1. Introduction
2. Aim and Methods
A literature analysis was carried out with the aim to find out what has been scientifically proven about the effects of an interrupted family history on physical health and whether consequences can be derived from this for the internal medical care of this group of people.
3. Results
Kress, L., Hansbauer, P. (2012). “Kleine Kinder in stationären Hilfen: Ergebnisse eines
Praxisentwicklungsprojekts” [4] |
Participants |
Objective |
Study design |
Results |
9 children younger than
6 who were placed in out-of-home care |
Identification of key problems and burdens in the out-of-home-placement of younger children |
Nine case studies with
different satisfaction
ratings were selected
and analysed using a
questionnaire and
practical workshops |
In addition to various psychological
reactions, psychosomatic reactions such
as nausea or fever before/during/after
visiting contacts were observed as a
burden in out of home placement |
Fries, A. B. W., Ziegler, T. E., Kurian, J. R., Jacoris, S., Pollak, S. D. (2005). “Early experience in humans is
associated with changes in neuropeptides critical for regulating social behavior” [8] |
Participants |
Objective |
Study design |
Results |
18 previously institutionalised children living with adoptive
parents and a comparison group of 21 children
living with their biological parents |
Influence of early
childhood social
experiences on subsequent brain-dependent behavioural development (oxytocin and arginine vasopressin balance) |
Evaluation and
comparison of oxytocin
and vasopressin levels
in urine samples after
physical contact with (adoptive) mother or
unknown woman |
A disturbed neuropeptide balance
was detected, although the children
had been living with their adoptive
parents for an average of three years |
Fries, A. B. W., Shirtcliff, E. A., & Pollak, S. D. (2008). “Neuroendocrine dysregulation following early social
deprivation in children.” [9] |
Participants |
Objective |
Study design |
Results |
18 children with residential care experience who live with their adoptive parents and a comparison group of 21 children who live with their biological parents |
Investigation of
the long-term neurobiological effects
of early deprivation
(cortisol levels) |
Evaluation and
comparison of cortisol
levels in urine samples
after physical contact
with (adoptive) mother
or unknown woman |
After physical contact with the
(adoptive) parents, the cortisol levels
increased in the adoptive children
while they decreased in the comparison group. Basal cortisol levels were
similar in both groups. |
Bos, K., Zeanah, C. H., Fox, N. A., Drury, S. S., McLaughlin, K. A., & Nelson, C. A. (2011). “Psychiatric outcomes
in young children with a history of institutionalization” [5] |
Participants |
Objective |
Study design |
Results |
136 children under 31 months old living in
institutions in Bucharest who were assigned to
either a foster family or a residential home, as well
as a comparison group
that had never been
institutionalised before |
Investigation of the effects of either institutionalised care or placement in a trained foster family on attachment, attachment disorders, emotional reactivity and psychiatric symptoms. Evaluation of the electroencephalograms (EEG) of the
institutionalised
children. |
Split into 2 groups in a randomised procedure: Children living in foster care and children living
in residential care.
