Understanding the mental health and wellbeing of children in out-of-home care

Hilary Miller and Kristel Alla, Australian Institute of Family Studies, Australia, March 2024

Resource Summary

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This resource briefly explores mental health and wellbeing outcomes and experiences of children in out-of-home care (OOHC) in Australia. It is for professionals working with children in care, including social workers, child protection and care workers, mental health practitioners (e.g. psychologists, psychiatrists), health practitioners (e.g. general practitioners, nurses), and allied health professionals. Programs and practice approaches to support children’s mental health in OOHC are outlined in the following resources:

Key messages

  • Out-of-home care refers to alternative living arrangements of children managed by relevant state/territory child protection departments.
  • In Australia, Aboriginal and Torres Strait Islander children are significantly over-represented in the OOHC population, owing to historical and contemporary impacts of colonisation and racism.
  • Children who have experienced OOHC have increased risk for some mental health challenges and are at higher risk for poor mental health outcomes, compared with children who have not been in care. However, children’s experiences are highly varied and mental health is influenced by various factors, including pre-care and OOHC-specific factors. Children in OOHC have specific mental health needs and require tailored and effective wellbeing support.
  • Children in OOHC have highlighted factors they perceive as important for their mental health including feeling safe, receiving information about their care and decisions impacting them, and maintaining relationships with important people.
  • More holistic, strengths-based and participatory research and practice with children in OOHC is needed, to identify what can support children’s mental health and wellbeing.

Children in out-of-home care (OOHC) often experience a higher rate of mental health challenges compared to children who have not been in care. To effectively support children’s mental health in OOHC and tailor support to their individual needs, practitioners need a foundational understanding of:

  • the OOHC system in Australia (including placement types and population groups that are over-represented)
  • common mental health challenges that children in OOHC may experience; and
  • what influences the mental health and wellbeing of children in OOHC (including OOHC-specific factors).

This resource provides information about the OOHC system in Australia, the mental health outcomes of children in care, and the various factors that can influence psychosocial1 outcomes for children. Programs and practice approaches to support children’s mental health and wellbeing in OOHC are outlined in complementary resources (e.g. programs to support the mental health of children in care and guiding principles for effective practice) and further information is available in the related resources section of this paper.

 

The Australian out-of-home care system

In Australia, individual states and territories are responsible for child protection systems and arrangements (AIHW, 2021a). Child protection services include intensive family support services (to support families at-risk of OOHC placement), investigation of allegations of child maltreatment and the provision of legal arrangements for child welfare (i.e. care and protection orders), and the OOHC system (AIHW, 2021a; Productivity Commission, 2021).

Out-of-home care refers to alternative living arrangements for children who are in contact with the child protection system. Most children in OOHC (95%) are on care and protection orders which defer all legal responsibility for the child’s welfare to state or territory child protection departments and/or agencies (AIHW, 2023; Productivity Commission, 2021). Child protection departments and/or agencies are responsible for providing ongoing case management throughout a child’s time in OOHC, and for engaging with relevant community service organisations (CSOs) and/or Aboriginal community-controlled organisations (ACCOs) (AIHW, 2021a). CSOs and/or ACCOs provide everyday care of children in OOHC and are responsible for recruiting, training and maintaining foster and kinship carers and paid residential staff (AIHW, 2021a).

The most common OOHC placement types include:

  • foster care: in which a child is placed into the care of a foster carer
  • kinship care: in which a child is placed into the care of another family member or known adult; and
  • residential care: in which a child is cared for in residential facilities by paid staff.

Kinship care can include both formal and informal care arrangements. Formal kinship care refers to arrangements that have occurred following engagement with the child protection system. Informal kinship care placements are arrangements made by families without formal involvement of child protection services or agencies. As there is limited data on children in informal kinship care and carers, in this resource we focus on formal kinship care.

