Abstract
Background
Foster parents’ unique challenges significantly impact their mental health, which in turn influences child well-being and placement stability. Although various intervention programs have been developed to support foster families, research specifically targeting foster parents' mental health as a primary outcome remains limited. Previous reviews have examined parenting stress, leaving a gap in understanding the effectiveness of interventions addressing broader mental health domains such as depression and anxiety. This systematic review aims to evaluate the efficacy of foster parent training programs in improving psychological distress, depression, anxiety, and stress.
Methods
This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines and is registered with the Open Science Framework. Information sources will include MEDLINE, CENTRAL, PsycINFO, and Embase, searched from inception to May 2023. An updated search will be conducted prior to final analysis. The review will include randomized controlled trials published in peer-reviewed English-language journals. Eligible interventions will include structured training, educational, or support programs for foster parents. Eligible comparators will include any control condition (e.g., usual care, waitlist, no intervention) or other active interventions. Primary outcomes will include psychological distress, depression, anxiety, and stress. Secondary outcomes will assess family-related psychological outcomes. Risk of bias will be assessed using the Cochrane Risk of Bias Tool (RoB 2) and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data will be synthesized using meta-analysis when appropriate; otherwise, narrative synthesis will be conducted the Synthesis Without Meta-analysis (SWiM) guidelines. Subgroup analyses will explore differential effects by theoretical framework and specific mental health outcomes. The review began on May 14, 2023, with an anticipated completion date of August 31, 2025. The study is supported by Japan Society for the Promotion of Science (JSPS) KAKENHI, Grant-in-Aid for Scientific Research (B), Grant Number JP21H03253.
Discussion
This systematic review will evaluate interventions targeting foster parents' mental health across multiple psychological dimensions, surpassing the limited scope of prior studies. The rigorous methodology aims to inform the development of evidence-based mental health support programs for foster parents.
Systematic review registration
Open Science Framework (https://osf.io/qzd43).
Supplementary Information
The online version contains supplementary material available at 10.1186/s13643-025-02960-7.
Keywords: Foster parent, Mental health, Well-being, Program evaluation, Evidence-based interventions, Systematic review protocol
Background
Children in foster care often come from complex backgrounds involving abuse, neglect, parental illness, or separation, and are cared for by foster parents instead of their biological parents. Those children with histories of abuse or neglect are at a high risk of developing emotional and behavioral issues such as post-traumatic stress disorder (PTSD), depressive symptoms, developmental delays, deprivation with executive functioning, or conduct disorder [1–3]. Compared to parents in general, foster parents must provide additional care and attention to children who have undergone difficult experiences. Research has established associations between the challenges experienced by foster children and the increased prevalence of stress [4, 5], depression [6], and anxiety [7] among foster parents. As a result, foster parents face unique psychological challenges and report higher rates of mental health problems compared to parents in general [8, 9]. Additionally, the mental health of foster parents have been identified as significant predictors of foster children's mental health outcomes [4, 10, 11] and placement disruptions [12]. Placement disruptions can cause foster children to experience additional trauma on top of the separation from their biological parents [13]. Given these complex circumstances, mental health care for foster parents is crucial for the healthy development of foster children and the stability of their care environment.
While programs aimed at improving the mental health of parents in general are becoming increasingly well-documented [14, 15], these programs are insufficient to address the unique stressors and psychological needs of foster parents. For example, parent training programs that have proven successful in the general population have been found to be less effective in improving the psychological functioning of foster parents [16]. In response, recent research has focused on intervention programs tailored to the unique needs of foster families, targeting such areas as improving foster children's behavioral problems [17, 18], fostering attachment [19, 20], and addressing trauma experienced by foster children [21, 22]. These interventions have been shown to lead to improvements in foster children's behavioral issues, developmental delays, foster parents' stress, and their interactions with foster children [17–19, 21, 22]. However, most studies focus on improving foster children's outcomes and the quality of parent–child relationships, while research specifically addressing foster parents' mental health as a primary endpoint remains limited. Furthermore, there is a lack of sufficient evidence on which intervention components are most effective in supporting the mental health of foster parents.
