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Non-traditional upbringing and risk for Disordered Eating: The Attempt to Explain the Etiology of Eating Disorders in Adoptees Children in Foster Care

Seth Johnson






Foster care in America has unfortunately seen an exponential increase in enrollees over the past 20 years. Recent surveys put the number at 700,000 youth in non-family care settings in America. While the majority of American children do have families, the ones that don’t feel the sting of the social stigma that foster care brings about in today’s society. In addition to many other psychological pressures foster children face, their “outcast” status renders many to harmfully assume that they were/ are unwanted, which can severely damage a child’s sense of worth and furthermore cause serious defects in emotional development (Galehouse, Herrick, Raphel, 2010).


The statistics speak for themselves - it’s a widely known fact that foster care alumnus and adoptees have a higher prevalence of psychiatric disorders than those that were raised with biological parents. While the studies normally assess risks for general psychiatric disorders, there have been many studies that show a higher prevalence of eating disorders among adoptees and fostered children. For example, it was found that 3.8% of patients referred to the Mapperley Hospital at the University of Nottingham for Anorexia Nervosa (AN) and Bulimia Nervosa (BN) were adoptees, whereas the normal prevalence is 1.5% among traditionally-raised patients (Holden, 1991). We already know that fostered/adopted children are at higher risk, but now we must pinpoint why. Is it because of the notorious distress that foster cared and adopted children go through? Some explain that the higher prevalence of disorders among adoptees/foster alumnus occurs by mere coincidence and that environment has nothing to do with it; they feel that the risk for disorder is transmitted by genetics alone. The issue of deciding who is right is important because the goal of these studies is to understand risk factors and eventually treat sufferers. The focus of this review is to present and assess some popular takes on whether or not the adverse conditions associated with foster care are to blame for the higher prevalence of eating disorders.


What effects can “Prolonged Institutional Rearing” have?

A child’s emotional development is in a crucial stage during the early years. Emotional adversity can have a lasting impact on a child’s life. Fostered children have been found with a higher prevalence of anxiety disorders (Ellis, Fisher & Zaharie, 2004). That said, this high prevalence may indicate that the fostered/adopted children have a higher sensitivity to emotional distress. The easy part about this theory is the fact that it can be biologically verified. The difficult part is to run an accurate test with a large enough sample size to obtain conclusive results. This theory was tested via MRI. Parts of the children’s brain and limbic structures were measured, as an enlarged amygdala has been proven to indicate higher anxiety levels and more difficulty regulating emotions. The only statistically significant find was the fact that the amygdala volume differed in late-adopted subgroup (subjects adopted after 15 months of age). Furthermore, a regression line revealed a positive correlation between length of time and amygdala volume, (meaning the older the children were when adopted out of the orphanage, the larger their amygdala was). In attempt to verify that the amygdala volume is a fair indicator of anxiety level, a CBCL (well-known behavioral competency test) was performed on the children and then compared to the volume. It was affirmed that the children that tested with higher anxiety from the CBCL correlated very highly with enlarged amygdalas. The testing attempted to accurately compare results to a control group (38 fostered children, 40 “regular”children). The study’s results suggest that the caretaking in foster homes could act as a substantive psychological stressor and furthermore, “alter the developmental trajectory of a major neuroanatomical system involved in emotion processing” (Tottenham, Hare, Quinn, 2009).


It is important to note, however, that this study was not flawlessly conducted as “not all children completed both behavioral and MRI portions of the study as a result of a number of factors (e.g. motion artifact, fatigue, running out of time during the session)” (Tottenham, Hare, Quinn, 2009). Even in the discussion of the results, the surveyors admitted that there were “too few (children in the test group) to properly test whether the presence of an anxiety disorder was related to amygdala volume” (Tottenham, Hare, Quinn, 2009). That being said, the association between “amygdala volume” and “age adopted” out of the orphanage remained even when children with clinical anxiety were excluded from the analysis.


It is clear that the most pressing problem with studies like the above is the difficulty finding a larger population in foster care/adoption studies. Observational studies are easier to conduct, as it’s easier to merely compile and analyze data when variables aren’t being consciously controlled for. With the nature of this study, there is a test and control group being implemented, in hope to control for variables. As much as surveyors may want to sample larger populations for more accurate results, they are limited by the size and demographics of the population in a foster home. Moreover, this study required a follow up, as surveyors needed to see how the limbic system would react after spending enough time away from the orphanage. Ideally, everybody should return for follow ups, but since there is not direct incentive for some, many times people do not end up following up and results cannot be as accurate.