The Aboriginal and Torres Strait Islander Child Placement Principle (ATSICPP) is a national policy aimed at decreasing the number of Aboriginal and Torres Strait Islander children in child protection and OOHC and supporting cultural continuity and connectedness for children within OOHC (AIHW, 2022). Under the ATSICPP, all Aboriginal and Torres Strait Islander children in OOHC should be placed with kin or in the care of Aboriginal and/or Torres Strait Islander carers (AIHW, 2022a; SNAICC, 2019). In addition to preferencing kinship placement, the ATSICPP also outlines other special care provisions for Aboriginal and Torres Strait Islander children. However, the implementation of ATSICPP and related policies has been inconsistent (Blackstock et al., 2020; McDowall, 2016). For example, only two-thirds (63%) of Aboriginal and Torres Strait Islander children in OOHC nationally are living with Aboriginal and/or Torres Strait Islander kin, non-Indigenous kin, or other Aboriginal and/or Torres Strait Islander carers (AIHW, 2022a).

It should be noted that placement arrangements for children can, and often do, change. Children may move between placement types (e.g. from foster care to residential care) and between placements (e.g. from one foster home to another).

 

Children in out-of-home care in Australia

As of June 2022, there were around 45,400 Australian children living in OOHC, including 19,400 Aboriginal and Torres Strait Islander children (AIHW, 2023). A significant number of children in care are aged between five and 14 years old (61%); around 21% are under five years and 17% are over 15 years old (AIHW, 2023). Most children (70%) are in long-term care arrangements and/or have been in care for more than two years (AIHW, 2023).

Most children in OOHC in Australia are either in foster (35%) or kinship care (54%) (AIHW, 2023). These care arrangements are collectively referred to as ‘home-based care’. A smaller proportion (9%) of children live in residential care (AIHW, 2023). Kinship care is the most common OOHC placement for Australian children, even when excluding children who have informal care arrangements (AIHW, 2023).

Aboriginal and Torres Strait Islander children are vastly over-represented among children in OOHC (O’Donnell et al., 2019; Liddle et al., 2022). This over-representation is linked to historical and systemic factors, such as the ongoing impacts of colonisation, intergenerational trauma, and racist policies, including the forced removal of Aboriginal and Torres Strait Islander children (Blackstock et al., 2020; Human Rights and Equal Opportunity Commission, 1997; Yoorrook Justice Commission, 2023). Aboriginal and Torres Strait Islander children are more than 10 times more likely to have contact with the child protection system than non-Indigenous children (AIHW, 2021a; O’Donnell et al., 2019; Liddle et al., 2022). Despite the high rates of removal of Aboriginal and Torres Strait Islander children and government commitments to reducing their over-representation in care, the numbers of Aboriginal and Torres Strait Islander children in care continue to increase (AIHW, 2021a, 2023).

There is strong evidence of a social gradient in contact with child protection and OOHC; that is, children from lower socioeconomic backgrounds experience a greater risk for contact with child protection and OOHC placement (AIHW, 2021a; Turney & Wildeman, 2017; Wood et al., 2022). In Australia, more than a third of children who receive child protection investigations are from the most socioeconomically disadvantaged neighbourhoods (AIHW, 2021a). Children with disability are also over-represented in OOHC, and there is emerging evidence of high numbers of LGBTQ+ children and young people in OOHC (Baams et al., 2019; Maclean et al., 2017; Schaub et al., 2022; Shannon et al., 2023).

1.  Psychosocial factors include both psychological and social factors (e.g. social determinants) that can influence mental health and wellbeing (Washington et al., 2018).

Psychosocial outcomes of children in out-of-home care

The following section outlines common psychosocial (psychological and social) outcomes for children in OOHC and factors that influence mental health that have been outlined in research literature. Much of the existing research on the mental health of children in OOHC has focused on the extent of mental health disorders, challenging behaviours, and risks for poor mental health. Relatively less research has explored and identified protective factors, and how to promote good mental health and wellbeing for children in care (ACYP, 2021; Devaney et al., 2023).