Examination with regard
to attachment, attachment disorders, emotional
reactivity, psychiatric symptoms with follow-up checks after 30, 42 and
54 months. Evaluation of the EEG
examinations of the
136 children from
residential care |
Children in out-of-home care show
significantly more diagnosable
psychiatric disorders than the control group The EEG of children in
out-of-home care shows more theta
waves and fewer alpha waves in the
frontal, temporal and occipital areas. This altered activity is known from AD(H)D research and is associated
with delayed cortex maturation. |
Hellbrügge, T. (1966). “Zur Problematik der Säuglings- und Kleinkinderfürsorge in Anstalten,
Hospitalismus und Deprivation” [7] |
Participants |
Objective |
Study design |
Results |
69 people aged 17 - 23 who grew up in “Lebensborn” homes during the National Socialist era and a comparison group of
the same age |
Identification of abnormalities during growing up in special
homes and identification
of peculiarities in
adolescence |
Catamnestic assessments and (in-depth)
psychological examinations, contrast with comparison group and evaluation of medical reports, care
reports and biographical anamnesis |
The following special characteristics
were found: Infants: deprivation syndrome Toddlers: poor developmental status (speech delay, no eye contact, crying
out of fear, blank facial expression,
no contact with other children or
aggressive behaviour) Adolescents:
neurotic dissociality, lower intelligence, performance disorders |
| [16] Zlotnick, C., Tam, T. W., & Soman, L. A. (2012). “Life course outcomes on mental and physical health:
the impact of foster care on adulthood” |
Participants |
Objective |
Study design |
Results |
70,456 surveys
conducted in California
in 2003 and 2005. |
Comparison of the prevalence of physical
and mental health
problems in adults with
and without a history of out-of-home care |
Data analysis from the
“California Health Interview Survey” of 2003 and 2005. Investigation of the
connection between out-of-home care in
childhood and mental
and physical problems in adulthood. Consideration
of demographic and
socio-economic aspects |
Higher rates of asthma, diabetes,
hypertension and epilepsy or seizure
disorders in people with experience of out-of-home care. They were more likely to be smokers. Mental health problems were more common. Correlations can also be identified after adjusting the data for
demographic and socio-economic aspects. It is unclear whether a factor before
or during the out-of-home placement
was the cause. |
Gao, M., Brännström, L., & Almquist, Y. B. (2017). “Exposure to out-of-home care in childhood and adult
all-cause mortality: a cohort study” [10] |
Participants |
Objective |
Study design |
Results |
15,048 people born in Stockholm in 1953 |
Investigation of the effects of out-of-home care in childhood on all-cause mortality in adulthood |
Analysis with data from
the Stockholm Birth Cohort Study: Out-of-home
placements up to the 19th birthday and data on
mortality between 1973 and 2009 were collected and assessed. Comparison with two control groups who grew up under similar
conditions but without out-of-home care. |
Increased overall mortality between
the ages of 20 and 56 in people with
experience of out-of-home care. Even
in comparison to control groups who
grew up under similar conditions but without experiencing out-of-home
care, people who were placed in out-of-home care had a 62% - 114%
higher risk of death. |
Turney, K., & Wildeman, C. (2016). “Mental and Physical Health of Children in Foster Care.” [6] |
Participants |
Objective |
Study design |
Results |
92 159 children
(including 481 children
in foster care) aged 0 - 17 living in the USA who are not in residential care. |
Comparison of the physical and mental health of children in foster care with the general population. In addition, comparison of children in foster families with children living in socio-economically
disadvantaged
environments. |
Analysis of data from
the National Survey of Children’s Health (NSCH) from 2011-2012. Interviewing an adult from the household about the children’s physical and mental health. Recording
of family circumstances
and socio-economic
background. |
Children in foster care have more health problems compared to the general
population: Depression occurred about seven times as often, AD(H)D and hearing problems occurred about three times as often. Asthma and speech and language problems were around twice as common, Compared to children who are
socio-economically disadvantaged, children in foster care are more likely to have mental health problems. Physical problems occur disproportionately frequently. |
Alastalo, H., Raikkonen, K., Pesonen, A. K., Osmond, C., Barker, D. J., Kajantie, E., Heinonen, K., Forsen,
T. J., & Eriksson, J. G. (2009). “Cardiovascular health of Finnish war evacuees 60 years later.” [17] |
Participants |
Objective |
Study design |
Results |
