Original Article – Children and Adolescents Originalarbeit – Kinder und Jugendliche (English Version of) Verhaltenstherapie 2010;20:37–44 DOI: 10.1159/000274622
Published online: Feb 2010
Post-Traumatic Stress Symptoms in Foster Children Following Maltreatment and Neglect Sylvia H. Oswald Jörg M. Fegert Lutz Goldbeck Department of Child and Adolescent Psychiatry/Psychotherapy, Ulm University Medical Center, Germany
Key Words Foster children · Posttraumatic stress disorder · Trauma assessment
Schlüsselwörter Pflegekinder · Posttraumatische Belastungsstörung · Trauma · Diagnostik
Summary Background: Foster children have often experienced traumatic situations in their biological families, which made it necessary to place them in family foster care. Nevertheless, there is little research on posttraumatic stress symptoms in this risk population. Patients and Methods: Twenty 7–16 year old foster children (10 boys, 10 girls) from the population of an outpatient psychiatric clinic were compared with 20 matched patients living with at least one biological parent regarding traumatic experiences and posttraumatic stress symptoms. The diagnostic assessment was realized with the UCLA PTSD Reaction Index for DSM-IV and the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present und Lifetime Version, K-SADS-PL. Results: Foster children often experienced chronic and multiple traumata such as maltreatment and/or neglect (n = 19); control children, however, more often reported single and circumscribed traumata (n = 9). As compared to the control children, the foster children showed a significantly higher prevalence of posttraumatic stress symptoms. Conclusions: Due to their history of maltreatment and neglect, foster children develop posttraumatic stress disorders more often. Psychiatric diagnostics of foster children should include an assessment of their trauma history and posttraumatic stress symptoms. If indicated, a trauma-focused psychotherapy should be offered.
Zusammenfassung Hintergrund: Pflegekinder haben häufig traumatisierende Situationen erlebt, die ihre Fremdunterbringung erforderlich machten. Dennoch gibt es bislang kaum Untersuchungen zu Traumafolgestörungen in dieser Risikopopulation. Patienten und Methoden: Die traumatische Belastung bei 20 7- bis 16-jährigen Pflegekindern (10 Jungen, 10 Mädchen) aus der Inanspruchnahmepopulation einer kinder- und jugendpsychiatrischen Sprechstunde wurde mit einer hinsichtlich Alter und Geschlecht vergleichbaren klinischen Kontrollgruppe von 20 Patienten, die bei wenigstens einem biologischen Elternteil leben, verglichen. Die Diagnostik erfolgte anhand des UCLA PTSD Reaction Index für DSM-IV und des semistrukturierten Diagnostikinterviews K-SADS Present und Lifetime Version. Ergebnisse: Bei den Pflegekindern liegen häufig multiple und chronische Traumata durch Misshandlung und/oder Vernachlässigung vor (n = 19); die Kinder der Kontrollgruppe hingegen weisen häufiger einmalige, umschriebene Traumata auf (n = 9). Die Prävalenz posttraumatischer Stresssymptome bei Pflegekindern ist signifikant höher als bei den Kindern der Kontrollgruppe. Schlussfolgerungen: Pflegekinder entwickeln vor dem Hintergrund ihrer Misshandlungs- und Vernachlässigungsvorgeschichte gehäuft Traumafolgestörungen. Werden Pflegekinder wegen psychischer Auffälligkeiten zur Diagnostik vorgestellt, sollte daher eine gezielte Traumadiagnostik und bei Bedarf eine traumafokussierte Psychotherapie erfolgen.
