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. Author manuscript; available in PMC: 2011 Oct 1.
Published in final edited form as: Child Youth Serv Rev. 2010 Oct 1;32(10):1338–1345. doi: 10.1016/j.childyouth.2010.05.003

The Impact of Continued Contact with Biological Parents upon the Mental Health of Children in Foster Care

Lenore M McWey 1, Alan Acock 2, Breanne Porter 3
PMCID: PMC2928481  NIHMSID: NIHMS205361  PMID: 20802844

Abstract

This study examined depression and externalizing problems of children in foster care using a subsample of data (N = 362) from the National Survey of Child and Adolescent Well-Being. Our findings indicated that more frequent contact with the biological mother was marginally associated with lower levels depression and significantly associated with lower externalizing problem behaviors. The association with externalizing problem behavior was significant even after controlling for gender and exposure to violence. Further, differences with regard to gender were revealed. Specifically, girls had higher depression scores than boys even after controlling for exposure to violence. Results suggest that supporting frequent, consistent, visitation may impact the levels of depression and externalizing programs children in foster care exhibit.

Reunification with biological parents is the goal for the majority of children in foster care, at least initially (U.S. Department of Health and Human Services, 2005). When children are removed from their homes and placed in foster care, parental visitation is considered the primary intervention for maintaining the parent-child relationship (Mallon & Leashoer, 2002). Although contact with biological parents may be beneficial for children in foster care, it is not uncommon to also hear concern that visits with biological parents may be emotionally distressing for children (Moyers, Farmer, & Lipscombe, 2006) and lead to displays of emotional and behavioral problems (Fanshel, Finch, & Grundy, 1990). Given the critical psychological needs of children in the child welfare system (Holtan, Ronning, Handegayrd, & Sourander, 2005), it is important to examine the impact of contact with biological parents upon depression and externalizing problems of children in foster care.

The high risk for emotional and behavioral problems among children and adolescents in foster care has long been documented (Jonson-Reid, 1998; Ryan, Herz, Hernandez, & Marshall, 2007). Youth in foster care are up to 10 times more likely to use mental health services than those not in foster care (Cuffe et al., 2001; Farmer et al., 2001; Leslie et al., 2000), accounting for a disproportionately large percentage of mental health claims (Garland, et al., 2003; Harman, Childs & Kelleher, 2000; Mennen & Trickett, 2007). Children in foster care are at risk for these mental health problems for a number of reasons. Specifically, researchers have widely documented the negative effects of maltreatment on mental health (i.e., Cicchetti & Toth, 1995; Kaplan, Pelcovitz, & Labruna, 1999; Kaplan, Pelcovitz, & Salzinger et al., 1998; Livingston, Lawson, & Jones, 1993), and the majority of children in foster care have typically experienced some form of maltreatment such as neglect, physical abuse or sexual abuse (U.S. Department of Health and Human Services, 2005). Further, the disruptions associated with the removal of children from their homes have also been associated with negative mental health outcomes. Placement instability has been found to further increase the risk of delinquency, regardless of maltreatment history, among boys in foster care (Ryan & Testa, 2005).

Although the body of research demonstrating the mental health problems of children in foster care is growing (i.e., Belsky, 1993; Finzi, Ram, Har-Even, Shnit, & Weizerman, 2001; Harman et al., 2000; Heller, Larrieu, D’Imperio, & Borris, 1999; Kaplan et al., 1999), research examining specific predictors of children’s mental health using a nationally representative, randomly selected sample has been limited (Heflinger, Simpkins, & Combs-Orme 2000; Holtan et al., 2005). Guided by attachment theory, the present study will examine whether depression and externalizing problems experienced by children in foster care are related to the amount of contact they have with their biological parents after the children have been removed from the home.

Theoretical Background

Children form attachments with their biological parents and depending on the quality of the parent-child relationship, different attachment styles develop (Bowlby, 1982). Bowlby (1977) defined attachment as “the propensity of human beings to make strong bonds to particular others and of explaining the many forms of emotional distress and personality disturbance, including anxiety, anger, depression, and emotional detachment, to which unwilling separation and loss give rise” (p. 201). Theoretically, the separation of children from their parents is a risk factor associated with poor mental health of children in foster care (Lowental, 1999; McWey & Mullis, 2004). Bowlby (1982) asserted that children who experience the loss of an attachment figure will exhibit distress even if the attachment figure is replaced with a capable caretaker. Whether the attachment is secure or insecure, separation will likely be distressing and anxiety-provoking (Howe, Brandon, Hinings, & Schofield, 1999). This distress can manifest in problematic behaviors, such as aggression, delinquency, and depression (Kaplan et al., 1999).