What ages should we focus on?

Because little is known about the 100,000 “older youths” in America’s foster care system, a study was conducted with 373 17-year old enrollees. Trying to be conscious about accurate representation, the authorities conducting the study selected 7 of the 10 largest (in population) counties in Missouri to collect data from in order to “make the sample more ethnically representative of youths in the state’s foster care” (McMillen, Zima, Scott 2004). This effort to diversify is an integral part of trying to control for lurking variables. While some data might seeming be conclusive, if the population surveyed is too small and homogenous, results can be deemed useless because of the role that chance or demographic variables play.


After assessing which subjects met interview criteria, (to name a couple: IQ above 70 and a competent ability to communicate) professional surveyors conducted interviews and collected many forms of data. This study provides helpful insight into what goes on during the child’s time in foster care and what psychological distress emerges from their experience. Over 75% of those that had been physically and or sexually abused also reported another form of maltreatment in foster care (McMillen, Zima, Scott 2004). While these results are clearly disconcerting and appalling, it is essential to find out what really goes on in foster care so the mistreatment and abuse can be first stopped and then remedied by appropriate therapy. Furthermore, the maltreatment data was sorted based off demographics and race, giving further insight into who is at the greatest risk and who should be monitored even closer. See below for an example of a table organized by risk type.


TABLE 4 -- Logistic Regression Results: Demographic, Maltreatment History, and Living Situation Differences in Rates of Past Year Psychiatric Disorder


Any Disorder Past Year

Major Depression Past Year

CD/ODD Past Year

Externalizing and Internalizing Disorder Past Year











































Physical abuse














Physical neglect














Sexual abuse














Living situation a


Kinship care 














Congregate care 

























C statistic






−2 log likelihood,df











Table 4 is a very valuable tool that can be extracted from this study. This allows us to easily visualize the prevalence of specific psychiatric disorders in accordance to various risk factors.


This study was well done, achieving its goals which were: 1. to estimate the rates of psychiatric disorders among older youths in the foster care system, 2. to assess the onset of these disorders relative to the entry into the foster care system, and 3. to examine how rates of psychiatric disorder vary by gender, race, child maltreatment histories, and living situation, as the group strived to collect data from the most diverse and accurate representation of the foster care system in Missouri. The large sample size (373) is a prudent necessity in order to most accurately predict rates of psychiatric disorders in all of Missouri. On a side note, by paying each participant $40 to complete the interview, the results may have been more accurate as the interviewee was probably more focused than they would have been without payment.


To assess the second goal, the onset of disorders was obtained solely from youth report, which is especially problematic for disorders that begin at an early age.” Furthermore, conductors of this study admit that “findings from this study may not be generalizable to other foster care populations because the sample was restricted to eight counties in Missouri” (McMillen, Zima, Scott 2004).


 What role does heredity play?

Some experts have been skeptical that the environment isn’t the main deciding factor in the high prominence of psychiatric disorders in foster children. The criticism of many studies conducted to date is the fact that they are done on too small a scale to be considered conclusive. They argue that much of the results could have happened by chance or furthermore, by lurking variables having to do with genetic predisposition to psychiatric disorders. For this reason, experts have been conducting studies with twins and siblings as heredity may help account for the high prevalence of psychiatric disorders. Some skeptics claim that results affirming high prevalence of psychiatric disorders emerging from foster care are just a coincidence; they feel that is really because all the test subjects involved were already of high risk because of genetic predispositions. While this is a possible explanation of the results in many studies done to date, it is highly improbable that every study was coincidentally conducted using children that were genetically predispositioned to be at a high risk for a psychiatric disorder. The results have been too consistent across the board – it may seem feasible to make such a claim about one study that, for example, only used 10 test subjects, but such a sample size would be an abysmal travesty of a survey conducted by a healthcare professional. Furthermore, it would be very difficult to prove the genetic predisposition that the children have, as family records are limited and even non-existent in the case of many foster children.


A twin study conducted by Klump, Suisman and Burt in 2009 did verify that 59%-82% of eating pathology is attributed to genetic factors. They did, however, qualify that “non-shared environmental factors account for the remaining variance” (Klump, K., Suisman, J., Burt S., 2009).