320 people separated from their families as a result of the war and 1683 people without experience of out-of-home placement |
Investigation of the long-term effects of
family separation on cardiovascular health
and type 2 diabetes in
adulthood |
Interview and clinical
examination of participants (glucose levels, cholesterol, HDL, LDL, triglycerides, apolipoprotein A and B, lipoprotein (a), BMI,
blood pressure) |
In adulthood, those who had been separated were more likely to have cardiovascular
disease, type 2 diabetes and high blood
pressure. Those who had been separated
the longest were the most frequently
affected. Elevated values for lipoprotein(a), but no abnormalities were found for
cholesterol, HDL, LDL, triglycerides,
apolipoprotein A and B as well as BMI,
waist circumference and gender |
Ahrens, K. R., Garrison, M. M., & Courtney, M. E. (2014). “Health outcomes in young adults from foster
care and economically diverse backgrounds.” [15] |
Participants |
Objective |
Study design |
Results |
Group 1: 596 people
with experience of out-of-home care in
childhood Group 2: 456 people
without experience of out-of-home care with a low economic background Group 3: 1461 people without experience of out-of-home care with
a high economic background |
Examination of the health of young adults with
experience of out-of-home care regarding
cardiovascular risk
factors and other
chronic abnormalities. Comparison with the
health of young adults without experience of out-of-home care from economically insecure
and secure backgrounds. |
Data analysis from two
US birth cohorts with
socioeconomic data and health data (from late
adolescence and early
adulthood) |
For most of the health-concerning results: Increase from “economically high” to
“economically low” to “external
accommodation”, even after adjustment
for covariates. Group 1: worst general state
of health at both times of the study. Comparison of group 1 with group 3: Among those in out-of-home care, high blood pressure, smoking, seizure disorder, ADHD, asthma, presence of a cardiovascular risk factor and other chronic illness
were more common. Diabetes was
disproportionately common. No group differences for dyslipidaemia Comparison of group 2 with group 3: only asthma and smokers more frequent,
and no other noticeable differences |
Batty, G. D., & Hamer, M. (2021). “Public care during childhood and biomedical risk factors in middle age:
the 1970 British cohort study.” [20] |
Participants |
Objective |
Study design |
Results |
371 people with experience of out-of-home care up
to their 16th birthday and 8210 people without experience of
out-of-home care |
Investigation of the relationship between
out-of-home care in childhood and
biomarkers in adulthood |
Clinical examination of participants aged 46 to
48 years (blood pressure, height, weight, blood
values: lipids, CRP,
glycated haemoglobin) |
Slightly poorer values for BMI, systolic
blood pressure, HDL, glycated
haemoglobin, CRP and triglycerides
in those living elsewhere. After
adjustment for health and
socio-economic background from
childhood, no differences were found.
The biomarkers analysed do not
appear to have any influence on the
existing relationship between
out-of-home care and mortality |
de Mestral C, Bell S, Hamer M, Batty G. D. (2020). “Out-of-home care in childhood and biomedical risk
factors in middle-age: National birth cohort study.” [19] |
Participants |
Objective |
Study design |
Results |
322 people with
experience of out-of-home care before their 16th birthday and 7690 people without experience of out-of-home care |
Searching for causes
for poorer health in
adulthood after former out-of-home-care: Investigation of the influence of out-of-home care on biomedical
factors in adulthood |
Analysis of the 1958 UK birth cohort with a survey of the socio-economic
and health background
in childhood as well as
interviews and
examinations in middle adulthood (42 and
44/45 years) |
After adjusting the health data for
gender, 4 of 19 analysed factors were
conspicuous: fibrinogen, cortisol, forced expiratory volume in 1 second and
forced vital capacity. After adjustment
for cofactors (poverty and health in
childhood): essentially no longer
detectable correlation between
out-of-home care in childhood and
biomarkers in adulthood. The
physiological pathway leading to
poorer health in adulthood does not
appear to include the biomarkers
analysed here |
Viner, R. M., & Taylor, B. (2005). “Adult health and social outcomes of children who have been in public care:
population-based study.” [12] |
Participants |
Objective |
Study design |
Results |
343 people with and
16,224 people without experience of out-of-home care before their 17th birthday |
Investigating the
long-term impact of
public welfare on
socioeconomic status,
education, social and
health outcomes |
Study of 16,567 people from a UK birth cohort born 1970, analysing
parental interviews and self-reports at 5, 10, 16