Although attachment theory historically described infants’ behaviors toward their mothers, attachment behaviors are now considered seen as continuously illustrated throughout life and important in identity development and one’s ability to relate to others (Bretherton & Munholland, 1999; Erich, Kanenberg, Case, Allen, & Bogdanos, 2009). Attachment theorists assert that individuals organize lessons learned about the responsiveness of others, and this organization results in the formation of internal working models (Bowlby, 1980). Internal working models become the framework by which one forms expectations about the predictability of the caregiver’s responsiveness and their ability to elicit reactions (Bowlby, 1980). Although such models are originally formed with the primary caregiver, internal working models may be templates by which individuals construct expectations in other relationships.

In 1975, Littner was heralded as the first to stress the importance of attachment to biological parents for youth in foster care. Littner (1975) proposed that youth in foster care who are not able to visit their families could develop an unrealistic image of their biological parents which could damage their self-esteem and ability to relate to others. He declared, “For better or worse, they are his roots to the past, his support and foundation. When he is separated from them, he feels that he has lost a part of himself” (p. 177).

The importance of family upon attachment and well-being specifically for adolescents has been well documented (Erich et al., 2009). During adolescence one attempts to balance dependence and autonomy. Finding this balance may be more difficult for adolescents in foster care, who likely lack secure attachments (Schofiled & Beek, 2009). For adolescents in foster care, promoting a sense of family membership and family availability are key aspects of helping establish a secure base (Schofiled & Beek, 2009). Roberts (2002) asserted that disruption of the parent-child relationship could actually cause youth to feel like they are being disloyal to their parents. Even if the biological parent-child relationship is not entirely positive, some espouse that continued contact allows youth to have a more realistic view of their biological parents (Fahlberg, 1991), and can help to preserve family relationships (Hess, 1987; Hess & Proch, 1988).

Also rooted in attachment theory is the concept of ambiguous loss, which has been used to explain the distress experienced by children in the foster care system. According to Boss (2004), ambiguous loss often results in boundary ambiguity. Conceptually, boundary ambiguity is a lack of clarity regarding who is in and who is out of the family system, and what role each member plays (Boss, Pearce-McCall, & Greenberg, 1987). Boss (1988; 1999; 2002) argues that the higher the boundary ambiguity in the family after a loss, the greater the likelihood of dysfunction. For families involved with the social services system, the child’s removal from the home does not necessarily represent a clear-cut and final exit from the family, possibly resulting in a high degree of boundary ambiguity. In fact, Jones and Kruk (2005) found many children in foster care reported they do not feel like they are part of any family. This ambiguity can lead to feelings such as hopelessness and depression (Boss, 2004).

Contact with Biological Parents for Children in Foster Care

Visits between youth and their biological parents are complex and diverse (Haight, Kagle, & Black, 2003). An ideal visitation context would include an emotionally supportive and enriching environment, however visits are not always “ideal” (Haight, Black, Workman, & Tata, 2001). Congruently, adolescents in foster care report a range of responses to visiting with their biological parents (Haight et al., 2003). Although there are complexities of visitation, consistent visitation with biological parents is considered an important aspect of family preservation efforts (Haight et al., 2003) and important in developing or maintaining the parent-child attachment relationship (Haight et al., 2003).

The theoretical assumptions associated with the importance of visitation for children in foster care and their biological parents have been empirically tested. Some studies show that continued contact between children involved in the foster care system and at least one biological parent is positively correlated to children’s current well-being (Cantos, Gries, & Slis, 1997; McWey & Mullis, 2004). Simsek, Erol, Oztop, and Munir (2007) found that regular contact with parents was a significant protective factor against internalizing and externalizing problems. Researchers have also demonstrated that children who continue to visit their biological parents tend to form new relationships with fewer relationship difficulties (Egeland & Sroufe, 1981; Finzi et al., 2001; McCarthy & Taylor, 1999; Wekerle & Wolfe; 1998). Further, consistent contact with biological mothers is a predictor of reunification (Davis, Landsverk, Newton, & Granger, 1996). Not only has the value of continued parent-child contact been supported, but it has also been proposed that disruption of the parent-child attachment could be detrimental to the well-being of children in foster care (Grigsby, 1994).

Despite evidence that suggests there are positive outcomes associated with continued contact biological parents and children in foster, there is contradictory evidence. For example, Neil, Beek, and Schofield (2003) observed that at least one-third of children in foster care seemed to be experiencing stress associated with contact with their biological parents. Farmer and Pollock (1998) found that 56% of adolescents in foster care felt that either some or most of their contacts with their parents were unhelpful to them. Additionally, Leathers (2003) found that children who had strong relationships with both biological parents and foster parents experienced greater loyalty conflict. She concluded that the results of her research were consistent with other studies that failed to detect an association between parental visiting and the positive adaptation of children in foster care.

