Do adolescents in care systematically under-report their mental health difficulties in population studies? A narrative review

The present article reports findings of a narrative review of self- and carer-report mental health data that addressed the research question: Do adolescents who reside in statutory out-of-home care (OOHC) systematically underreport their mental health difficulties in population studies? A literature search was conducted to identify population studies of the mental health of older children and adolescents in OOHC that obtained self-report data. Studies were selected for review if mental health data were gathered in population studies (i.e., not clinical or treatment studies); data were collected while participants were in care; and participants were not selected on the basis of their clinical status. With few exceptions, adolescents in family-based (foster and kinship) care report less informant-standardized mental health difficulties than do their carers in population studies, with substantially lower rates of clinical-level scores. Conversely, self- and carer-report mean scores obtained for adolescents in residential care are more closely aligned. Foster carer-reported rates of clinical-level difficulties concord with rates estimated from clinician-administered semi-structured psychiatric interviews, suggesting carer-report data are accurate. The reviewed studies collectively suggest that adolescents in family-based care systematically underreport their mental health difficulties in population studies. Several hypotheses for why this phenomenon occurs are discussed in relation to available evidence and theory. Epidemiological investigations of this population’s mental health should not solely employ self-report measures. The findings have no relevance or implications for clinical assessments.