Sleep in Youth Who Have Aged out of Foster Care: Impact on Mental Health

Background and Purpose: Children who enter the foster care system are at risk for long-term mental health problems. Many develop depression, anxiety, or post-traumatic stress as a result of the accumulation of stress in their lives. In addition to the effects of child maltreatment, these youth have experienced the loss of birth parents, extended family, and familiar environments. Prior researchers have suggested that exposure to such stressors can cause marked impairment of sleep and interference with sleep architecture, suggesting that children who spend time in foster care may be at risk for sleep problems.

The ability to initiate and maintain sleep is closely related to stress regulation and hyperarousal. Individuals who regularly experience high levels of vigilance or who perceive their environment as unsafe are vulnerable to sleep disturbances. Sleep disruptions have been strongly associated with psychiatric problems in community samples of young adults. For youth who have experienced significant trauma and stress in their lives, sleep may be an important mediator in the relationship between stress and poor mental health.

Methods: Eighty youth aged 18-25 who had spent time in foster care (FC) were recruited with a matched group of 40 youth who had never been in care. All youth were given surveys to measure depression, anxiety, and trauma symptomology as well as their life experiences. All youth completed a measure of their perceived sleep quality. Youth wore sleep monitors to objectively measure quality and duration in their own homes for five consecutive nights. Structural equation modelling (SEM) was used to explore the mediating role of sleep and the relationship between time in care and number of placements, and depression, anxiety, and trauma symptoms. Youth were excluded from the study if they had a diagnosed sleep disorder, a psychotic disorder, or lacked a regular place to sleep.

Results: The FC group reported an average of 2.8 years in care (range 18 months-6 years) and an average of 3.2 placements (range 1-6). FC youth showed significantly fewer hours of sleep and more sleep disruptions than the control youth. All greatly overestimated the amount of sleep they were getting. Anxiety and trauma were significantly higher among FC youth, but both groups had similar rates of depression. SEM showed that both sleep quality and duration fully mediated the relationship between years in care and trauma symptomology.  Both sleep quality and duration fully mediated the relationship number of placement and anxiety symptomology. Sleep quality mediated the relationship between years in care and depression.

Conclusions and Implications: Results show that improving sleep in FC youth could have significant mental health benefits. Agency providers, foster caregivers, and youth in care should be educated about the importance of good sleep hygiene, including practices such as using white noise machines and avoiding screen time for at least 30 minutes before bedtime. Cognitive Behavioral Therapy for Insomnia has shown effectiveness for those who have serious sleep problems, especially when there is a trauma history, and may help youth improve sleep, and in turn, prevent later mental health problems.