Several review studies have evaluated interventions targeting foster parents. A systematic review by Kemmis-Riggs et al. [23] demonstrated that psychosocial interventions in foster care and kinship care are effective in improving children's behavioral and emotional problems. Similarly, a meta-analysis review by Schoemaker et al. [24] found that intervention programs for foster and adoptive parents improved parenting skills and reduced parenting stress. However, findings on attachment-based interventions suggest only small reductions in parenting stress among foster parents, with inconclusive effects on depression [25]. The necessity of providing sustained support for foster parents' mental health has been increasingly recognized [26]. Despite this emerging need, existing research has predominantly concentrated on mitigating parenting stress among foster parents [20, 25, 27], with relatively few reviews examining the impact of intervention programs on their overall mental health. Importantly, foster parents' mental health challenges may extend beyond parenting stress to encompass secondary psychological issues, such as depression and anxiety, which emerge as part of the coping process. Current review studies have inadequately addressed this broader perspective on mental health, leaving a limited understanding of which intervention programs effectively address the full range of mental health challenges experienced by foster parents.
Developing and refining effective programs to support the mental health of foster parents necessitates a quantitative assessment of the efficacy of existing intervention programs. Accordingly, this study seeks to synthesize evidence from randomized controlled trials to evaluate the impact of foster parent training programs on mental health outcomes, including psychological distress, depression, anxiety, and stress. A meta-analysis approach will be used to generate reliable and comprehensive evidence regarding the efficacy of these programs.
This research aims to offer more robust and reliable evidence concerning the effectiveness of programs designed to enhance the mental health of foster parents.
Methods
This systematic review will adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines [28]. A completed PRISMA-P checklist including recommended items for a systematic review protocol is provided in Additional file 1. This protocol has been registered with the Open Science Framework (https://osf.io/qzd43). The review was commenced on May 14, 2023, with an anticipated completion date of August 31, 2025.
Eligibility criteria
Population
This review will include individuals and families involved in foster care, including foster parents, foster mothers, foster fathers, foster caregivers, and foster carers. The population will consist of individuals and families providing foster home care across all ages, genders, ethnicities, and caregiving experiences. To ensure comprehensive representation, foster families and caregivers with varying levels of experience who provide care for children and youth in foster care settings will be included.
Intervention
This review will include structured training programs, educational interventions, and support services designed for foster carers. Eligible interventions will encompass training programs, educational initiatives, social support, community support, and training support services. The review will consider interventions delivered through diverse modalities, including in-person workshops, online seminars, and group sessions. No restrictions will be applied regarding the theoretical framework, delivery method, or provider type.
Control group
This review will include studies comparing groups with or without such parameters as intervention (e.g., treatment as usual or care as usual), waitlist controls, alternative interventions or support services, and minimal interventions (e.g., provision of written materials or assessment-only conditions). Additionally, studies comparing varying types of foster carer support interventions will be included to comprehensively evaluate intervention effectiveness.
Outcomes
This review will examine mental health and psychological outcomes among foster carers, categorized into critical and important outcomes based on their relevance to program effectiveness evaluation. All outcomes will be measured using standardized scales at baseline and post-intervention.
Critical outcomes:
- Mental health status
- Psychological distress (measured by Kessler Psychological Distress Scale [K6, K10] or other validated scales)
- Depression symptoms (measured by Beck Depression Inventory [BDI], Patient Health Questionnaire-9 [PHQ-9], or other validated scales)
- Anxiety symptoms (measured by Generalized Anxiety Disorder-7 scale [GAD-7] or other validated scales)
- Stress (measured by Parenting Stress Index-Short Form [PSI-SF], Parent Daily Report [PDR], or other validated scales)
- Burnout (measured by Burnout Assessment Tool [BAT], Maslach Burnout Inventory [MBI], or other validated scales)
- Fatigue (measured by Fatigue Assessment Scale [FAS] or other validated scales)
- Psychological well-being
- General psychological well-being (measured by World Health Organization-Five Well-Being Index [WHO-5] or other validated scales)x
Important outcomes:
- Family-related outcomes
- Parent–child psychological aspects
- Family psychological functioning
- Adoption-related psychological outcomes
Study design
This study will utilize randomized controlled trials (RCTs), including both individual RCTs and cluster RCTs.
