How do social determinants of health, including unstable housing and inadequate parenting, affect the health outcomes of children in foster care?

Health Outcomes for Children in Foster Care: The Critical Role of Social Determinants

Children in foster care experience significantly worse health outcomes than the general population, driven primarily by unstable housing, inadequate parenting, poverty, and multiple placement disruptions—all of which create a cumulative burden of social determinants that directly compromise their physical health, mental health, and developmental trajectories.

The Magnitude of Health Disparities in Foster Care

Children entering foster care face extraordinary health challenges from the outset:

• 66% of children entering foster care have abnormalities in at least one body system, with 42% having problems in multiple systems 1
• Foster children experience mental health disorders at rates far exceeding the general population, with the most common diagnoses including oppositional defiant disorder/conduct disorder, major depressive disorder, post-traumatic stress disorder, and reactive attachment disorder 2
• Fewer than 15% of children in poverty who need mental health care actually receive services, and even fewer complete treatment 3
• Children in foster care face multiple threats to healthy development including poor physical health, attachment disorders, compromised brain functioning, inadequate social skills, and mental health difficulties 4

Social Determinants of Health: The Framework for Understanding Youth Outcomes

Defining Social Determinants in Youth Populations

The World Health Organization defines social determinants of health as "the circumstances in which people are born, grow up, live, work, and age" 3. For youth, these determinants operate on two levels:

Upstream determinants are features of the social environment over which children have no control but which profoundly influence their health trajectories, including inequities in daily living conditions and inequitable distributions of power, money, and resources 3.

Downstream determinants are the direct clinical manifestations seen in practice—the trickle-down effects that result in worse health outcomes, more frequent symptom exacerbation, and repeated hospitalizations 3.

The Gradient Effect of Social Risk

There is a strong gradient effect where as social risk factors increase in number, the risk for poor mental health increases proportionally 3. This is not a threshold phenomenon—children from families across the spectrum of lower income levels incur risk, with those facing the greatest poverty experiencing the greatest risk 3.

• Lower socioeconomic status creates a consistent gradient where increasing poverty correlates with worsening mental health outcomes 5
• Poverty status at birth and low parental educational attainment are the demographic factors most strongly associated with being persistently poor throughout childhood 3
• 10% of children live in "persistent poverty" (spending at least half their childhood poor), putting them at dramatically greater risk for adverse outcomes across their life span 3

Housing Instability: A Fundamental Determinant

Why Housing Matters for Child Health

Unstable housing represents perhaps the most difficult social determinant to address, yet it is critical to eliminating health disparities 3. For children in foster care, housing instability manifests in multiple ways:

• Multiple out-of-home placements directly predict worse mental health outcomes 3
• Unstable housing is associated with increased risk of postponing needed medical care 3
• Safe and affordable housing is a fundamental resource whose absence unfavorably affects health 3

The Compounding Effect of Housing on Other Determinants

Housing instability creates cascading effects on other social determinants:

• When housing costs compete with basic needs, families must make impossible decisions between healthcare appointments and food or shelter 3
• Unstable housing reduces access to medications, education, and health services, leading to significantly poorer health outcomes 3
• Lack of safe housing and environmental safety compounds the trauma already experienced by children in foster care 3

The Critical Importance of Quality Parenting

Parenting as a Protective Factor

Healthy parents are best able to promote the attachment and overall support that children need, making parental behavioral health a prevention priority 3. For foster children specifically:

• Family stability is best viewed as a process of caregiving practices that, when present, can greatly facilitate healthy child development 4
• Providing stable and nurturing families can bolster the resilience of children in care and ameliorate negative impacts on their developmental outcomes 4
• Addressing parental behavioral health challenges is essential, as parental capacity issues account for 24.2% of foster care placements 1

The Consequences of Inadequate Parenting

Children in foster care have typically experienced profound parenting failures:

• 50.2% of foster placements result from neglect, 20.1% from physical abuse, 11% from emotional abuse, and 3.2% from sexual abuse 1
• 33.2% of children entering foster care come from single-parent families, and 18.4% from no-parent families 1
• 53.7% come from high-risk families and 33.9% from families with multiple problems 1

The Foster Care Paradox

Children in foster care face additional difficulties within the child welfare system itself that may further compromise their healthy development, beyond the troubling family circumstances that brought them into care 4. This includes:

