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In March 2019, ∼78 children per 10 000 and 109 children per 10 000 were looked-after by local authorities in England1 and Wales, respectively.2 This represents a lower rate than the 1970s,3 but the absolute number of children in non-parental care have been steadily increasing for the past decade. Suggested reasons for these phenomena include fewer children entering care but those that do tending to stay longer,4 and changes to admission criteria favouring home care over residential care except in more severe or complex cases.5
Based on evidence predominantly from the UK but also from the USA, Australia and Sweden, it is known that people who have spent part of their childhood in out-of-home care report significantly more adverse outcomes later in life, including worse health,6–13 than children from the general population. This includes not only mental6–13 and physical health3,9,14,15 but also increased mortality.3 Evidence shows correlations between care type and later health might differ depending on the type: mental health is consistently worse for children in non-parental care compared with general population children,16–19 but a recent meta-analysis found children in residential care had worse psychosocial outcomes than children living in non-residential care.20 Possible explanations include residential care putting children, particularly young children, at risk of attachment disorder and developmental delays.21 A few studies have shown that children in residential care have more mental health problems than those placed with non-relatives, while those in relative households have fewer problems still.22 Various theories explaining these findings, include minimization of trauma through residing with kin,16 more regular contact with a parent18 and selection into care type by health-related factors.20
Research investigating later life health differentials by care type are limited. We are only aware of one study, using the 1970 British Cohort Study, which investigated health outcomes at the age of 30 years.13 They showed that residential care childhood was related to higher rates of depression and lower life satisfaction, than foster care (relative and non-relative combined); even after adjustment for pre-care family background. A few other studies have shown that middle-aged adults who had spent time in non-parental care had worse mental health8,9,15 self-rated health (SRH)9 and mortality3 than children who had not been in non-parental care, but in these studies care status was collected retrospectively and not split by care type.
We improve on these studies by using the prospectively collected nationally representative Office for National Statistics Longitudinal Study (ONS LS) to examine whether children in various types of care settings (residential care, relative household, unrelated household or parental household) differed in their SRH 10, 20 and 30 years later; and whether these differences could be explained by the demographic and socioeconomic backgrounds of the children.
The ONS LS is a 1% representative sample of the population of England and Wales, drawn initially from respondents to the 1971 census postal questionnaire who had been born on one of four birthdays.23 New members are added to the LS if either newly born or immigrants and have the same birthdays. Additional 1% samples have also been drawn from the 1981, 1991, 2001 and 2011 censuses, as well as each sample being followed up. In order to only include dependent children whom we could identify as being in non-parental care, the sample for this analysis includes individuals <18 years; of single marital status; not living alone or independently with friends, a partner and/or child; and who were not a temporary visitor in the household/residential setting on the census date. If the LS member met these study criteria for two consecutive censuses, data from both censuses were included in the analysis. Baseline was considered to be the first census the sample member responded, separately for each follow-up period.
Our outcome was SRH, an indicator of physical and mental health problems,24 self-reported at both the 2001 and 2011 censuses. For the 2001 census, respondents were asked ‘over the last 12 months would you say, your health has on the whole been: good, fairly good or not good?’ For the 2011 census, the SRH question changed to ‘How is your health in general’ and expanded to five options: very good, good, fair, bad and very bad. For consistency across time, we collapsed categories for both time periods into ‘good’ or ‘not good’ categories by the ONS method25: 2001 ‘good’ and ‘fairly good’ = ‘good’ vs. ‘not good’; 2011 ‘very good’ and ‘good’ = ‘good’; ‘fair’ ‘bad’ and ‘very bad’ = ‘not good’.
For each census from 1971 to 2001, household grid and residential type data were used to classify dependent children as: (i) living with a parent, (ii) living with a relative >18, (iii) living with an unrelated family or (iv) living in residential care (children’s home or place of detention) on the census day. Those living in other communal establishments (e.g. hotel, hostel, hospital) at the census were excluded from the sample.
Baseline childhood demographic (age, gender, cohort and country of birth) and social circumstances [head of household (HoH) marital status, HoH employment status, HoH education, HoH social class and number of children in household] were investigated as potential confounders. These covariates were collected at each census year, albeit asked in slightly different ways in some censuses and collapsed into the following categories. Cohort (1971–2001) refers to the first census for which the LS member had a record in childhood. Country of birth was collapsed into born outside the UK or not. HoH marital status was collapsed into three categories: single, legally married or divorced/widowed (1971–1991 censuses asked separated respondents to choose married or re-married categories). HoH employment status was collapsed into three categories: employed, unemployed or other. HoH education was collapsed into achievement of post-18 qualifications or not. HoH social class was based on the NS-SEC classes26: (i) higher managerial, administrative and professional, (ii) lower managerial, administrative and professional, (iii) intermediate, (iv) small employers and own account workers, (v) lower supervisory and technical, (vi) semi-routine, (vii) routine and (viii) never worked and long-term unemployed. The number of children in the household was based on the number of dependent children usually resident in the household.