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Dipl.-Psych. Dr. Sylvia H. Oswald Universitätsklinikum Ulm Klinik für Kinder- und Jugendpsychiatrie/-psychotherapie Steinhövelstraße 5, 89075 Ulm, Deutschland Tel. +49 731 500-61636, Fax -61683
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Introduction Foster children, because of their stressful past history, are at risk for developing behavioral and developmental disorders. In their biological families, they often had massively anxietyprovoking experiences such as neglect, maltreatment, abuse, or domestic violence, which made foster care necessary. In many cases, it is only after the failure of outpatient counseling that foster care is provided for the child, so that these children first endure a long phase of traumatic experiences within the family. In 2006, 78% of the children in Germany who were in full-time foster care had previously received outpatient counseling [Statistisches Bundesamt Deutschland (German Federal Statistical Office), 2007]. At the end of 2007, there were 49,673 children in full-time foster care in Germany [Statistisches Bundesamt Deutschland, 2009]. A survey conducted in England showed that as of March 31, 2008 out of 59,500 foster children, 36,700 (61.7%) had been placed in foster care because of abuse or neglect. Family court decisions on placement in foster care testify to a danger to the children’s welfare in their original home environments (22% of cases in 2006) [Statistisches Bundesamt Deutschland, 2007]. In the U.S.A., substance abuse by the parents is one of the most common reasons for placement of the children in foster care [Chernoff et al., 1994]. In 2004, 7 out of 10 abused or neglected children had substance-abusing parents [National Center on Addiction and Substance Abuse at Columbia University, 2004]. Epidemiological studies show a high prevalence of mental disorders among foster children. In the U.S.A., with a sample of 373 17-year-old foster children, the Diagnostic Interview Schedule for DSM-IV showed that 61% had had a lifetime prevalence of mental disorders [McMillen et al., 2005]. Thirtytwo percent of the adolescents had exhibited multiple mental disorders during their lifetimes. In the year preceding the survey, 27% of the adolescents had suffered from major depression, 6% from mania, 14% from post-traumatic stress disorder (PTSD), 47% from social conduct disorder, and 20% from attention deficit and hyperactivity disorder (ADHD). A county physician found, in interviews with 6- to 12-year-old American foster children, their foster parents, and their teachers, that in 80% of cases (n = 203) there was at least 1 mental disorder [Zima et al., 2000]. Forty-one percent of the children showed disruptive behavior disorders, 32% affective disorders, 20% anxiety disorders, 13% adjustment disorders, and 12% learning disorders. In Switzerland, a study of children and adolescents representative of the general population revealed a 22.5% point prevalence of mental disorders [Steinhausen et al., 1998]. Of these children and adolescents, 12.5% had multiple mental disorders. Due to foster children’s frequent prior traumatic experiences, it seems likely that they are at a higher risk for developing PTSD. PTSD is characterized by re-experiencing the symptom cluster (e.g., recurrent thoughts about the traumatic event), avoidance and blunted affect (e.g., avoidance of places
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Verhaltenstherapie 2010;20:37–44
or things that remind one of the trauma, feelings of alienation, a limited range of affect), and hyperarousal (e.g., irritability, sleep disturbances, hypervigilance, nervousness, etc.). According to the ICD-10, the WHO’s multiaxial classification schema for mental disorders, the criteria required for a diagnosis of PTSD are: 1 symptom of re-experiencing the trauma, 1 of avoidance, and 2 of hyperarousal [Remschmidt et al., 2002]. The DSM-IV [Sass et al., 2009] requires 1 symptom of re-experiencing, 3 of avoidance, and 2 of hypervigilance, thereby raising the threshold for diagnosis of PTSD. However, Carrion et al. [2002] have shown that traumatized children with partial symptomatology can also have a clinically significant, functional psychosocial impairment. In Germany, the Bremen Adolescent Study found that 1.6% of the 1,035 students tested, ages 12–17, from the general population, had developed PTSD sometime during their lives [Essau et al., 1999]. Although many foster children have had traumatic experiences, we found, in a systematic review of the literature, just one study that dealt specifically with PTSD in foster children [Oswald et al., in press]. Dubner and Motta [1999] studied the incidence of PTSD in three groups of foster children in the U.S.A., based on a screening procedure and a semi-structured clinical interview: (1) foster children who had been sexually abused, (2) foster children who had been physically abused, and (3) foster children who had not experienced either sexual or physical abuse. In the first group, 64% of the children met the criteria for PTSD; in the second group, 42%; and in the third group, 18%. The high prevalence in the third group suggests that these foster children were exposed to other traumatic experiences, such as neglect or domestic violence. Disorders resulting from trauma, so-called ‘post-traumatic disorders,’ are often overlooked in clinical diagnosis, if the patients present with nonspecific symptoms and say little spontaneously about their past history. With regard to the high risk of foster children developing PTSD, the aim of the present study is to investigate the prevalence of post-traumatic stress symptoms in foster children at an outpatient psychiatric clinic. It is assumed that foster children have more often experienced potentially traumatizing events and more often exhibit post-traumatic stress symptoms than do children who live with at least one biological parent.
Patients and Methods Sample A consecutive sampling of foster children who were patients at the child and adolescent outpatient clinic of the Ulm University Medical Center between January 2008 and April 2009 was compared with a clinical control group of children who live with at least one biological parent and who were attending the same outpatient clinic. The control patients were recruited such that each foster child from the research group was matched by age (+/- 6 months) and gender with a child chosen from the clinic’s registration documents (matched-pair method). Data collection was conducted as part of the initial clinical examination. The study included patients 6-18 years of age; the purpose and approach of the study were ex-
Oswald/Fegert/Goldbeck
Tab. 1. Traumata in foster children and control children in the child and adolescent outpatient clinical psychiatric population, recorded with the Trauma Exposure/Loss Profile
p
Traumatizing event present
20 (100%)
9 (45%)