Psychosocial Factors of Behavioral Health Outcomes Among Children in Foster and Kinship Care: A Systematic Review

Purpose: Children with behavioral problems are at risk for delinquency and physical violence, substance use, and antisocial behaviors in young adulthood; many children who experience foster and kinship care suffer from these negative outcomes. Thus, research should be conducted to identify factors that can be used for prevention and to develop effective treatments for this population.  This systematic review has three aims: 1) examine the characteristics (e.g., research design, instrumentation) of studies exploring psychosocial factors associated with behavioral health outcomes (e.g., internalizing and externalizing behaviors, ADHD) among foster and kinship care children; 2) explore the associations between psychosocial factors and behavioral health outcomes; and 3) assess the methodological quality of these studies.

Methods: Our systematic review was conducted using methods consistent with the PRISMA Group and Gough and colleagues; the methodological rigor of each study was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment tool. In general, the research team used the following steps: create protocol; search, store, and screen studies; data extraction; assess for risk of bias; date synthesis; and write report.  The review’s quality was enhanced by utilizing internal and external quality procedures including double-blind screening and coding, and pilot testing the study’s coding instruments (e.g., data extraction form).  Social Work Abstracts, PsycInfo, and Social Service Abstracts electronic databases were searched to identify English language studies published in academic journals, books, and grey literature. Other inclusion criteria consisted of psychosocial factors (e.g., family, community, social factors, beliefs, etc.) as independent variables; behavioral health as a dependent variable; and study samples that included children 18 years of age or younger living in formal/informal foster or kinship care.

Results: The searches identified 2766 studies, 285 underwent full-text review, and of these 33 studies were eligible. Inter-rater reliability as followed: titles/abstracts screening, Cohen’s κ=0.90; full-text review, Cohen’s κ=0.88.We utilized a PRISMA diagram, tables, and narratives to analyze data that revealed 58% of studies were cross-sectional (19/33); 12% were intervention studies (4/33); and 55% had a sample that consisted of predominantly racial/ethnic minorities (18/33). The most used scale to assess behavioral health problems was the Child Behavior Checklist (58%; 19/33). Foster or kinship caregivers’ parenting practices was the most examined psychosocial factor to predict children’s behavioral health; followed by maltreatment and type of placement. For example, parenting quality, permissiveness, and discipline style were related to behavioral health problems; subtype and severity of childhood trauma were significant predictors of behavioral health problems; and children in kinship care placements had fewer behavioral problems and experienced greater gains from behavioral health interventions. The majority of studies (76%; 25/33) had a global methodological rating of moderate.

Conclusions/Implications: This review’s findings suggest the importance of parenting practices on children’s behavioral health. Thus, practitioners should work with foster and kinship caregivers to support specific parenting skills to ensure positive outcomes for children.  Given the minute number of intervention studies identified in this review, future research should focus on evidence-based intervention research, as well as use findings from this review to develop and/or adapt interventions.