Publication criteria
The review will include publications written in English and published in peer-reviewed journals. The restriction to English-language literature will reflect the research team's language capabilities and resource constraints, while acknowledging the potential for language bias. The focus on peer-reviewed publications will ensure a baseline standard of methodological quality through external expert evaluation.
Exclusion criteria
The exclusion criteria for this review include quasi-randomized controlled trials (quasi-RCTs), studies involving animals, studies focused on foster care staff, studies exclusively examining foster children, studies addressing only kinship care, and unpublished studies or gray literature.
Search strategy
The search strategy will target published primary studies. An initial limited search of MEDLINE (PubMed) and the Cochrane Central Register of Controlled Trials (CENTRAL) will be conducted to identify relevant articles. Titles, abstracts, and index terms from these articles will inform the development of a comprehensive search strategy for MEDLINE (PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), and PsycINFO (EBSCOhost). The search will cover studies from the inception of each database through May 14, 2023. To ensure the currency of the review, an updated search will be conducted prior to final analysis. Specifically, the search will use keywords related to ‘foster parent’, ‘foster carer’, ‘training program’, and ‘mental health’, combined with Boolean operators (see Additional file 2). The search strategy will be developed and implemented by an information specialist with expertise in systematic review methodology. The specialist will generate search terms, execute searches across all databases, and provide search results to the research team. The search strategy will be tailored to each database. When necessary, corresponding authors of included articles will be contacted to clarify missing data or interpretations.
Study selection
Identified records will be compiled and imported into EndNote21 (Clarivate Analytics, PA, USA) and duplicates will be removed. Prior to formal screening, reviewers will participate in discussions to ensure a shared understanding of the research objectives and inclusion and exclusion criteria. Two independent reviewers will screen titles and abstracts for eligibility. Potentially relevant articles will be retrieved in full, with citation details imported into EndNote 21. Full-text articles will be assessed against inclusion criteria by two or more independent reviewers. Reasons for excluding full-text articles will be recorded and reported. Disagreements will be resolved through discussion or consultation with a third reviewer. Search results will be fully reported in the final review and presented using a PRISMA flow diagram [29].
Data extraction
To ensure consistency in the data extraction process, the lead and second authors will first conduct a pilot extraction on one sample study using the predeveloped data extraction tool. This example will be shared with all reviewers as a reference model before independent extractions begin. Two independent reviewers will extract data from each included study using this standardized tool. Disagreements between reviewers will be resolved through discussion or consultation with a third reviewer. A draft version of the extraction tool is provided in Additional file 3. The tool will be revised as necessary during the review process, with changes detailed in the final review.
Extracted data will include bibliographic information, participant characteristics, eligibility criteria, intervention components (theoretical framework, content, delivery format, duration, and target population), and outcome measurements with corresponding time points. For outcome data, both specific timepoint measurements and change-from-baseline data will be extracted when available. If only change-from-baseline data are reported, these values will be extracted, and specific timepoint data will be calculated when feasible. Any limitations associated with such conversions will be documented in the analysis. Authors will be contacted for missing or additional data when required.
Assessment of risk of bias
The Cochrane Risk of Bias Tool (RoB 2) will be used to assess the methodological quality of the included studies. The assessment will examine the five standard domains outlined in the RoB 2 framework. For the domain related to deviations from intended interventions, the evaluation will focus on the effect of assignment to intervention, consistent with an intention-to-treat approach. Studies will be classified as having low risk, some concerns, or high risk of bias, in accordance with RoB 2 guidance.
To ensure consistent application of the tool, all reviewers will adhere to the RoB 2 guidance document shared within the team. Two or more independent reviewers will evaluate the risk of bias, under the supervision of a co-author with extensive systematic review expertise. Supervision will support consistent application of the assessment criteria across reviewers. Discrepancies in risk of bias judgments between reviewers will be resolved through discussion until consensus is reached.