In practice, caseworkers and foster parents also report beliefs that children’s continued contact with biological parents can be disruptive, causing behavioral problems to worsen and threatening children’s coping and adaptation to their foster homes (Haight, Kagel & Black, 2003; Mennen & O’Keefe, 2005). Several studies describe foster parents and social workers who perceive visitation as problematic (Mennen & O’Keefe, 2005; Moyers et al., 2006). Moyers and colleagues (2006) found that 34% of the foster parents believed the current visitation arrangements were not in the best interests of the children in their care, and 49% believed the children experienced difficulties associated with their contact with family members. Further, Sanchirico and Jablonka (2000) suggest that caseworkers often reduce visitation frequency if they fear foster-parent displeasure with frequent contact between children and their biological parents.

Although most states have written policies regarding visitation between parents and children in foster care, there is wide variability from state to state (Hess, 2003). For example, some states specify a minimum amount of visitation required whereas other states use non-specific language such as “as frequent as possible” (Hess, p. 7). Although frequent visitation is recommended, studies have found that - in cases where visitation occurs - visitation is intermittent (Leathers, 2003; McWey & Mullis, 2004). For example, of the cases involved in Leathers (2003) study, the majority involved approximately 13 visits in 6 months. Unfortunately, the research that has been conducted on continued contact between children and their biological parents mirrors the lack of consistency in state policies and largely involves state or site-specific locations using small, non-random samples.

Until recently, there were no national investigations of the impact of visitation upon outcomes of children involved in the foster care system, forcing professionals to rely on state-specific data and research employing convenience sampling to make predictions about the well-being of children nationally. The present study used data from the National Survey of Child and Adolescent Well-Being (NSCAW, 2002, 2005), a national and longitudinal study of the well-being of children involved in the foster care system, to investigate the relationship between continued contact between children and their biological parents upon depression and externalizing behaviors of children in foster care.

Depression and Externalizing Problems of Children in Foster Care

The disproportionate number of children and adolescents in foster care demonstrating clinically significant internalizing and externalizing problems has been well documented (Heflinger et al., 2000; Zima, Bussing, Yang, & Belin, 2000). Using the Child Behavior Checklist (CBCL; Achenbach, 1991), studies indicate that behavior problems of children in foster care are 2.5 – 3.5 times higher than the general population (Clausen, Landsverk, Ganger, Chadwick, & Litrownik, 1998; Dubowitz, Zuravin, Starr, Feigelman, & Harington, 1993). Researchers have concluded that not only do children in foster care have high rates of emotional and behavioral problems when compared to children not in foster care but they also have “exceptionally high” rates in absolute terms (Baker, Kurland, Curtis, Alexander, Papa-Lentini, 2007; Tarren-Sweeney, 2008, p. 7). Estimates of the prevalence of clinically significant behavior problems of children in foster care, as indicated by scores on the CBCL, range from 47% (Burns, Phillips, Wagner et al., 2004) to 74% (for boys, Tarren-Sweeny, 2008). More specifically, Shin (2005) found youth in foster care had significantly higher rates of depression when compared to youth in the general population. Because the consequences of externalizing problems include behaviors such as involvement with the juvenile or criminal justice systems, however, externalizing problems of maltreated children tend to garner greater scholarly attention (Maschi, Morgen, Bradley, & Hatcher, 2008). Yet the consequences of internalizing problems may also be severe and include the development of mood and anxiety disorders, drug use, and suicide attempts (Hughes & Gullone, 2007). Andersson (2005) concluded that the “psychiatric symptoms” (p. 53), and lower general senses of well-being of youth in foster care warrant greater scholarly and clinical attention. Therefore, in the present study, we will focus on both the internalizing and externalizing problems of youth in foster care as related to amount of contact with biological parents. Although there is contradicting evidence of the impact of contact with biological parents and depression and externalizing problems of youth in foster care, relying on theory and existing research (Leon, Ragsdale, Miller, & Spacarelli, 2008; Simmell, Barth, & Brooks, 2007) we expect that children who have more frequent contact with their biological parents will exhibit less depression and externalizing problems compared to children with less frequent contact; however we also expect specific factors (discussed below) may be associated with changes in such behaviors.