For each follow-up period separately (10, 20 and 30 years), childhood demographic, childhood social circumstances and health outcomes were compared across baseline care status categories (parental household, relative household, non-relative household and residential care) using analysis of variance for continuous variables and the chi-square statistic for categorical variables.
Given that census non-response is known to vary by socio-demographic variables (i.e. not missing completely at random),27 and the rich availability of data from other census years on each person, including auxiliary variables, we used multiple imputation to account for missing covariate data. Fourteen datasets were obtained through the chained multiple imputation program in STATA 14. For adults who were in residential care at baseline, HoH social background variables were imputed from other data including their own childhood characteristics from subsequent censuses. More detail is available in the Supplementary data. A complete case analysis was largely consistent with the imputed results with the exception that poor health 30 years later for LS members in residential care appeared downwardly biased in the complete case model.
For the main analysis, data were fitted as random intercepts mixed effects models of repeated measurements nested within individuals. Separately by follow-up period, we fitted the following mixed effects logistic regression models: (i) unadjusted, (ii) adjusted for childhood demographic factors, individually and in combination (age, sex, country of birth and cohort), (iii) adjusted for childhood social circumstances, individually and in combination (HoH marital status, HoH employment status, HoH education, HoH occupational class and number of children in household) and (iv) a final model with all covariates. To check whether relationships between care type and health varied by cohort, a type by cohort interaction term was added to the three final models.
A total of 157 896, 166 844 and 173 801 dependent children had follow-up health data at 10-, 20- and 30-year follow-ups. Some children had baseline and follow-up data between two census intervals (40 100, 31 982 and 43 014), resulting in total observations of 197 996, 198 826 and 216 815, respectively. Children in residential care were on average older and more likely to be male than children in other care categories. Almost all children in parental households and in residential care had been born in the UK, while the percentages were slightly lower for non-relative and relative households. At every census, parental households, followed by non-relative and then relative households, had the highest proportion of HoH’s that were married, employed, had 18+ qualifications and worked in managerial or professional occupations. Over time, fewer HoH’s were married and more had 18+ qualifications and worked in managerial or professional occupations.
For all follow-up periods, there was no indication that associations between care type and health varied by cohort year, so associations are presented with cohorts combined. In unadjusted analysis, children who had been living in any type of care setting had worse SRH 10 years later than children who had been living with their parent(s). However, odds of reporting not good SRH varied by care type, with an odds ratio of 1.7 (95% confidence interval: 1.4–2.0) if they had lived with a relative, 3.4 (2.7–4.2) if they had lived with a non-relative and 5.8 (3.7–9.2) if they had lived in residential care. Adjustment for childhood demographic and social circumstances reduced but did not eliminate associations [relative 1.6 (1.3–2.0); non-relative 2.2 (1.8–2.8); residential care 3.0 (1.9–4.8)]. Age at baseline, cohort (1991 or 2001), HoH employment status and HoH social class altered associations the most of all of the potential confounders. Adjustment for gender, country of birth and number of children in the household hardly affected strengths of associations.
For the 20-year follow-up, the overall care type and health patterns were similar, but fully adjusted odds ratios were stronger than for the 10-year follow-up sample. For example, the odds ratio of reporting not good SRH for residential care compared with parental care was 4.1 (2.9–5.9) at 20-year follow-up and 3.0 (1.9–4.8) at 10-year follow-up. The effects of adjustments were broadly similar, except that adjustment for cohort (1991 compared with 1981) increased odds ratios of residential care groups reporting not good SRH 20 years later.
For the 30-year follow-up patterns were again similar to prior follow-up periods, with magnitudes of the fully adjusted odds ratios between those for the 10- and 20-year follow-ups [relative households 1.3 (1.1–1.6), non-relative households 2.0 (1.6–2.5) and residential care 3.9 (2.8–5.4), compared with parental households]. Effects of adjustments were also similar, with adjustment for cohort (care status in 1981 vs. 1971) increasing odds ratios for children who had been in relative or non-relative households. Adjustment for HoH marital status also increased odds ratios for children who had been in relative households, unlike the shorter follow-ups.
Sensitivity analyses indicated that residential care was associated with poorer health years later than care in a non-parental household even for the 10-year follow-up with smaller numbers in residential care. Changing the reference group to only those living with a HoH in a disadvantaged social class did not alter the findings
In this large, nationally representative study of dependent children resident in England and Wales, across four census periods, relationships between out-of-home care and SRH varied by care type. After adjustment for childhood demographic and social circumstances, adults who had lived in residential care settings in childhood had 3.0–4.1 times higher odds of reporting not good health than adults who had lived in parental homes. The odds of not good health at all three follow-up periods were much lower for children residing in a relative’s household, at 1.3–2.0 times.