To date, there are not many foster care and adoption studies. The demanding and extensive nature tends to deter many from taking on such a task. First of all, they require a lot of background research into each test subject’s childhood. This is very difficult to do, as family history of many foster children is generally unknown. In this way, many studies rely on detailed accounts from the fostered/adopted children alone – an approach that many impugn as unprofessional and inaccurate. Secondly, the actual studying of the subjects can be a taxing affair, as surveying large populations for accuracy is time consuming and difficult to manage. Additionally, the majority of adoption/foster care surveys require follow ups for years after the initial interviews in order to analyze their reintegration with society. As one can imagine, this is not an easy step of the study, keeping in touch with participants for years. This is very unfortunate, as results are necessary to provide insight into what aspects of foster care and adoption should be modified.


Further Studies and Speculation

Two below studies act as supplements to the above data about foster care life. The above studies discuss prevalence of disorders before and after foster care; the following two seek to explain the psychiatric state of foster children even after leaving care and/or becoming adopted.


Studies done over the past 30 years have revealed a trend of low educational achievement in fostered and adopted children. It had been postulated that some of the etiology of psychiatric disorders could be attributed to the adopted patients “failing to achieve the educational expectations of the adopted family.” Johnson and Flach (1985) verified that higher achievement expectations were associated with severity of bulimic symptoms.


A study by Sants (1964) found that lack of knowledge about who they (foster children) are in a genealogical sense distorts the development of self-image and self-esteem. If this is true and verifiable, this study should be reproduced and further investigated, as eating disorders are known to be comorbidly associated with self-image and self-esteem problems.


How do we use the results?

There is a lot that can be taken away from the above studies on multiple levels. While some studies may lack the rich demographics required in order to generalize results for all foster children and adoptees, as mentioned in (McMillen, Zima, Scott 2004), locally run studies at least give solid framework for evidence-based initiatives that can be applied to a state’s system. Speaking in specifics, while the Missouri study was deemed ungeneralizable because of lacking demographics, the data is far from useless. Applying some of the principles learned in the study to the local foster care facilities can get the ball rolling at the very least. It is clear that larger and more exhaustive studies must be performed in order to obtain more generalizable data.


Logically, since the McMillen, Zima, and Scott study suggests that “older youths in the foster care system have disproportionately high rates of lifetime and past year psychiatric disorders,” it seems most useful for the government to work on bridge and mentoring programs to ease foster graduates into the unforgiving adult world.


As children grow get older, they start understanding more about social pressure and feel the negative effects of stress. Further suggestions could include implementation of programs that educate foster parents more about the risks their adopted child could face in the coming , as the Tottenham, Hare and Quinn study affirmed with evidence that the fear/stress response lobe of the brain (amygdala) enlarged as foster children got older and closer to adoption.


Why should we care?

Why study the etiology in depth? In addition to being morally responsible citizens that have genuine concern for the well-being of others, the financial burden on our public resources seems like reason enough to work on a resolution to this prominent problem. To put things into perspective, foster care children only represent 5% of the Medicare recipients, but use about 40% of the Medicare resources (Galehouse, Herrick, Raphel 2010). A little bit of time and money invested in prevention can go a long way.


If the general concern for the well-being of others isn’t enough motivation, it is in our best interest as a globe to study the disorders and the risk factors in order to prevent them because emotionally distressed foster alumnus and adoptees become serial killers and thieves at much higher rates than do traditionally raised children.  






Works Cited


Klump, K., Suisman, J., Burt S., McGue, M., Iacono WG. (2009). Genetic and environmental influences on disordered eating: An adoption study. Journal of Abnormal Psychology. 118 (4), 797-805.


Galehouse, P., Herrick, C., Raphel, S. (2010). On Foster Care International Society of Psychiatric-Mental Health Nurses. Journal of Child and Adolescent Psychiatric Nursing. 23, 36-39.


Mc Millen, J., Zima, B., Lionel, S., Wendy, A., Munson, M., Ollie, M., Spitznagel, E. (2004). Prevalence of Psychiatric Disorders Among Older Youths in the Foster Care System. Journal of the American Academy of Child and Adolescent Psychiatry. 44(1),


Tottenham, N., Hare, T., Quinn, B. McCarry, T., Nurse, M.,Gilhooly, T. Millner, A., Galvan, A., Davidson, M.,  Eigsti, I-M., Thomas, K.,Freed, P., Booma, E. (2009). Prolonged institutional rearing is associated with atypically large amygdale volume and difficulties in emotion regulation. Developmental Science. 13, 46-61.







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