Factors Associated with Depression and Externalizing Problems of Children in Foster Care

Although the high levels of depression and internalizing problems among adolescents in foster care have been well documented, few studies attended to factors that may influence that relationship (Grogran-Kaylor, Ruffolo, Ortega, & Clarke, 2008; Jonson-Reid, 1998). Research indicates that the gender of the child and the exposure to violence that a child experiences may be related to differing rates of behavior problems (Tarren-Sweeny, 2008). There is no known study, however, that has examined whether contact with biological parents impacts the emotional and behavioral problems of adolescents in foster care using a nationally representative sample (Johnson-Reid & Barth, 2000; Ryan, Testa, & Zhai, 2008). The present study will address this issue by examining the relationships between contact with biological parents and both child gender and the exposure to violence on depression and externalizing problems of youth in foster care.

Gender

Generally, girls tend to exhibit internalizing behaviors when coping with stress, whereas boys are more likely to externalize (Maschi et al., 2008). Findings from Ryan and Testa (2005) confirmed that girls had lower probabilities of delinquent behaviors compared to boys. However, when comparing rates of delinquent behaviors of children in foster care to the general population, Jonson-Reid and Barth (2000) reported that the increased risk for girls in foster care was double the increased risk for boys.

Maschi and colleagues (2008) demonstrated that whereas there is a direct relationship between maltreatment and externalizing behavior problems boys, girls internalizing problems mediate the relationship between child maltreatment and externalizing behaviors (Maschi et al., 2008). Using the NSCAW dataset, Rosenthal and Curiel (2006) used the Child Behavior Check List (CBCL, Achenbach, 1988) to identify predictors of total behavior problem scores of children aged 4–18 in foster care. They found that caregivers reported higher levels of problem behaviors for boys. Given extant research, an important question becomes whether there is a gender difference in the relationship between contact with biological parents and depression and externalizing problems.

Exposure to Violence

Children who have been maltreated are significantly more likely to experience internalizing and externalizing problems than children who were not maltreated (Clark, De Bellis, Lynch, Cornelius, & Martin, 2003; English et al., 2005; Mennen & Trickett, 2007; Turner, Finkelhor, & Ormrod, 2006). Exposure to violence can lead to depression, lowered self-esteem, identity disturbances, feelings of guilt and shame, social isolation, increased aggression, and conduct disorder (Avery, Massat, & Lundy, 2000; Carlson, Furby, Armstrong, & Shales, 1997; Staudt, 2001). In the foster care population specifically, foster youth who have experienced child abuse are more likely to use mental health services than foster youth without a history of child abuse (Garland et al., 1996; Leslie et al., 2000).

The severity of exposure to victimization that children experience is an important factor in the relationship between contact with biological parents and depression and externalizing behavior problems. Johnson, Pike, and Chard (2001) found that more severe victimization is related to more psychological difficulties. Ruggiero, McLeer, and Dixon (2000) observed that victims who experience more frequent abuse tend to experience more negative outcomes overall. Additionally, severity and duration of physical abuse predicts individual differences in internalizing symptoms (Naar-King, Silvern, Ryan, and Sebring, 2002). Danielson, de Arellano, Kilpatrick, Saunders, and Resnick (2005) found that adolescents who experience a series of abusive events report more severe levels of depression than those who experience only a single incident. More severe acts of violence (e.g. being bitten, kicked, punched, beaten, or threatened with a weapon) have stronger relationships with depression than more mild acts of violence such as spanking and being hit with an object (Naar-King et al., 2002; Wind & Silvern, 1992).

Severity of maltreatment has also been linked to externalizing behaviors. Smith and Thornberry (1995) discovered that more extensive maltreatment, with increased frequency, severity, and duration is associated with higher rates of delinquency. More frequent and more chronic maltreatment is also related to aggression (Bolger & Patterson, 2001; Bolger, Patterson, & Kupersmidt, 1998; Manly, Cichetti, & Barnett, 1994). Similarly, Manly, et al. (2001) found that severity of physical abuse during the preschool period predicts aggression and other externalizing behaviors.

Further investigation into the role that children’s contact with their biological parents plays in their mental health is needed to better inform theory and practice. The present study examined the association between contact with biological parents, gender, and severity of maltreatment on the mental health of children in foster care using a large national sample of children in foster care. Drawing from attachment theory, which proposes that preserving the connections between children and their biological parents is beneficial to children’s mental health even when the early relationship has been troubled, it is proposed that children’s contact with their biological parents will moderate the relations between the severity of child maltreatment and depression and externalizing behavior problems. Specifically, when children in foster care are able to maintain consistent contact with biological parents, the link between the exposure to violence and their symptoms of depression and problematic behavior will be attenuated. Additionally, it is hypothesized that boys will exhibit higher externalizing behavior problems scores, whereas girls will demonstrate higher depression scores. Lastly, the exposure to violence experienced will be associated with increases in both depressive symptoms and externalizing behavior problems.

