during childhood. The syndromes are psychopathic (or sociopathic) personality and depression; the symptoms (lead to) delinquency and suicide…The psychopath (or sociopath) is a person who, whilst not being psychotic or mentally subnormal, persistently engages in: (1) acts against society, e.g. crime; (2) acts against the family, e.g. neglect, cruelty, promiscuity, or perversion; (3) acts against himself, e.g. addiction, suicide, or attempted suicide, repeatedly abandoning his job.”[2]
Kulp summarizes common pathologies of foster children that are made worse by a continuing lack of permanence.[3]
- Delayed development in personal hygiene
- Immaturity and poor social skills
- Problems with authority figures (feelings of powerlessness, acting out, etc.)
- Stress reactions (fire setting, animal abuse, etc.)
- Self-destructive behaviors (lying, stealing, running away, suicide attempts, etc.)
- Difficulty in relating to others (passivity, dissociation, etc.)
- Attachment and separation problems
- Psychosomatic complaints (nightmares, stomach aches, etc.)
- Physical and mental impairments
Many other researchers commented on the dangers associated with a history of multiple moves and documented similar lists of childhood mental disorders resulting from interrupted attachments.[4]
Steinhauer[5] reported on the wide-ranging negative effects from subjecting children to a series of short-term attachments. “Neglect, abuse, and/or multiple moves set the stage for a reactive attachment disorder resulting in children who resist relationships. These children develop pseudo-relationships with others that on the surface appear engaging, but in actuality are highly manipulative and self-serving, lacking the warmth and empathy necessary to sustain any true bonding…Examples of attachment-disordered behaviors that do not allow reciprocity include manipulation, promiscuity, instigating conflict, and theft.”
The Committee on Early Childhood, Adoption, and Dependent Care of the American Academy of Pediatrics[6] stated: “The following important concepts should guide pediatricians’ activities as they advocate for the child:
- Biologic parenthood does not necessarily confer the desire or ability to care for a child adequately.
- Supportive nurturing by primary caregivers is crucial to early brain growth and to the physical, emotional, and developmental needs of children.
- Children need continuity, consistency, and predictability from their caregiver. Multiple placements are injurious.
- Attachment, sense of time and developmental level of the child are key factors in their adjustment to environmental and internal stresses.”
The American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) has included the following common childhood diagnoses caused or aggravated by the disruption of attachments and bonds.
- Reactive Attachment Disorder (RAD)
- Separation Anxiety Disorder (SAD)
- Adjustment Disorders
- Attention-Deficit/Hyperactivity Disorder (AD/HD)
- Oppositional Defiant Disorder (ODD)
- Developmental Delay
- Learning Disorders
The American Psychiatric Association has identified foster care drift as one cause of RAD. The DSM-V indicates that Reactive Attachment Disorder may arise from the “repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care.)” To remove a child from the biological home to protect him from abuse or neglect and then subject him to a series of foster care placements is a cruel folly. We have corrected the initial problem while creating another.
Separation Anxiety Disorder is characterized by inappropriate and excessive fear or anxiety concerning separation from home and those to whom the person is attached. SAD may display itself as a fear of getting lost or kidnapped, a fear that attachment figures may suffer harm, refusal to attend school, a fear of being alone, sleep problems, nightmares, and repeated complaints of physical symptoms. (DSM-V)
Adjustment Disorders are described as expressing clinically significant emotional or behavioral symptoms in response to an identifiable stressor or stressors… (DSM-V) The symptoms may include depression, anxiety, flattened emotions and/or misbehavior. The obvious stressor in foster care drift and delay is the continuing insecurity resulting from the lack of a permanent place to call home.
AD/HD is described as “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development….” (DSM-V) The pattern of inattention may be the result of attachment problems endemic to temporary care. The hyperactivity may also be expressed in misconduct as a result of the anxiety and pervasive anger generated by separation.
Oppositional Defiant Disorder is described as “a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months…” (DSM-V) Included among the many symptoms are loss of temper, arguing, refusing to comply, annoying others deliberately, blaming others, and being angry and vindictive. The disruption or lack of a secure base is a causative factor in the development of strong resentment. Attachment insecurity has a neural base and leads to problems in the regulation of emotions and the self-monitoring of conflicts.