Assessment of quality
The certainty of the evidence for each outcome will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. This assessment will consider five key domains: (1) risk of bias in the included studies; (2) inconsistency of results across studies; (3) indirectness of evidence in relation to the population, intervention, comparator, and outcomes of interest; (4) imprecision of effect estimates; and (5) potential publication bias. Evidence from randomized controlled trials will be rated as high quality initially and may be downgraded based on limitations identified in these domains.
The GRADE approach will be applied to all person-important outcomes, categorized as either critical or important for decision-making. Overall certainty of evidence will reflect the lowest certainty rating among the critical outcomes.
Critical outcomes:
Mental health status (including psychological distress, depression, anxiety, stress, burnout, and fatigue)
Psychological well-being
Important outcomes:
Family-related outcomes (including parent–child psychological aspects and family psychological functioning)
Adoption-related psychological outcomes
The findings will be summarized using GRADEpro GDT (Guideline Development Tool) software.
The results of quality assessment will inform our interpretation of review findings and guide sensitivity analyses to test the stability of conclusions. Studies showing significant methodological limitations or high risk of bias will be identified accordingly. In cases where studies demonstrate severe quality concerns, we may consider their exclusion from meta-analysis after careful consideration of the extent of bias and its potential effects on the aggregate findings.
Data analysis and synthesis
The systematic review will identify foster parent programs by their theoretical frameworks and evaluate their effects on foster parents' mental health. Meta-analyses will be conducted if at least two studies with sufficiently comparable outcomes are available. A random-effects model will serve as the default analytical approach due to anticipated clinical and methodological heterogeneity across studies. For binary outcomes, risk ratios (RRs) with 95% confidence intervals will be calculated. For continuous outcomes, mean differences with standard deviations will be pooled when all studies use the same measurement scale; when different validated scales are used, standardized mean differences (SMDs) with 95% confidence intervals will be calculated. Statistical heterogeneity will be assessed using the I2 and Q statistics, with I2 values interpreted as low (< 25%), moderate (25–50%), and high (> 50%) [30]. If substantial heterogeneity is detected, potential sources will be explored through subgroup analyses and, if sufficient data are available, meta-regression. To further evaluate the impact of heterogeneity, both fixed-effect and random-effects models will be applied as a form of sensitivity analysis. RevMan Web (The Cochrane Collaboration's Review Manager Web) will be the primary software for meta-analysis.
In the case of cluster-randomized controlled trials (cRCTs), clustering effects will be adjusted using reported intraclass correlation coefficients (ICCs). If ICCs are not reported, estimates from similar studies will be used to calculate design effects and adjust effective sample sizes. To account for uncertainty in imputed ICCs, a sensitivity analysis will be performed using a range of plausible values (e.g., the imputed value, and lower- and upper-bound values from the literature) to assess the robustness of findings. When no reasonable estimate is available, the study will be excluded from the meta-analysis and included in the narrative synthesis. If meta-analysis is not feasible due to excessive heterogeneity or limited data, a narrative synthesis will be conducted following the Synthesis Without Meta-analysis (SWiM) guidelines. This structured approach will systematically describe and interpret the findings of the included studies, with a focus on how different intervention characteristics relate to foster parent mental health outcomes.
Subgroup analyses will be conducted to examine the differential effects of foster parent support programs based on the following criteria:
Theoretical framework–based subgroups: Programs will be categorized by stated theoretical underpinnings (e.g., cognitive-behavioral, attachment-based, trauma-informed approaches) to explore potential differences in mechanisms of action.
Mental health outcome-specific subgroups: Separate analyses will be conducted for different mental health outcomes, including psychological distress, depressive symptoms, anxiety symptoms, stress, burnout, fatigue, general psychological well-being, and family-related psychological outcomes.
These analyses will be exploratory; formal evaluation of subgroup differences will involve interaction tests, with p values interpreted cautiously due to potentially low statistical power when few studies are available. Subgroup categorizations will align with the primary objective of identifying support program types potentially associated with improved foster parent mental health. The feasibility and scope of these analyses will depend on the number and heterogeneity of included studies.