It is important to note that children in OOHC are a heterogeneous (diverse and varied) group, whose mental health and other outcomes can vary depending on complex and intersecting factors (which are explored in the next section). Mental health outcomes and presentations are also influenced by children’s experiences prior to OOHC (including exposure to adversity) and their experiences within OOHC (including their placement arrangements). As a result, it is difficult to determine the prevalence of specific mental health challenges among children in OOHC.

 

Common child mental health outcomes in out-of-home care

Children in OOHC have often experienced potentially traumatic events and disrupted attachment with caregivers and other significant people in their lives. They may also have experienced abuse or neglect. This can have substantial impacts on their mental health and wellbeing and lead to a higher risk of mental health challenges than for their peers who have not experienced OOHC care.

Research literature indicates that children in OOHC often experience poor mental health outcomes, including a higher rate of mental health challenges and disorders compared to children with no care experience (Engler et al., 2022; Tarren-Sweeney & Hazell, 2006). Some children in OOHC will not experience any long-term mental health challenges and will experience good psychosocial outcomes (Alvarez et al., 2022; Bell et al., 2015; Washington et al., 2018). However, around half to two-thirds of children in OOHC will experience a mental health challenge of some kind (AIFS et al., 2015; Westlake et al., 2023).

Some mental health challenges that may present among children in OOHC include2:

  • Trauma-related outcomes: Many children in OOHC have experienced potentially traumatic events. For some, the impacts of trauma can persist in the form of  trauma-related, stress-related or dissociative challenges and/or disorders (e.g. post-traumatic stress disorder (PTSD; Bollinger et al., 2017; Hiller et al., 2021; John et al., 2019; McGuire et al., 2021; Perzow et al., 2013; O’Hare et al., 2021). Please refer to our accompanying practice guide for details about trauma-informed practice for children in OOHC.
  • Attachment challenges: Many children in OOHC experience disruption to their relationships and attachments with caregivers and other significant people in their lives. Moreover, some children have experiences of maltreatment and/or interpersonal trauma that can impact their sense of safety and trust in others. These challenges can be temporary, and children can still develop strong attachments with others. However, for some children, these challenges can persist, and in some cases will progress into attachment-related disorders (e.g. reactive attachment disorder [RAD], disinhibited social engagement disorder [DSED]; Baldwin et al., 2019; Guyon-Harris et al., 2019; Guyon-Harris et al., 2018; Humphreys et al., 2017; Tarren-Sweeney, 2021). Please refer to our fact sheet for more details on attachment-based and interpersonal programs, and to our practice guide for details on relationships-focused practice for children in OOHC.
  • Psychological distress, internalising symptoms and mood disorders: Some children in OOHC experience distress, which can manifest as internalising symptoms – internally-directed emotions or behaviours including sadness, anxiety, guilt, social withdrawal, or disordered eating. Children in OOHC have higher rates of internalising symptoms and depression and anxiety disorders, compared to children with no OOHC contact (AIFS et al., 2015; Engler et al., 2022; Gabrielli et al., 2015; Larsen et al., 2018; Westlake et al., 2023).
  • Externalising symptoms: Psychological distress can also manifest as externalising symptoms – emotions or behaviours that are externally directed or displayed, including aggression and impulsivity (Westlake et al., 2023). For some children in OOHC, these symptoms are more severe and/or long-lasting and in these cases, a behavioural problem and/or an externalising disorder may be present (e.g. conduct disorder, oppositional defiance disorder [ODD]; AIFS et al., 2015; Engler et al., 2022; Goemans et al., 2016; Vanderwerker et al., 2014). Although externalising behaviours can be challenging for parents or carers, it is important to recognise that they can be a response to distress or other mental health challenges. To ensure children receive appropriate support, practitioners should therefore seek to identify what underlying factors may be influencing their behaviour and mental health.

Other less common mental health, developmental and psychosocial challenges include disordered eating (Cox et al., 2017; Tarren-Sweeney & Hazell, 2006; Walsh et al., 2018), executive control difficulties, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD; Baidawi & Piquero, 2021; Cidav et al., 2018; Tarren-Sweeney, 2017), personality disorders and conduct disorders (Engler et al., 2022; Vanderwerker et al., 2014; Walsh et al., 2018).