Although Developmental Delay is more often associated with physical causes, it may also be the response of a detached child who has decided that it is easier to give up and not to try. Experts have estimated that foster children are often one to two years behind academically and emotionally. Being moved and shuffled around can retard development.
Learning Disorders were formerly referred to as “Academic Skills Disorders.” They are diagnosed “when the individual’s achievement on individually administered standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence. The learning problems significantly interfere with academic achievement or activities of daily living.” (DSM-V) As with developmental delay, learning disorders may develop as the result of being shifted from home to home, from school to school.
Childhood experiences carry over
The pathological response to neglectful or abusive parenting is not always expressed immediately. In some cases, the initial reactions are repressed. Feelings go underground where they may remain hidden, waiting for a time free of the need to conform. The young adult may have appeared an ideal and obedient child, never any problems at all. Until now.
Early or later on, our relationships with others are significantly linked to our mental health. In speaking of early attachment problems, Dozier goes beyond the initial trauma. “Just as important as the loss itself are the child’s subsequent experiences with caregivers.”[7] For a foster child, waiting while in temporary care is a significant form of continuing neglect. Neglect is a form of silent abuse, more serious than actual physical abuse because it more difficult for the child to identify and target.
Reviewing the many studies correlating the nature of early attachments to adult psychopathology, Dozier and Rutter[8] summarized the connections between painful childhood experiences with caregivers and later adult mental pathology.
Mood Disorders: Bowlby[9] lists three early experiences which he postulates can lead to adult depressive disorders. First, the death of a parent is an experience over which the child has no control and can lead to hopelessness. Second, the lack of opportunity or inability of the child to form stable relationships with caregivers can lead to a sense of self as a failure. Third, when the caregiver gives the message that the child is incompetent or unlovable, the later adult may anticipate the same hostility and rejection from his or her peers. The stage is prepared for a “what’s the use?” approach.
Anxiety Disorders: Almost all anxiety disorders can be accounted for by early insecurity regarding the availability of attachment figures.[10] Subsequent chronic fear and avoidance in later adult life is understandable.
Dissociative Disorders: Adult dissociative disorders involve a turning away from some perceived difficult new relationships or experiences. Learning to disconnect as a child creates a pattern of failing to resolve problems with others. With schizophrenia, the dissociation may deepen to a psychosis, the loss of touch with reality, hallucinations and delusions.
Borderline Personality Disorder is associated with the exaggeration of symptoms and a negative outlook together with concerns about relationship issues. As with most adult states of mind, it has its origin in childhood experiences. The BPD adult often views experienced caregivers as unhelpful or unavailable and has developed an unstable sense of self.
Antisocial Personality Disorder is expressed in a disregard for the rights and feelings of others. Caregiver abuse and threatened or actual separation in childhood is met with anger. This anger is often repressed in children and may be directed to other targets in later adult life.
Dozier and Rutter[11] sum up their findings: “psychiatric disorders are nearly always associated with non-autonomous (or insecure) states of mind. Furthermore, unresolved status is the most overrepresented state of mind among people with psychiatric disorders.”
Adult mental illness
Disorders of childhood generated by delays and multiple moves are mild compared to what is yet to come. The breaking of bonded relationships can cause even more serious problems in adulthood. Pay me now or pay me later. While there are many contributing and confounding antecedents of adult disorders, adult mental illness, crime, poverty and homelessness have all been positively correlated with time spent in foster care. Problems submerged in childhood behind a veneer of compliance are apt to surface in adult life.
Foster care, even when necessary and optimal, carries with it uncertainty. Delay adds the impact of rejection. Feelings of insecurity and low self-worth are a natural consequence. The person who carries this condition into adulthood is much more vulnerable to mental, emotional and behavioral disorders. Childhood experiences have lifelong consequences.