To ensure transparency and methodological rigor, study characteristics and findings will be summarized in comprehensive tables, and key relationships and patterns will be illustrated using appropriate figures or diagrams. Missing data will be documented and assessed for potential impacts on findings. When necessary, authors will be contacted for clarification. The first author will be responsible for the synthesis, consulting with the second author as needed and discussing with the research team.
Discussion
This systematic review and meta-analysis protocol addresses a critical gap in the literature on mental health support for foster parents. While previous reviews primarily examined parenting stress or child outcomes, this study evaluates the effectiveness of interventions across multiple dimensions of foster parents' mental health, including psychological distress, depression, anxiety, and stress. The review emphasizes the unique challenges of supporting foster children.
The protocol employs a systematic search strategy and rigorous quality assessment to identify randomized controlled trials. Standardized data extraction and analysis methods are applied to evaluate intervention components within foster care support systems. This systematic approach aims to strengthen the evidence base for developing effective mental health interventions for foster parents.
Supplementary Information
Additional file 1. Reporting checklist for protocol of a systematic review and meta analysis.
Additional file 2: Appendix I. Search strategy. MEDLINE (PubMed). CENTRAL. Embase (Ovid). PsycINFO (EBSCOhost).
Additional file 3: Appendix II. Data Extraction Tool.
Acknowledgements
Not applicable.
Abbreviations
- PTSD
Post-Traumatic Stress Disorder
- PRISMA-P
Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols
- K6, K10
Kessler Psychological Distress Scale
- BDI
Beck Depression Inventory
- PHQ-9
Patient Health Questionnaire-9
- GAD-7
Generalized Anxiety Disorder-7 scale
- PSI-SF
Parenting Stress Index-Short Form Stress
- PDR
Parent Daily Report
- BAT
Burnout Assessment Tool
- MBI
Maslach Burnout Inventory
- FAS
Fatigue Assessment Scale
- WHO-5
World Health Organization-Five Well-Being Index
- RCTs
Randomized Controlled Trials
- MEDLINE
Medical Literature Analysis and Retrieval System Online
- CENTRAL
Cochrane Central Register of Controlled Trials
- PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RoB 2
Risk of Bias Tool
- RRs
Risk Ratios
- RevMan Web
The Cochrane Collaboration's Review Manager Web
- SWiM
The Synthesis Without Meta-analysis
- GRADE
Grading of Recommendations Assessment, Development and Evaluation
- GDT
Guideline Development Tool
- JSPS
Japan Society for the Promotion of Science
Authors’ contributions
FC, MT, CH, SM, EF, YI1, NF, and YI2 developed the research concept and drafted the manuscript. FC, MT, MI, CH, SM, and KT conducted the literature review and data extraction. EF, YI1, NF, YI2, and EO supervised the quality assessment process. All authors critically reviewed and approved the final manuscript. FC and MT are designated as the guarantors of the work.
During the preparationare of this work, the authors used ChatGPT (GPT-4o, by OpenAI), and Claude (Claude Haiku, by Anthropic) to enhance the readability and proofread the English text. After using these services, the authors reviewed and edited the content as needed. We take full responsibility for the content of this publication.
Funding
The present study is supported by Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Numbers JP21H03253, JP25H01081.
Data availability
The datasets analyzed during this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
As this systematic review does not involve the collection of primary data, ethical approval is not required. The findings will be disseminated via publications in pertinent scientific journals, as well as through oral and poster presentations at academic conferences.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Fumika Chibana, Email: chibana.f.918c@m.isct.ac.jp.
Maki Taniguchi, Email: taniguchi.m.c117@m.isct.ac.jp.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Additional file 1. Reporting checklist for protocol of a systematic review and meta analysis.
Additional file 2: Appendix I. Search strategy. MEDLINE (PubMed). CENTRAL. Embase (Ovid). PsycINFO (EBSCOhost).
Additional file 3: Appendix II. Data Extraction Tool.
Data Availability Statement
The datasets analyzed during this study are available from the corresponding author upon reasonable request.