There is also strong evidence that children and young people who have been in OOHC are at higher risk for developing long-term psychosocial challenges, including poor mental health outcomes in adulthood (Mendes & Chaffey, 2023; Seker et al., 2022), self-harm and risk for suicide (Gabrielli et al., 2015; Palmer et al., 2021; Taussig et al., 2014), and substance use and addiction issues (Maclean et al., 2016; Walsh et al., 2018). Children who have been in OOHC are also at increased risk for chronic illnesses and of dying prematurely, poor educational and employment outcomes, homelessness, early pregnancy and intergenerational contact with the OOHC system, and contact with the justice system (Batty et al., 2022; Jaggi et al., 2022; Steenbakkers et al., 2018; Tarren-Sweeney, 2018; Walsh et al., 2018).

To understand why children in OOHC have a higher risk for poor mental health and psychosocial outcomes, and to design effective mental health and wellbeing supports, it is important to be aware of the factors that can influence their mental health. This can enable support to be tailored to children’s individual strengths and needs. Common factors that research evidence has shown to be key influences on the mental health of children in OOHC are summarised in the following section.

2.  Our analysis did not include a comprehensive review of outcomes in children under five years or in young people aged over 12 years. For more information on mental health outcomes in preschool-aged children, refer to:

  • Vasileva, M., & Petermann, F. (2018). Attachment, development, and mental health in abused and neglected preschool children in foster care: A meta-analysis. Trauma Violence Abuse, 19(4), 443-458.

For more information on mental health outcomes in teenagers and young adults, refer to:

  • Everson-Hock, E. S., Jones, R., Guillaume, L., Clapton, J., Duenas, A., Goyder, E., Chilcott, J., Cooke, J., Payne, N., Sheppard, L. M., & Swann, C. (2011). Supporting the transition of looked-after young people to independent living: a systematic review of interventions and adult outcomes. Child: Care, Health and Development, 37(6), 767-779.
  • Harwick, R. M., Unruh, D., & Lindstrom, L. (2020). Transition to adulthood for youth with disabilities who experienced foster care: An ecological approach. Child Abuse & Neglect, 99, 104310, 1-10.
  • Mendes, P., & Chaffey, E. (2023). Examining the mental health care needs and outcomes of young people transitioning from out-of-home care (OOHC) in Australia. Institutionalised Children Explorations and Beyond, July, 1-22.

Factors influencing children’s mental health and wellbeing in out-of-home care

Mental health and wellbeing outcomes for children in care are influenced by a complex interplay of psychosocial factors (Tarren-Sweeney, 2017; Walsh et al., 2018). Taking a ‘whole child’ approach is useful for understanding the various psychosocial factors that may influence mental health and wellbeing among children in OOHC. A whole child approach recognises that mental health outcomes are shaped by interactions across different levels or systems, including environmental, family and social, interpersonal, and individual. This includes both protective factors (things that promote mental health and/or wellbeing, or that mitigate other risk factors for wellbeing) and risk factors (things that can negatively influence children’s mental health or wellbeing).

The following section outlines factors that are commonly reported in the research literature as influential for the mental health and wellbeing of children in OOHC. It should be noted that most of the reviewed literature focused on poor mental health outcomes, and risk factors for poor mental health.

Children’s mental health and wellbeing in OOHC is influenced by experiences and factors that occur prior to children entering OOHC, and factors specific to the OOHC experience. Children’s experiences of transitioning and leaving OOHC, and the systems and environments that they interact with when doing so, are also likely to affect their mental health and wellbeing. However, an examination of these factors is beyond the scope of this resource, as our review did not specifically explore these factors (for more information on leaving care, see Everson-Hock et al., 2011; Harwick et al., 2020; Mendes & Chaffey, 2023).