and 30 years of age |
The socio-economic and health status
was worse after state care: there was
more poor general health. |
Hjern, A., Brännström, L., Vinnerljung, B., Frank, P., & Batty, G. D. (2023). “Cardiovascular disease in
individuals with a history of out-of-home care: a Swedish national cohort study.” [13] |
Participants |
Objective |
Study design |
Results |
24,637 people with and 838,789 people without experience of out-of-home-care |
Investigation of the influence of out-of-home care on cardiovascular health in adulthood |
Cohort study on the
years of birth 1972-1981, analysing data from various national Swedish registers. The data of the study
participants were analysed from the age of 18 to
39 - 48 years with regard
to cardiovascular diseases, deaths and socio-economic background |
Adjusted for the cofactors age and
education of the mother: twice the risk of cardiovascular disease (stroke, myocardial infarction) in adulthood in people with
experience of out-of-home care. Link
between out-of-home care and death
from a cardiovascular event more
prominent in women than in men. Clear correlation between out-of-home
care and overall mortality. Higher risk
of cardiovascular problems if the out-of-home care occurred after the
11th birthday. Duration of out-of-home
care without influence. |
Schneider, R., Baumrind, N., Pavao, J., Stockdale, G., Castelli, P., Goodman, G. S., & Kimerling, R. (2009).
“What happens to youth removed from parental care?: Health and economic outcomes for women with
a history of out-of-home placement.” [11] |
Participants |
Objective |
Study design |
Results |
368 women with
experience of out-of-home care and 9240 women without experience of out-of-home care |
Evaluation of mental and physical health problems, educational status and economic hardship in women with experience
of out-of-home care. |
Analysis of data collected by telephone as part of
the “California Women’s Health Survey’. |
Physical health: more reports of
moderate/poor health, more smokers,
more overweight people. No
abnormalities in alcohol consumption |
Xie, T., de Mestral, C., & Batty, G. D. (2021). “Association of public care in childhood with social,
criminal, cognitive, and health outcomes in middle-age: five decades of follow-up of members of
the 1958 birth cohort study.” [18] |
Participants |
Objective |
Study design |
Results |
420 people with
experience of out-of-home care before their 16th
birthday and 10740 people without experience of
out-of-home care. |
Investigating the disadvantageous effects
of out-of-home care in middle age with regard
to social, criminal and
health issues. |
Analysis of data from the UK birth cohort of 1958 with information on
childhood from parental interviews and data on adulthood by interviewing the subjects at the age of
42 and conducting a
cognitive test at the
age of 50. |
3 out of 8 somatic health aspects were
noticeable: Physical disabilities 3 times
as frequent, general health was worse
and a cancer diagnosis was significantly more frequent (factor >1.5). No clear
correlations regarding obesity, diabetes,
high blood pressure, hospitalisation
and accidents. |
Brännström, L., Vinnerljung, B., & Hjern, A. (2020). “Outcomes in Adulthood After Long-Term Foster Care:
A Sibling Approach.” [14] |
Participants |
Objective |
Study design |
Results |
533 people with at least
5 years of experience in out-of-home care before their 13th birthday and
their 616 siblings or half-siblings on their mother’s side who were
not in out-of-home care. |
Investigating the effects
of long-term out-of-home care on later life. |
Data analysis of a Swedish birth cohort (1973-1982)
on siblings of whom one was in out-of-home care, regarding education,
social and health at the
age of 30 - 39 years. |
Those in out-of-home care had poorer
scores in terms of disability pension
(reason for disability unknown) and
mortality |
The literature analysis revealed 17 relevant publications with information on the physical consequences of being taken into care/interrupted childhood biographies, which are summarised in Table 1 with regard to the research question.
From the scientific studies presented in the table, the following relationships between placement in care and somatic abnormalities could be derived:
The physical abnormalities described during separation, out-of-home care and during childhood/adolescence are as follows:
The effects on physical health in adulthood have been described in the literature as follows:
A specific biomarker that is clearly responsible for chronic diseases and increased mortality in adulthood after the experience of being placed in an out-of-home care setting has not yet been identified [19] [20]. Beyond that, etiology for the increased health issues both in childhood and adulthood is largely unknown. In terms of higher rates of AD(H)D correlations with the detected abnormalities in EEG-activity are known from ADHD research [5].