• LGBTQ youth in foster care experience increased rates of parental rejection and multiple unstable placements, with significantly elevated suicide risk 3
• The severity and complexity of mental health problems in foster children, combined with challenges engaging this transitory population in services, makes intervention particularly difficult 6

Specific Health Outcomes Affected by Social Determinants

Mental Health Outcomes

The clinical severity of mental health conditions strongly correlates with decreased quality of life, with more severe symptoms leading to worse outcomes 5. For foster children:

• Children of low socioeconomic status experience higher rates of parent-reported mental health problems and higher rates of unmet mental health needs compared to children of higher socioeconomic status 3
• Comorbid depression consistently emerges as one of the strongest predictors of poor mental quality of life 5
• Type of maltreatment and type of placement directly predict mental health outcomes 2

Physical and Developmental Health

The physical health burden is substantial:

• 38.1% of children entering foster care have dental problems, 29.9% dermatological issues, 18.4% vision problems, and 10.3% psychomotor delay 1
• 20.1% have incomplete immunizations at entry 1
• 34.6% experience delayed or precocious school abandonment 1

Long-Term Trajectory

More extended exposure to poverty and exposure during childhood have been linked with poorer outcomes, making the timing of intervention critical 3. The risk for adverse long-term outcomes is great if needs go unaddressed or inadequately addressed while in placement 7.

Barriers to Care Created by Social Determinants

Structural Barriers

Children and families living in poverty face a range of barriers that reduce their ability to access mental health services, maintain compliance with treatment, and achieve favorable treatment outcomes 3. These include:

• Clinic hours during business hours do not accommodate people working in low-wage shift positions who lack flexibility for weekly appointments 3
• Long wait times for appointments and multiple intake procedures create additional obstacles 3
• Families may rely on their own coping skills or support from family and friends whose disapproval of formal mental health treatment creates barriers 3

Cultural and Systemic Barriers

Studies document significant racial and ethnic disparities in access to community-based services, accurate diagnostic assessment, access to evidence-based interventions, and significantly higher out-of-home placements and juvenile justice dispositions 3. This requires:

• Structural competence, in which clinicians recognize how social, economic, and political conditions produce health inequities and influence how symptoms manifest 3
• Cultural humility as a lifelong process of self-reflection, acknowledging gaps in knowledge and openness to learning from patients' cultural perspectives 3

Clinical Implications and Actionable Strategies

Screening and Identification

Screening for social determinants should be systematically integrated into care 3. The CMS Accountable Health Communities screening tool has 100% sensitivity for detecting unstable housing among vulnerable populations 3.

Intervention Priorities

Treatment approaches must address both mental health symptoms and sociodemographic factors to effectively improve outcomes 5. This means:

• Prevention efforts are especially valuable when working with youth with exposure to violence or maltreatment, family disruption, limited community supports, and multiple out-of-home placements 3
• Early identification and early intervention are essential, as are ongoing wellness activities within a framework committed to active youth and family participation 3
• Developmentally-sensitive child welfare policies and practices designed to promote the well-being of the whole child, including ongoing screening and coordinated systems of care, are needed 4

The Role of Primary Care

Pediatric primary care providers are in a unique position to take a leading role because families often turn to them first for help with mental health concerns 3. However, providers must recognize that:

• Provider biases exist—those presented with lower SES clients appear less inclined to work with them and more likely to view them as having mental illness 3
• With adequate trauma-informed training, providers can quickly become comfortable and competent in identifying mental health needs of children in foster care who have experienced trauma 2

Advocacy and Systems Change

Clinicians must advocate for resources to be assigned to prevention and early intervention, including promotion of service eligibility for young, at-risk children 3. This includes:

• Working collaboratively with other health and human service providers, including school personnel, child welfare workers, and juvenile justice workers 3
• Advocating for investment in affordable housing and restructuring of communities' prioritization of housing support 3
• Supporting policy makers and social justice advocates in working toward decreasing upstream disparities 3

Common Pitfalls to Avoid

Many manualized, evidence-based practices have limitations because the diversity of the population served contrasts starkly with populations studied in traditional clinical research 3. Therefore:

• Clinicians must embrace greater adaptability and flexibility in treatment approaches, including culturally specific therapeutic modalities and appropriate use of interpreters and cultural brokers 3
• There is not yet consensus regarding how to adapt interventions to the foster care population, requiring individualized clinical judgment 6
• Most interventions have yet to be rigorously evaluated in community-based settings with children in foster care, meaning real-world implementation requires careful monitoring 6