It is important to note that these factors do not necessarily mean that a child will experience a mental health challenge, and possible risk and protective factors interact with each other and other factors at various levels. As outlined by Walsh and colleagues:

‘Children’s [mental health] trajectories through the care system are determined by interactions between the different risk and protective factors over the course of their placement. It is these interactions, rather than the factors themselves, which are likely to have the greatest impact on children’s wellbeing over time’ (Walsh et al., 2018, p.90).

Select the headings to read more about how different factors influence the mental health and wellbeing of children in care.

  • Research shows that children’s experiences, relationships and home environment before entering an OOHC placement (or before having contact with child protection services) can strongly influence their mental health (both positively and negatively).

     

    Protective pre-care factors for child mental health include strong attachments, relationships and social support (Mendes & Chaffey, 2023; Walsh et al., 2018). Conversely, children in OOHC have often experienced trauma or had adverse childhood experiences (ACEs) which can be the cause of their entry into care and can increase their risk for mental health challenges (Westlake et al., 2023).

     

    ACEs may include parental mental health challenges or substance use issues, family violence, housing insecurity and financial stress (Engler et al., 2022; Turney & Wildeman, 2017; Washington et al., 2018). Children entering into care may also have experienced emotional, physical and/or sexual abuse or neglect (Jackson et al., 2014; Lum et al., 2018; Washington et al., 2018). A history of abuse is one of the strongest predictors of mental illness in children with a care experience (Baldwin et al., 2019; Engler et al., 2022; Lee et al., 2020).

  • Research consistently demonstrates that OOHC-specific factors, including placement type and stability, also influence children’s mental health outcomes (Hassall et al., 2021; Liming et al., 2021; McGuire et al., 2018; Ryder et al., 2022; Washington et al., 2018).

     

    In general, mental health outcomes tend to be better for children in home-based care arrangements than for children in residential care or intensive placement types (Engler et al., 2022; Galvin et al., 2022; Hassall et al., 2021; Shlonsky et al., 2017; Washington et al., 2018). Kinship and relative carer arrangements are also sometimes associated with more positive outcomes than foster and non-relative care placements, but the evidence is variable and the reasons for this are not always clear (AIFS et al., 2015; Hassall et al., 2021).

     

    The stability of placement arrangements is also highly influential for child mental health outcomes (Fawley-King et al., 2017; Troller-Renfree et al., 2017; Walsh et al., 2018). Children with more placement stability (i.e. those who change placement less often) tend to have a lower risk for mental health challenges than those who experience more instability (Engler et al., 2022). However, it is important to note that the relationships between placement type, stability and mental health are dynamic and multi-directional – children with less complex issues (and thus a lower risk for mental health challenges) are more likely to be placed in home-based care (compared to residential care), and to have greater placement stability, which in turn influences their mental health outcomes (Hodgdon et al., 2013; Jimenez-Morago et al., 2015; Liming et al., 2021).

     

    The presence of healthy attachments and relationships is another key influence on children’s mental health (Humphreys et al., 2017; Larsen et al., 2021; Walsh et al., 2018). Consistent and supportive relationships with carers, birth families and peers can foster secure attachments and child wellbeing (Bell et al., 2015; Chodura et al., 2021; Hindt & Leon, 2022; Washington et al., 2018). Being placed with or continuing to have contact with siblings appears particularly influential for children’s wellbeing (Macpherson et al., 2022; McDowall, 2015). Other protective factors that influence children while they are in care include living in a safe neighbourhood, receiving a good quality education, and having access to services and supports (Mendes & Chaffey, 2023; Walsh et al., 2018). For Aboriginal and Torres Strait Islander children, connection to their culture and communities, contact with family members, and culturally safe supports and services are also critical for social and emotional wellbeing (AIHW, 2021b; McDowall, 2016; Raman et al., 2017).

     

    It is important to note that child maltreatment can also occur within OOHC, including from staff, carers, or other children in care. The extent of maltreatment within OOHC is difficult to estimate; however, in 2021–22 1,200 children were found to have experienced abuse within care (AIHW, 2023). The most common form of maltreatment was physical abuse (32%) followed by emotional abuse (29%) (AIHW, 2023).

