Background
Research has shown that mental health problems, such as social problems, internalizing and externalizing problems, and depression [
1‐
6], are more frequently observed among children in out-of-home care, especially in child care institutions, than children in typical home care. This could be because most of them experienced stressful events in their original household, such as maltreatment, history of criminality by family members, parents’ mental disease, and low socioeconomic status, which are known risk factors for depression [
7‐
9]. Institutionalization itself can also be a risk for depression as it is assumed to be a type of parental deprivation [
10]. Additionally, the frequent turnover of primary caregivers due to the shift-work system in the institution has been shown to result in a lowered sense of belonging among these children [
11], which can also induce depression [
12]. Under the circumstances, it is considered an important task to reduce the psychological burden among institutionalized children.
In Japan, nearly 30,000 children were living in alternative care because their parents were either unable or unwilling to care for them properly as of 2015; nearly 60% of these children had a history of maltreatment [
13], and over 80% of them were placed in institutions while the rest received care from foster parents, which is higher compared to other developed countries such as the U.S. (8%) [
14,
15]. Since institutionalization is still common in the Japanese child welfare system, where nearly 50 children may live in the same facility [
16], Japan has received recommendations to enhance alternative care, such as foster parents and family reunification, from the United Nations Committee on the Rights of the Child [
17]. However, since there are not enough resources for child care institutions in Japan, in reality, it is crucial for ensuring children’s safety by providing a home-like, intimate environment at institutions with support from their own family members when possible, and to carefully assess and protect the connection between parents and children [
18]. According to a report from the Ministry of Health, Labour and Welfare, nearly 50% of these children have some kind of contact (visitation, letters, or phone calls) with their parents [
19].
In general, communication with parents is important for healthy development and well-being among children and adolescents [
20,
21], although the results of previous studies on the impact of contacts with biological parents within children in foster care or institutions are controversial. Some studies have indicated that regular contact by biological parent(s) was positively associated with stronger attachment, children’s well-being, prevention of behavioral problems, and decreased depression scores [
22‐
25]. On the other hand, a study revealed that one-third of children in foster care experienced conflicts when they have contacts with their biological parents [
26], and workers in child care institutions or foster parents have shown reluctance to have visitation or regular contact with biological parents because it may cause psychological distress in children [
27]. It was shown that 56% of adolescents in foster care recognized that contact with their parents was unhelpful for them [
28], and children who established good relationships with both biological parents and foster parents were more likely to have loyalty conflicts [
29].
Healthy communication with parents in early life could have fundamental and long-lasting impacts on the well-being through establishment of attachment. John Bowlby, the father of attachment theory, stated that infants have an ability to form an “affectional bond” with their caregiver (mostly the mother) to survive the world, as a primitive communication style [
30]. Attachment experience with caregivers early in development is essential, as a child can internalize the attachment figure as a good one, and internalize the self-image as a valuable one to be treated in a good way through those experiences. This early attachment experience forms an “internal working model” which determines the form of interpersonal relationships throughout one’s life [
31]. Moreover, established attachment affects the choice of health behaviors and hence both psychological and physical health in adulthood [
32,
33]. A meta-analysis revealed that more than half of institutionalized children showed a disorganized pattern that cannot be classified in the three categories of attachment style (i.e., secure, avoidant, and ambivalent) [
34], and it is estimated that 82% of maltreated children develop disorganized attachments [
35]. The security of attachment may modify the quality of parent-child communications, especially among institutionalized children, who seem to lack secure attachment formation.
The objectives of this study were therefore (I) to investigate the association between parental visitation and depressive symptoms among institutionalized children in Japan and (II) to explore whether the established security of attachment interacts with that association.
Methods
Participants and data collection/procedures
The data used in this study were collected as part of a study on the Stress and Mental Health of Children in Residential Foster Care Facilities. Among 32 child care institutions asked to participate, 16 institutions across six prefectures in Japan agreed to participate in the survey. Children in fourth grade to sixth grade (age 9 to 12 years) completed the survey under supervision of facility staff members, who were able to explain the directions of questionnaires and answer questions if needed. Adolescents (age 12 to 18 years) were handed a packet of questionnaires, which they completed by themselves. A staff member for each child and adolescent completed a questionnaire about background information (e.g., maltreatment history, household situations) of the child and adolescent by referring to the record that was obtained as a part of the normal assessment process during the child’s institutionalization and preserved in each institution. After the questionnaires were completed, facility staff collected them and sent back to the researcher. Questionnaire data were obtained from 468 children and adolescents. Additional details of the survey profiles have been described elsewhere [
5].
Measures
Total number of visits made in a year and relationship with the person who visited children were obtained. We categorized them as having visitation or not by (1) either father or mother, (2) father, (3) mother, and (4) grandparents, other relatives, and friends.