By examining the results with control groups that grew up under similar conditions but were not separated from the family of origin, it was possible to find an indication that the observations are not only due to potentially traumatising experiences in the family of origin, but also due to the additional stress in the care setting [6] [10] [14].
4. Discussion
Child protection interventions, especially the most invasive of which is taking children into care, are carried out in an attempt to do good to children and young people and to avert the known detrimental effects of child abuse and neglect. In this occasion, child protection is based on standards whose effects have not been fully evaluated. The conducted evaluation of the scientific studies shows that there are medical peculiarities in the lives of people who have been taken into care. In the period of separation, out-of-home care with visiting contacts and during adolescence somatic abnormalities such as nausea, fever, AD(H)D, asthma, hearing problems, vision problems and psychiatric symptoms are described. While immediate reactions (e.g. nausea) occur directly [4], the time until other symptoms appear is not reported. Various somatic abnormalities were found not only during the period of out-of-home-placement, but also well into adulthood [4]-[18]. This means that there is evidence to assume that even many years after separation there is no full recovery of health. From an internal medicine perspective, the health abnormalities found in the literature research in adulthood, such as diabetes [15]-[17], asthma [15] [16], high blood pressure [15] [17], epilepsy/seizure disorders [15] [16], also raise the question of whether the intervention of being taken into care leads to a change in health history that should be taken into account by doctors.
As studies suggest that children who are taken into care have poorer health outcomes in adulthood than control groups from socioeconomically comparable families [6] [10] [15] [16], and this has been shown to be due not only to previous family experiences but also to the stress of being taken into care [6] [7], both the potential harm of inaction and the potential harm of hasty intervention need to be weighed up before a child is taken into care.
This assessment is particularly difficult due to the lack of knowledge about the consequences of being taken into care. Most of the abnormalities during out-of-home care were found in studies with young children under six years of age [4] [5] [8] [9]. However, it is not known which age group is most likely to have short- and long-term health problems, especially because many studies do not differentiate between age groups. There is no study that scientifically monitors a group of people who has been taken into care or was separated from their caregivers over a longer period of time. Therefore, there is a great need for scientific monitoring of children and adolescents before, during and after being taken into care into adulthood in order to be aware of the possible impact of being taken into care and to be able to guarantee long-term medical and psychological support.
From an internist’s point of view, it can be deduced that the collection of medical and family history can be complicated not only by an interrupted family history, as some information may not be available to the person, but that the interrupted family history itself can also constitute important anamnestic information.
5. Study Limitations
There are existing only a few scientific publications on the health development of people after being placed in out-of-home-care. The available scientific literature shows heterogeneous research methodology which aggravates comparing study results. No group of people with experience of out-of-home-placement has yet been scientifically accompanied for a longer period of time. It is therefore difficult and often not possible to differentiate whether the abnormalities described are due to circumstances prior to the separation from the familiar environment and caregivers or to the separation/custody itself, or whether other factors come into question. This results in a need for further research.
Some publications do not aim to analyse the physical effects of taking children into care and the information on taking children into care is only taken from marginal notes.
Some publications also do not explicitly analyse the consequences of taking children into care and include placements where the reason for separation from the parents is unknown as well as placements for protection from wartime attacks.
6. Conclusion
The analysis of the studies indicates that being taken into care has physical effects that are noticeable both directly and in adulthood. Direct reactions to the stress of being taken into custody can be nausea and fever. However, effects that go beyond the acute situation and persist into adulthood have also been described, such as AD(H)D, asthma, diabetes, cancer, hypertension and cardiovascular diseases (myocardial infarction, stroke), epilepsy and increased overall mortality in adulthood. Studies show that this is not only triggered by previous experiences, but also by the stress of being taken into care.