Many researchers have written of the correlation between attachment problems and adult mental illness among children who graduate from foster care. Bowlby[12] cites a number of other studies that show a strong correlation between disrupted bonding and a significant increase in antisocial behavior, illegitimacy and suicide. When attachments are damaged or broken, the research confirms an increase in Depression, Anxiety Disorders, Eating Disorders, Substance Abuse, Schizophrenia, Borderline Personality Disorders, and Antisocial Personality.[13]
Results of the Casey National Alumni Study[14] and the Northwest Alumni Study[15] (2005) reveal that former foster children are experiencing much higher rates of mental illness as adults than the general population. Here is a summary of their comparisons.
- Fifty-four percent of former foster children in the states of Washington and Oregon had one or more mental disorders in adulthood, compared with 22 percent in the general population.
- Foster care graduates nationally were four times as likely to suffer from post-traumatic stress disorder as a comparable group (21.5% to 4.5%). They were almost twice as likely to suffer from PTSD as war veterans from Vietnam, Iraq and Afghanistan.
- Former foster children were 2.1 times more likely to become clinically depressed than the general population.
- Former foster children were over twice as likely to suffer from panic and anxiety
- Former foster children were 2.8 times more likely to suffer from psychotic problems and 2.5 times more likely to suffer paranoia.
- Foster care alumni experienced seven times the rate of drug dependence and nearly two times the rate of alcohol dependence as their counterparts.
The psychological trauma incurred through child abuse and in foster care can have serious consequences that begin in childhood and last throughout life. Foster children and emancipated foster care alumni are more than twice as likely as other children to become mentally ill.
Chapter 7 Delay, Despair, and Detachment: The Mental Health of Foster Children Notes
[1] John Bowlby, The Making and Breaking of Affectional Bonds, (London: Tavistock, 1979)
[2] Ibid.
[3] Jodee Kulp, Families at Risk, (Minneapolis: Better Endings, 1993)
[4] See Robert Karen, Becoming Attached, (New York: Warner, 1994); Mary Main, “Introduction to the special section on attachment and psychopathology: Overview of the field of attachment,” Journal of Consulting and Clinical Psychology, 64(2), 1996, 237-243; H. Clark et al. (1998) “An individualized wraparound process for children in foster care with emotional/behavioral disturbances: follow-up findings and implications from a controlled study,” In Michael H. Epstein, Ed, Outcomes for children and youth with emotional and behavioral disorders and their families: Programs and evaluation best practices, Austin, TX: Pro-Ed, Inc, xviii, 513; Mark T. Greenberg, “Attachment and psychopathology in childhood,” In Jude Cassidy and Philip Shaver (Eds.). Handbook of Attachment: Theory, Research, and Clinical Applications, (New York: Guilford, 1999) 469-496.
[5] Steinhauer, op.cit.
[6] American Academy of Pediatrics. Committee on early childhood, adoption, and dependent care. “Developmental issues for young children in foster care,” Pediatrics. 106(5), 2000, 1145-50.
[7] Mary Dozier and Michael Rutter, “Challenges to the Development of Attachment Relationships Faced by Young Children in Foster and Adoptive Care,” In Jude Cassidy and Philip Shaver (eds.), Handbook of Attachment: Theory, Research, and Clinical Applications. 2nd Edition, (New York: The Guilford Press, 2008)
[8] Ibid.
[9] John Bowlby, Attachment and Loss. Vol. 3. Loss, Sadness, and Depression, (New York: Basic Books, 1980)
[10] John Bowlby, Attachment and Loss. Vol. 2, Separation, Anxiety and Anger, (London and New York: Hogarth, 1973)
[11] Dozier and Rutter, p. 738, op.cit.
[12] Bowlby, 1979, op.cit.
[13] See JohnTriseliotis, “Identity and security in adoption and long-term fostering,” British Agencies for Adoption and Fostering, 7(1), 1983; Jane Aldgate, “Graduating from care: a missed opportunity for encouraging successful citizenship,” In Children & Youth Services Review, special issue: Preparing foster youth for adulthood, Vol. 16(3-4), 1994.
[14] Peter Pecora et al, “Assessing the Effects of Foster Care,” Casey National Alumni Studies, 2003.
[15] Peter Pecora et al, “Improving Family Foster Care,” Findings from the Casey Northwest Foster Care Alumni Study, 2005.