Method

Sample and Procedure

This study involved secondary data analyses of the restricted release version of the National Survey of Child and Adolescent Well-Being (NSCAW; National Data Archive on Child Abuse and Neglect, 2002). The NSCAW is a national study of the well-being of children involved in the child welfare system. The NSCAW dataset includes data from more than 5,000 children involved in the child welfare system across the country. The target population included all children in the U.S. who were subjects of child abuse or neglect investigations within a 15 month period between October 1999 and December 2000. A two-stage stratified sampling design was used for the study (National Data Archive on Child Abuse and Neglect, 2002). First, the U.S. was divided into nine sampling strata; within each stratum, primary sampling units were formed. These units represent distinct geographic areas across the U.S. and are of differing sizes. A random selection scheme was then used so that the same number of children was selected from each unit, regardless of the size of the unit (NDACAN, 2002).

For the purposes of this study, all children ages 7–16 in the Child and Protective Services (CPS) subsample who had been in out of home placements for a minimum of 6 months, and who had complete data for the variables of interest in this study, were included in the analysis (n = 362). The sample consisted of 54% girls. Regarding race, 40% were African American, 45% Caucasian, 8% American Indian/Alaska Native, 2% Asian, and 5% identified themselves as “other.” The researchers asked a separate question about ethnicity and 13% of the children were Hispanic. The age of the children with complete data for the dependent variables ranged from 7 to 15 (M = 11; SD = 2.8). The length of time a child had been in foster care was reported in days. All children who were in foster care for at least six months (180 days) were included in the analyses. The mean number of days children were in out-of-home care was 800.53 (SD = 293.9).

Measures

Data were collected from children, their current caretakers, and local and state child protective services agencies. All data were collected through interviews and surveys except when sensitive data -- such as exposure to violence, maltreatment, risky behaviors, and delinquency -- were gathered from older children and adults. In those instances, the researchers used a computer assisted mechanism for collecting data in which participants heard audio files and entered data directly into a computer. The specific measures for this study are described below.

Contact with Biological Mother

Children were asked to report the amount of contact they have with both their biological mothers and their biological fathers. Choices ranged from “never” to “everyday.” Whereas the majority of the children had complete data for the variable pertaining to contact with their biological mothers, substantially fewer children reported contact with biological fathers (i.e. the majority of the children did not answer the question and 150 reported they “never” had contact with their biological father). Therefore, only contact with the biological mother was included in the analyses. For the purposes of this study, responses were categorized as “never” if the children reported as such (n = 107), “some” if the child visited with his or her mother once or twice a month (n = 91), and “often” if the child visited at least once a week (n = 164).

Depression

The Children’s Depression Inventory (CDI, Kovacs, 1992) was administered to children ages 7 and older, in order to assess the level of depressive symptoms they exhibit. The CDI contains 27 items measured on a 3-point Likert type scale. Items include assessments of children’s feelings, and their engagement in certain activities. Timbremont, Braet, and Dreessen (2004) report that the CDI is the most widely used self-report assessment of depression in children and further state that the reliability and predictive, convergent, and construct validity of the measure are high. The Cronbach’s alpha for this measure ranges from 0.71–0.86 and for the subsample of this study the reliability coefficient was over 0.90. Higher scores indicate higher rates of depression. A t-score of 65 indicates a clinically significant level of depression; however the cut-off score is suggested as a guideline not an absolute rule (Kovacs, 2004).

Externalizing behavior problems

The Child Behavior Checklist (CBCL, Achenbach, 1988) was completed by the caregivers of children ages 4 and older in out-of-home care. The total measure includes 113 items and subscales that reflect the two empirically derived behavior problems commonly found in children and adolescents, internalizing and externalizing disorders. The measure has sound reliability and construct and criterion related validity. The reported test-retest reliability of this measure ranges from 0.72–0.93. For the purposes of this study, the Externalizing Behavior Problems subscale was used. The reported internal consistency of the externalizing subscale for the NSCAW sample is 0.91 (National Data Archive on Child Abuse and Neglect, 2002) and the Cronbach’s alpha for the purposes of this study was 0.95. Scores of 60–63 indicate borderline behavior problems for both the externalizing and internalizing subscales and scores of 64 or higher are indicative of clinically significant behavior problems (Achenbach, 1991).