  • In addition to the OOHC-specific experiences and environments described previously, there are other individual, environmental or system-level factors that can influence children’s mental health and wellbeing. These factors can also interact with their OOHC-specific experiences.

     

    Individual-level factors that can shape children’s mental health outcomes (or the way they experience mental health challenges) include age and developmental status, gender, physical health, and disability (Baldwin et al., 2019; Bell et al., 2013, 2015; Washington et al., 2018). For example, as children who have experienced OOHC get older, the risk for mental health problems increases. However, research shows that this is likely due to greater exposure to adverse and traumatic events over time, rather than being a product of age itself (AIFS et al., 2015; Jackson et al., 2014; Tarren-Sweeney & Hazell, 2006; Walsh et al., 2018).

     

    System-level factors can also influence a child’s mental health and wellbeing outcomes. Examples of system-level factors relevant to child outcomes in OOHC include:

    • child protection legislation, regulations, policies and practices (including the over-surveillance and removal of children from Aboriginal and Torres Strait Islander families)
    • discrimination and stigma (including racism and ableism); and
    • other social determinants including remoteness of location, cultural connection, access to services and supports, and neighbourhood and community factors (Walsh et al., 2018).

     

    Individual, cultural and environmental factors can also intersect. For example, there is evidence that Aboriginal and Torres Strait Islander children (Raman et al., 2011; Raman 2017; AIHW), children of colour, children with disability, and other children from marginal or minority backgrounds have poorer mental health outcomes in OOHC and are less likely to receive adequate support for their mental health and wellbeing while in OOHC (Raman et al., 2017; Schaub et al., 2022; Walsh et al., 2018; Ziviani et al., 2012). This may be due, in part, to systematic racism and ableism within child protection systems.

     

    The complex interaction of individual and environmental or system-level factors, as well as OOHC factors, highlights how children’s mental health is not influenced by one factor alone. Children’s experiences occur within the context of the whole child and their ecology and are shaped by the interaction between various risk and protective factors. Given this complexity, it is important to view the child within the context of their wider environment. It is also important to take a holistic approach to understand children’s unique strengths and vulnerabilities when working with children who have experienced OOHC.

Children’s experiences of out-of-home care

Children’s perspectives on OOHC are often absent from research and practice (Fox & Berrick, 2007; Rafeld et al., 2020). However, existing literature indicates that children can have both positive and negative experiences in care (McDowall, 2018; Steenbakkers et al., 2021). Children’s experiences of mental health and wellbeing are often multi-dimensional and influenced by the individual, interpersonal and OOHC-specific factors described previously (Zhang & Selwyn, 2020).

The following are common themes in the literature around children’s experiences in OOHC:

Information and participation

Children have described how a lack of information about their care, and limited involvement in decision-making, can contribute to feelings of powerlessness and uncertainty (ACYP, 2021; CCYP, 2019; McDowall, 2018; Selwyn & Briheim-Crookall, 2022). Children often perceive a lack of support from care workers and/or that their feelings or concerns have been dismissed or minimised (Moore & McArthur, 2023; Smales et al., 2022; Smales et al., 2020). As a result, children often want more communication about their care or case planning and greater involvement in decision-making (CCYP, 2019; McTavish et al., 2022; Robertson et al., 2017; Selwyn & Briheim-Crookall, 2022).

‘No one had ever actually explained. I think that’s what caused a lot of my distress and distrust in the system is that I didn’t know what was happening.’

- ACYP, 2021, p. 21

Sense of security and safety

Children often highlight the need for safety, as well as a sense of ‘felt safety’ in care. Children have highlighted how feeling safe with carers, having suitable levels of privacy (e.g. having a private bedroom), and the presence or absence of neighbourhood crime or violence can affect their sense of safety (CCYP, 2019; Moore & McArthur, 2023; Robertson et al., 2017). Stability and consistency are also critical to a child’s sense of safety. This can include stability in placements and care environments, as well as continuity of carers, caseworkers and other professionals (ACYP, 2021; CCYP, 2019; McDowall, 2018; Selwyn & Briheim-Crookall, 2022).