Depressive symptoms
The Japanese version of the Birleson Depression Self-Rating Scale for Children (DSRSC) was used for measurement of depressive symptoms. This scale consists of 18 items and was developed to evaluate depression in children [
36]. The instrument is easy to use and has a predictive value (equal to or higher than 16) comparable with that of a psychiatric global rating of clinical range of depression obtained in an interview. The 18 items on the scale are rated with a 3-point Likert scale (range: 0–36). Cronbach’s alpha among the study participants was 0.62.
Attachment
The Internal Working Model Scale (IWMS) was used for the assessment of attachment security [
37]. This questionnaire consists of 18 questions to assess three domains of attachment, namely, “secure,” “avoidant,” and “ambivalent.” The original version was developed by Hazan and Shaver [
38] and the reliability and validity of the Japanese version has been confirmed [
39]. As described in the Introduction, given that most institutionalized children seem to have established a disorganized attachment pattern that cannot be classified in the above-mentioned three categories, we used the secure attachment score of IWMS alone to focus on the variation of the insecurity among the participants. Cronbach’s alpha among the present study participants was 0.81.
Demographics, history of maltreatment, and social support
Children’s basic information included their age (in years), gender, family composition, and whether children were exposed to any kinds of child maltreatment such as physical abuse, sexual abuse, emotional abuse, neglect, and/or domestic violence. Social support, which is described as psychological and material resources exchanged between individual network members to promote personal well-being [
40], was assessed with the Perceived Emotional Support Scale; the scale was originally developed by Sarason et al. [
41] and then modified by Hisada et al. [
42]. Since the original version was established for assessing social support in youth, the wording was slightly changed for younger children. It consists of 16 questions, such as “when you feel depressed, the person cheers you up,” or “when you fail to do something, the person will help you,” to assess the perception of emotional support from close others. Each item was rated with a 4-point Likert scale for each person. The Cronbach’s alpha was 0.99, 0.99, and 0.96 for mother, father, and care workers among this study’s participants, respectively.
Data analysis
After excluding people who did not provide data on history of maltreatment, depression score, age, and gender, the size of the final sample used in the analysis was 399. Among them, 357 participants completed the questionnaire on attachment security. Since it was presupposed that depression symptoms among children may differ by household type (i.e., has both parents, single mother, single father, or has no parent) with which main analysis (i.e., visitation x depression) was conducted, DSRSC scores were compared between each group before the main analyses, controlling for age, gender, frequency of maltreatment (0, 1, 2 or more times), and perceived social support from care workers (ranges 16–80, which was then categorized into tertiles) using a mixed effects regression analysis with a random effects model to account for multiple individuals in each institution.
A mixed effects regression analysis was also used to investigate the association between visitation and DSRSC score. The outcome was used as a continuous variable as it was distributed normally. An association between mother’s or father’s visitation and DSRSC score was only investigated among children who have a mother or father in their household, respectively. Covariates included age, gender, frequency of maltreatment, and perceived social support from mother or father (if the child has a mother or father in their household) and care workers. Missing information for the covariates was included as missing categories in order to maintain the statistical power. Parental visitation by either mother or father, mother’s visitation, father’s visitation, visitation by grandparents, other relatives, and friends, and the total number of visits made in a year (none; 1 to 6 times a year; 7 or more times a year) were included in separate models. Each model included respective visiting persons regardless of other visiting persons. Standardized score of secure attachment and the interaction term with parental visitation were then included in the analysis to examine the potential moderating effect on the association between parental visitation and the DSRSC score.
All statistical analyses were conducted using Stata 13.1 (College Station, TX, USA). The level of statistical significance was set at p < 0.05 and p < 0.10 for the interaction effect (two-tailed).
Conclusions
The number of children who have been institutionalized because of child maltreatment or other adverse experiences keeps increasing in Japan, where child care institutions do not have adequate resources. Yamamoto et al. [
48] reported in 2010 that more than half of institutionalized children returned home without resolving their household problems, and 11–14% of those children were institutionalized again within 1 year. Under these circumstances, the relationship between biological parents and children is regarded as inseparable and it is thus an urgent task to develop an assessment system for evaluating the parent-child relationship.
The present study indicated that the association between visitation and psychological well-being among children depends on each child’s situation (e.g., either having father/mother or not) and interacted with the established attachment security. It is the first study that indicated a positive association between parental visitation and depressive symptoms; it is significant as it is widely believed that parental visitation is important for maintaining parent-child relationships [
18]. It may be important to conduct precise assessment before starting parental visitation, especially when children seem to have problems with attachment. It should be noted that the present study does not emphasize that parental visitation should be avoided. Professionals should pay attention to the attachment figure of each child and their perception of the relationship with their parents regardless of the presence or frequency of visitation.