Our general finding that health outcomes vary by care type is consistent with previous literature. For LS children who might have been <18 at 10-year follow-up, results mirror previous studies showing children in residential care have more health problems than children with other care arrangements.16,20,28,29 Particularly for young children, it is hypothesized that residential care puts them at risk of attachment disorder and developmental delays.21 This theory is borne out by our results, and others, that children who resided with relatives had better SRH than those living with non-relatives. However, these health differences by care type, at least for mental health, do not appear to be inevitable, with a recent meta-analysis showing that adverse psychosocial outcomes for children in residential care could be eliminated if evidence-based treatment was conducted during their stay.20
For LS children who could have been 18+ years at the 10-year follow-up and who were 18+ years at the 20-year follow-up, our results are in line with other studies that have shown that young people transitioning out of care have not overcome their ‘bad start’, but on average have worse health than their non-care peers.13,14 We also show that even with greater attrition for the longer follow-up, non-parental care differences at 20-year follow-up appeared larger than at 10-year follow-up. This could be due to changes in placement practices over time,28,30,31 but could also reflect existing health differences between care types being magnified by differential transitions into adulthood.12,13 A few studies have shown that social support and educational achievement, factors related to better health after transition out of care, can vary by care type10,12; suggesting some avenues for reducing health inequalities for children in non-parental care.
For the first time, our results show health differences by care type after 30-year follow-up. For young children in our sample, our results are similar to a study using the 1970 British Cohort Study that found higher rates of depression at age 30 in children who had been placed in residential vs. foster care.13 We improved on this study by showing that living with a non-relative, compared with a relative, was associated with higher reporting of not good health 30 years later. A few other studies have shown that middle-aged adults who had spent time in non-parental care had worse mental health,8,9,15 SRH9 and mortality3 than children who had not been in care, but these analyses were not split by care type.
Our results concur with two other studies that have shown that health differences by care type were not entirely explained by adjustment for childhood background factors.13,16 In our study, data on social background were limited to information collected on the day of the census. In a sensitivity analysis on LS members where we knew their long-term illness status, long-term illness prevalence was much higher for residential compared with other households (23.9% vs. 3.5%). However, after controlling for long-term illness, odds of not good SRH were still higher for LS members who had resided in any care type including residential care than in a parental household (data not shown).
Research from the USA where, like the UK, informal relative care is common, suggests that there are few differences between formal and informal relative families with the children having similar needs for health and social services.32 There is a culture of informal relative care in Poland and Southern Europe, while in Sweden, Belgium and Germany, among others, relative care is expanding.33 If relative care is to become a more integral part of child welfare services across Europe, we would agree with recommendations by others that policies need to encompass all relatives and the children in their care, including those with informal arrangements.34,35 For children where placements with non-relatives are unavoidable, further work could determine what interventions can be applied to mitigate their elevated risk of poor health in adulthood. Moreover, for all care leavers we suggest that the recommendation that care leavers programmes should facilitate easy access to diagnosis and treatment is extended to far beyond the transition-to-adulthood phase.36,37
Our study has implications for countries outside the UK too. While England, has been at the vanguard of the movement away from residential to non-residential care, a decline in residential care is the general policy across Europe, albeit at varying rates of change.5,38 Our findings of better long-term health after non-residential care provides evidence of potential economic as well as health benefits in support of these changes.
A major disadvantage of using the ONS LS dataset is a lack of data on reason(s) for non-parental care and family characteristics prior to care, which are likely to correlate highly with SRH. For example, residential care tends towards older children with behavioural issues,39,40 and higher rates of depression.41,42 Contradictorily, living in a relative household is more likely for poorer families,43 with a poorer carer44,45; a strong determinant of health.46 Therefore, associations between care type and SRH could be explained by differential selection into care type.
Another disadvantage of using census data is that they are only available every 10 years. Consequently, we were not able to identify the exact timings of when children were in care. Moreover, we are unable to identify children with and without local authority care orders. As far as we are aware, there is no reason why misclassification would occur more for relative than for unrelated care groups. Our relative care group comprises children with care orders and those with informal kinship arrangements. Others have found few differences in the social circumstances or the health and wellbeing of children in these two situations.32,35 Reverse causality may be an issue for the 10-year follow-up results, as younger children could still be in non-parental care at follow-up due to their poor health, but no such issue exists for the 20- and 30-year results as they were ineligible to be in care. However, confounding by indication could still occur if health issues preceded entering care, especially for the residential care group as we could not control for health in childhood. As in any LS, sample attrition occurred. There were indications in our data that loss to follow-up was greater in the non-parental care groups, particularly for residential care, suggesting that differential associations of health status by care type may be larger than estimated. Finally, as in any study using routine self-reported data, we cannot rule out the possibility of measurement error.
The main strength of this article was the repeated prospective collection of care type, health and covariates across four decades. Coupled with the data being nationally representative, this allowed us to investigate whether children who had resided in non-parental care had differential self-reported health up to 30 years later; impossible using a dataset with a smaller sample or shorter follow-up. Using longitudinally linked census data reduced loss to follow-up, and multiple imputation of missing covariate data improved the precision of, and reduced potential confounding in, our results.
In conclusion, even after accounting for childhood demographic and social circumstances, care type is associated with health status decades later. The European Convention on Human Rights 1998 and UK’s Children Act 1989 underpin the legal framework that when non-parental care is required, priority be given to non-residential care, especially the child’s extended relatives and friends.47,48 Our findings resonate with this policy.
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