‘I just keep being moved around … This makes me confused and scared. It has been dark and scary when I move, and I am told where, as we drive. I never meet the people beforehand, and my things take time to catch up with me.’

- Selwyn & Briheim-Crookall, 2022, p. 61

Healthy and consistent relationships

Healthy, secure and consistent relationships are critical to children’s wellbeing. When given the chance to express their opinions, children in OOHC have highlighted the importance of maintaining contact with their birth families (particularly siblings), friends and other important people in their lives (CCYP, 2019; McDowall, 2018; Robertson et al., 2017; Sprecher et al., 2021; Zhang & Selwyn, 2020). Maintaining connections to family, kin, culture and community are particularly important for Aboriginal and Torres Strait Islander children (ACYP, 2021; Krakouer, 2023; Krakouer et al., 2018; McDowall, 2016; Raman et al., 2017).

‘Being put in kinship care was really, really important for me … seeing the difference between that and being placed off [Country] or with someone who wouldn’t know culture. Even though they can be culturally literate, it does not equate to actually being placed with an [Indigenous] carer.’

- ACYP, 2021, p. 36

Children see consistent and positive relationships with carers and professionals as critical to their wellbeing (Brown et al., 2019; Harder et al., 2017; Robertson et al., 2017; Zhang & Selwyn, 2020).

‘Really building relationships with the kids works, because then they feel safer to come with you with pretty much any problem. They’re not going to come to you with problems … if they think you don’t like them or that you don’t listen … Building relationships was important in keeping kids safe, because you can’t keep kids safe if they won’t talk to you.’

- Moore et al., 2018, p. 71

Children in care also emphasise the importance of peer relationships for their wellbeing. Frequent changes in care arrangements and disruptions to school and extracurricular activities mean that maintaining relationships while in OOHC can be challenging. Some children in care also report stigma from peers about being in care and experiences of bullying (ACYP, 2021; CCYP, 2019; Selwyn & Briheim-Crookall, 2022). On the other hand, consistent and supportive friendships are often highlighted as important for the subjective wellbeing of children in OOHC (ACYP, 2021; CCYP, 2019; Selwyn & Briheim-Crookall, 2022).

Implications and conclusions

Research consistently demonstrates that children in OOHC have increased risks of developing mental health difficulties and are also more likely to experience long-term adverse psychosocial outcomes. It is important to note, however, that negative outcomes are not inevitable. Experiences in OOHC are highly heterogeneous, and mental health outcomes are influenced by a complex interplay of risk and protective factors that operate at various socioecological levels including the interpersonal, environmental and system levels (Devaney et al., 2023; Walsh et al., 2018). A comprehensive understanding of the complexity of factors that influence mental health for children who have experienced OOHC, and a child-centred approach that acknowledges the heterogeneity of experiences, is essential to inform effective support.

There is also a need for more holistic and strengths-based research on mental health and wellbeing among children in care. Researchers need to move beyond identifying mental health challenges, and instead explore the resilience of children and ways to support positive mental health and wellbeing (ACYP, 2021; Devaney et al., 2023). Involving children with lived experiences of OOHC in research and the design and evaluation of interventions can also help shape more effective services (Green et al., 2022; Kertesz et al., 2018; Knight & Kingston, 2021; McTavish et al., 2022; Stafford et al., 2021).

Finally, it is critical to note that Aboriginal and Torres Strait Islander children are disproportionately represented among the OOHC population, and often experience adverse outcomes within OOHC (Gatwiri et al., 2020; Liddle et al., 2022). There is an urgent need to ensure that Aboriginal and Torres Strait Islander children’s cultural rights are respected, including compliance with the ATSICPP. Moreover, there is a need to prioritise Aboriginal and Torres Strait Islander-led solutions in this space to prevent over-representation and to promote cultural connection for children in OOHC (Creamer et al., 2022; Raman et al., 2011; Raman et al., 2017).

Further guidance for practitioners when supporting children who have experienced OOHC can be found in the following related resources and reading section.

 

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