Child Exposure to Violence

The Violence Exposure Scale (VES, Fox & Leavitt, 1995) is an assessment of the violence observed and experienced in the home. The 23 item measure was administered to children over the age of 5 in this study and asks specific questions about exposure to violence using cartoons to depict violent and criminal acts. The measure assesses the extent to which children witnessed or experienced minor to severe victimization. The mean exposure to violence score in this study was 6.09 (SD = 4.72). Reliability coefficients for the scale range from 0.80–0.86, and in this study the reliability coefficient was 0.88.

Results

A one-way ANOVA was conducted to test for a significant effect of gender on the outcome variables. There was a significant effect of gender of the child on the child’s depression [F(1,471) =13.86; p <.001], where girls had higher depression scores (M = 53.36, SD = 13.64) than boys (M = 49.02, SD = 11.22) for an effect size of Cohen’s d = .34 (Cohen, 1988). However, the effect of gender on externalizing problem behaviors was not statistically significant.

A one-way ANOVA revealed that contact, measured as never, some, and often had a marginally significant effect on depression [F(2,359) = 2.61, p < .10]. Additionally, contact had a significant effect on externalizing behavior [F(2,350) = 3.04, p < .05]. Those children who had no contact had a mean on externalizing problem behavior of M = 63.72, SD = 11.79, those with some contact had a M = 62.02, SD = 12.68, and those who often had contact had a M = 59.96, SD = 11.98. The effect size was Cohen’s f′ = .11 (Grissom & Kim, 2005). Additionally, there was a significant correlation between the exposure to violence and both depression, r = .23; p < .001, and externalizing behavior, r = .16; p < .001.

Next, we tested the effect of gender of the child on the child’s depression after controlling for both the amount of contact and the total exposure to mild or severe violence (centered) using multiple regression. The model was significant, F(4,353) = 9.06; p < .001; R2 = .09. Girls were significantly more depressed than boys. The total exposure to violence significantly increased depression. The effect of increased contact was not statistically significant. The results are presented in Table 1.

Table 1.

Gender of Child, Parental Contact, and Exposure to Violence and Child Outcomes

Predictor Depression Externalizing Behavior
B B
Gender (female = 1) 3.24* −1.19ns
Some Contact 2.03ns −1.29ns
Often Contact −0.91ns −3.62*
Exposure to Violence (centered) 0.66*** 0.39**
Intercept 49.67*** 64.09***
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Applying the same model to the child’s externalizing behavior the model was also significant, F(4,341) = 3.97; p < .01; R2 = .04. When controlling for both contact and exposure to violence, there was no significance difference by gender. A high level of contact significantly reduced the level of externalizing behavior and total exposure to violence significantly increased the externalizing behavior (see Table 1).

For both child depression and externalizing behavior, we tested for all possible interactions between gender, contact, and exposure. Table 2 presents the mean level of depression and externalizing behavior for boys and girls at each level of contact and exposure to violence. The gender differences for depression is apparent at all level of contact and at both low and high levels of exposure (we trichotomized exposure for the purposes of this table). The single exception is that girls have somewhat lower depression than boys when there is a moderate exposure to violence. The lack of significant gender differences for externalizing problem behavior can be seen in the similarity of the means for boys and girls across most levels of contact and of exposure to violence. Boys tend to have slightly but not significantly higher means on problem behavior across nearly all levels of contact and exposure to violence.

Table 2.

Amount of Parental Contact, Child Depression, and Child Problem Behaviors: Descriptive Statistics (N = 362)

Depression Externalizing Behavior
Variables Boys M (SD) Girls M (SD) Boys M (SD) Girls M (SD)
Contact
 None 51.51 (12.55) 52.76 (15.18) 64.11 (13.05) 63.40 (10.74)
 Some 50.44 (12.04) 56.23 (14.67) 61.51 (13.75) 62.39 (11.97)
 Often 47.54 (10.10) 52.36 (12.50) 60.33 (11.48) 59.61 (12.50)
Total Exposure to Violence
 Low 46.61 (10.7b3) 48.84 (11.07) 60.36 (13.67) 58.23 (12.34)
 Moderate 50.66 (9.76) 45.29 (15.23) 63.02 (10.25) 61.16 (10.84)
 High 51.07 (12.57) 56.62 (13.39) 63.40 (13.08) 62.80 (11.77)
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Discussion

Visitation between children in foster care and their biological parents is considered the primary intervention for maintaining the parent-child relationship (Mallon & Leashoer, 2002). It is purported that continued contact is beneficial for children; it helps maintain family ties, lessens feelings of grief, and increases an overall sense of well-being (Sanchirico & Jablonka, 2000). Foster parents, however, often state that visitation results in problematic behavior of children (Moyers et al., 2006). Unfortunately, as Sanchirico and Jablonka (2000) suggest “there are many areas of the parent-child connection that are largely unexplored and poorly understood” (p. 186).

The internalizing and externalizing problems of children in foster care have long been documented (Heflinger et al., 2000; Zima et al., 2000), however, less is known about the impact of continued contact between children in foster care and their biological parents. Understanding the impact of contact between children and their biological parents upon internalizing and externalizing problems of children in foster care is particularly important because of the potential for longer term, serious consequences of sustained emotional and behavioral problems (Cernkovich, Lanctot, & Giordano, 2008; Courtney & Barth, 1996).

In the present study, relying on attachment theory and the ambiguous loss literature, we predicted that depression and externalizing behavior problems would be higher for children who had no contact with the biological parents compared to children with more frequent contact. Results for externalizing behavior problems support our hypothesis. Children with no contact with their biological mothers had the highest externalizing behavior problem scores and the scores fell within the clinically significant range. Children who had limited contact had slightly, but not significantly, lower scores on externalizing behavior. However, those children with the highest level of contact had significantly lower scores of externalizing behaviors that fell below the clinically significant range.

Regarding depression, girls demonstrated higher levels of depression compared to boys which is consistent with past research (e.g. Maschi, Morgen, Bradley, & Hatcher, 2008). Depression scores for boys decreased from no contact to often contact. For girls, however, the highest depression scores were found for children with “some” contact. Perhaps an ambiguous loss framework could aid in the interpretation of such findings. Specifically, if an ambiguous loss is indeed more distressing than a clear-cut loss, then one might expect that an inconsistent pattern of contact with biological parents (as opposed to regular, frequent visits) might predict greater depression than no contact at all. Having no contact may allow children to begin the grieving process and to move forward in a way that sporadic contact does not. Moyers, Farmer, and Lipscombe (2006) found support for the idea that no contact is better than problematic contact. They concluded that when parents refused all contact it may give children space to try to come to terms with the rejection and move ahead. Conversely, Simsek, Erol, Oztop, and Munir (2007) found that consistent contact with biological parents was a protective factor against internalizing and externalizing problems. These results suggest that continued investigation into the impact of consistent versus inconsistent contact upon the well-being of children in foster care is needed. However, the overall effect of contact controlling for gender and exposure to violence did not reduce depression significantly in this study.

Consistent with past research (Avery et al., 2000; Carlson et al., 1997; Staudt, 2001), the more exposure a child has to violence the higher the depressive and externalizing symptoms. Therefore, it was important to include the violence observed and experienced in the home as a variable in this study. The effect of gender on the depression after controlling for both the amount of contact and the total exposure to mild or severe violence was significant where girls were significantly more depressed than boys. Maschi and colleagues (2008) suggest that internalizing problems mediate the relationship between maltreatment and externalizing problems specifically for girls. Given the gender differences found in this and previous studies, it is important for researchers to explore predictors of depression and factors that have the potential to impact depressive symptoms, particularly for girls.

Most state policies suggest that visitation between children in foster care and their biological parents occur frequently and some states are more specific than others in defining what “frequently” means. Hess (2003), however, found that a “sizable proportion” of state policies do not address issues of planning, implementation, or evaluation (Hess, 2003). Although state policies are based on beliefs that visitation is beneficial for the well-being of children in foster care, without specific standards for practice, visitation may only occur sporadically (Hess, 2003). In the present study, frequent maternal contact was associated with lower externalizing problem behaviors; however it is important to consider that the relationship between these two variables may spurious. Mothers who have frequent contact with their children in foster care may differ in important ways, including the nature of parent-child attachment, from mothers with less frequent contact. Therefore, it may be that differences account for lower externalizing scores in children, not frequency of contact. If, however, visitation is indeed related to reductions in depression and externalizing behavior problems of children in foster care, more consistent, clear standards for “frequent” visitation are needed. In this study, children who had at least weekly contact with their biological parents demonstrated the lowest levels of depression and externalizing problems. Given the relationship between frequent contact and positive mental health outcomes it is unfortunate that the majority of children in this and other studies have less frequent contact with their parents (Leathers, 2003; McWey & Mullis, 2004).

Haight, Kagle, and Black (2003) have made a series of recommendations for child welfare policy and practice based on the assumptions of attachment theory. They urge professionals to support regular and frequent parental visitation whenever reunification is a goal. They suggest that, ideally, visits should last for several hours at a time, take place more than once a week, and include caregiving activities. Professional social workers are advised to use visits as a way “to support parents and children as they learn to reach out and respond to each other, and develop a relationship that meets the children’s needs” (p. 204). Poirier and Simard (2006) observed greater parental involvement when social workers and foster parents seemed to have a positive attitude towards parental participation and towards the parents themselves. Haight and colleagues (2005) evaluated an intervention designed to decrease the distress surrounding leave-taking (separating at the end of visits). The intervention included a professional who listened to mothers, acknowledged the difficulty of their present circumstances, and drew attention to positive qualities of their parenting. Professionals also educated and coached mothers on specific strategies to use during leave taking. Mothers in the intervention group used more leave-taking strategies (having a clean-up routine, giving the child an object, saying good-bye, talking about the next visit, positive or neutral talk about foster home) than mothers in the control group. Results from the Haight et al. study indicate that a relationship with an empathic professional can help change parent-child interactions during visits.

Neil, Beek, and Schofield (2003) found that it is important to promote a positive relationship between biological parents and foster parents. Foster parents’ sensitivity, empathy, and values accepting of biological parents were essential in helping children use visits to understand their membership in both families. Contact arrangements were most successful when foster parents possessed these qualities and saw the potential value of contact. Contact was beneficial when foster parents did not try to take the place of the biological parent. Fortunately, most foster parents the Neil et al. study possessed these qualities, which resulted in persistent efforts to be flexible and cooperative. When contact is characterized by cooperation rather than conflict between foster and biological parents, the child can maintain a sense of belonging to both families (Neil, Beek, & Schofield, 2003).

Although this study addressed a major weakness of past research, namely the use of a nationally representative sample, there are limitations that warrant consideration. First, due to the limited data available for contact with fathers, only contact with biological mothers was examined. Thus, in future research, it would be important to include contact with fathers to examine if outcomes are clinically and/or statistically different. Second, there are a number of potentially important factors that were not examined in this study. Broadening the scope of determinants of externalizing and internalizing behaviors of children in foster care to include relationships with current caregivers, contact with siblings, and length of time in foster care may provide a more comprehensive view of the processes by which maladaptive behaviors develop. Additionally, more information about the visits themselves would be useful. Visits between youth and their biological parents are complex (Haight et al., 2003), therefore studying frequency of visitation does not allow for an in depth understanding of the visitation context. How does the quality of the contact between children and their parents impact mental health outcomes? Are there differences in outcomes depending on visit cancelations? Does it differ depending on if the visit was canceled by the parent, caseworker, or foster parent? Does the age of the child relate to different outcomes? These questions should be considered in future research. Finally, although we used both child report of depression and the caregiver version of the CBCL, Rosenthal and Curiel (2006) found that children’s self-report of problem behaviors as measured by the CBCL were higher than caregiver reports. Therefore, the use of the caregiver report in the present study may result in lower levels of externalizing problem behavior specifically than if reported by the children themselves. The CBCL, however, has been widely used in maltreatment and foster care research and has “major advantages” as a measure of behavior problems of children in foster care because of extensive psychometric support (Heflinger et al., 2000, p. 56).

Despite the limitations, this study examined depression and externalizing problems of children in foster care using data from a nationally representative sample. Our findings indicated that more frequent contact is marginally associated with lower levels depression and significantly associated with externalizing problem behaviors. Further, differences with regard to gender were revealed. Specifically, girls had higher depression scores than boys even after controlling for exposure to violence. These findings make an important contribution to the literature by examining the impact of contact with biological parents upon depression and externalizing problems. Although much more research is needed before definitive answers about the impact of frequent contact versus sporadic contact can be answered, results suggest that supporting frequent, consistent, visitation may impact the levels of depression and externalizing programs children in foster care exhibit.

Acknowledgments

The project described was supported by Grant Number R03HD055259 from the National Institute of Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development or the National Institutes of Health.

Footnotes

This document includes data from the National Survey on Child and Adolescent Well-Being, which was developed under contract with the Administration on Children, Youth, and Families, U.S. Department of Health and Human Services (ACYF/DHHS). The data have been provided by the National Data Archive on Child Abuse and Neglect. The information and opinions expressed herein reflect solely the position of the authors. Nothing herein should be construed to indicate the support or endorsement of its content by ACYF/DHHS.

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Contributor Information

Lenore M. McWey, Associate Professor in the Marriage and Family Therapy (MFT) Doctoral Program in the Department of Family and Child Sciences at Florida State University

Alan Acock, Knudson Chair for Family Policy Research and the Distinguished Professor of Family Science in the Department of Human Development and Family Sciences at Oregon State University

Breanne Porter, Doctoral student in the MFT Doctoral Program in the Department of Family and Child Sciences at Florida State University

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