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Comparing Long-Term Placement
Outcomes of Residential and Family
Foster Care: A Meta-Analysis
Dongdong Li
1
, Grace S. Chng
1
, and Chi Meng Chu
1
Abstract
This study presents findings from three separate meta-analyses investigating differences between children placed in resi-
dential care and in family foster care with regard to three outcomes: internalizing behaviors, externalizing behaviors, and
perception of care. Based on publications from the last 20 years, a total of 23 studies were included. The total sample
consisted of 13,630 children in care, with 7,469 from foster care and 6,161 from residential care. The results from this
study indicated that children in foster care had consistently better experiences and less problems across the three out-
comes as compared to children in residential care. Analyses did not reveal evidence of publication bias, and sensitivity
analyses also suggested that results were not influenced by individual studies. Additionally, moderation analyses revealed
that the differences between foster and residential care could vary depending on certain factors such as the publication
year, the gross domestic product of the country, and the length of care. The implications of differences in outcomes
between the two placements are discussed.
Keywords
residential care, foster care, placement, outcome
A great number of children who are unable to live with
their families need substitute care each year for reasons
such as being abused, neglected, orphaned, or abandoned.
It is estimated that 140 million children are orphans world-
wide and majority of them are from countries with low
Human Development Index (UNAIDS, 2004). Adverse
childhood experiences such as these often result in children
being taken into the custody of the state, and typically,
these children are referred to as children in out-of-home
care. The question of how best to provide good living
environments for these children to promote positive devel-
opment in different types of care remains a main concern
for many state child welfare agencies.
Rich literature on child placement research has exam-
ined the effects of out-of-home care on child development.
Residential and family foster care, the two most common
forms of substitute care, are usually compared with each
other as both conditions require children to be placed under
the care of strangers. Residential care is usually referred to
as a group home, institutional care, or an orphanage in
which professional caregivers are entrusted to look after
the daily care and welfare of these children. In contrast,
family foster care encompasses parent figures in private
families who are entrusted with the care of these children.
A small payment to the foster family is usually provided to
cover the costs of care.
Residential Care or Family Foster Care
A glance at the child placement literature does not offer a
simple solution to the question of how placement decisions are
made, due to a number of studies which have demonstrated
contradictory results (Bates, English, & Kouidou-giles, 1997;
Whetten et al., 2009). On the one hand, research has indicated
that there are both short- and long-term benefits in placing
children under family foster care as compared to residential
care (Dregan & Gulliford, 2012; Smyke et al., 2012). On the
other hand, some studies have found no differences in chil-
dren’s outcomes between foster and residential care (Delfab-
bro, Barber James, & Betham, 2002; Whetten et al., 2009).
Interestingly, in Whetten and colleagues’ subsequent study
with the same sample, better physical health and emotional
coping were found for children in residential care as compared
to those in family foster care (Whetten et al., 2014).
1
Centre for Research on Rehabilitation and Protection, Clinical and Forensic
Psychology Branch, Ministry of Social and Family Development, Singapore,
Singapore
Corresponding Author:
Dongdong Li, Centre for Research on Rehabilitation and Protection, Clinical
and Forensic Psychology Branch, Ministry of Social and Family Development,
512 Thomson Road, #12-00 MSF Building, Singapore 298136, Singapore.
Email: li_dongdong@msf.gov.sg
TRAUMA, VIOLENCE, & ABUSE
1-12
ªThe Author(s) 2017
Reprints and permission:
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DOI: 10.1177/1524838017726427
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Further examination of these studies suggests that these
mixed findings may have arisen from several factors. Firstly,
the standards of care differ in different studies, partially attrib-
uted to varying societal contexts and change in the sector across
time. For example, the residential environment may be far
worse in less developed countries (e.g., Romania) than in
developed countries (e.g., Germany) whereby there may be
better quality resources and more stimulating residential care
environments. Similarly, residential care in recent years may
have been equipped with better facilities and more skilled staff
as compared to residential care 10 years ago. Therefore, it is
highly probable that the year a study is conducted in has influ-
ence on the comparison results between the two placement
types. A previous meta-analysis supported this possible mod-
erating effect in that countries with a high Human Develop-
ment Index showed smaller delays in residential Children’s IQ
(van Ijzendoorn, Luijk, & Juffer, 2008).
Secondly, associations between child outcomes and place-
ment types can vary as a function of the timing and duration of
placements and their movement between the types of place-
ment (James, Landsverk, & Slymen, 2004). The age of entry
of children in care can be widely varied, and this factor may
also be subsequently linked to decisions over placement type
and duration. In a sample of 430 children in out-of-home care,
James, Landsverk, and Slymen (2004) found that higher lev-
els of externalizing behaviors were associated with experien-
cing delayed entries into stable placements, late disruptions,
and multiple short stays in care. Behavior problems have been
demonstrated as both a predictor and an outcome of multiple
placement changes (Newton, Litrownik, & Landsverk, 2000).
On the other hand, when using a matched sample, Berger,
Bruch, Johnson, James, and Rubin (2009) have found that
associations between out-of-home placement and child well-
being did not vary by the length and stability of placements
children experience.
Thirdly, the study quality may also be a contributing factor to
mixed findings in the literature. Some studies were cross-
sectional whereas others were longitudinal in nature. In some
studies, a variety of measures were completed (and also by
multiple informants), while others only utilized self-report sur-
vey tools. Lastly, some studies applied the same set of measures
on both comparison groups while others applied matching tech-
niques to obtain a comparison group from administrative data.
In the context of the above-mentioned differences across
studies, a meta-analysis which synthesizes and controls for
differences is highly useful for the examination of results from
studies comparing foster and residential care. A meta-analysis
enables the identification of patterns and disagreements from
various findings and/or to discover other interesting relation-
ships that may arise in the context of multiple studies (Green-
land & O’Rourke, 2008). It allows for the testing of the
consistency of effect size across a body of data. If the effect
is consistent, the effect size can be estimated and be reported as
robust across the different types of studies. If it varies substan-
tially from study to study, the extent of this variance can be
quantified and the dispersion of effects is studied.
Previous Reviews on Outcomes of Children in Care
Anumberofreviewshaveexaminedtheoutcomesofchildren
in residential care and family foster care, with many focusing
on specific treatment programs in residential or family foster
care. These reviews generally indicated significant improve-
ment in children’s outcomes after treatment (James, 2011;
Knorth, Harder, Zandberg, & Kendrick, 2008; Osei, Gorey,
&Jozefowicz,2016;Reddy&Pfeiffer,1997;Turner&
Macdonald, 2011). For example, James (2011) examined five
models of residential treatment model and found four of them
promising. There have also been qualitative reviews on resi-
dential and foster treatment which did not show obvious dif-
ferences between the two modalities (Bates et al., 1997; Curtis,
Alexander, & Lunghofer, 2001).
Fewer review studies have compared the long-term outcomes
for children who live in residential care and family foster care
settings. In general, there are consistently negative views on
group residential care as a place to raise young children on a
long-term basis (Dozier, Zeanah, Wallin, & Shauffer, 2012).
However, certain reviews have also found that family foster care
has neither positive nor negative effect on children’s develop-
mental trajectories (Goemans, van Geel, & Vedder, 2015). To
the best of our knowledge, only two meta-analyses have focused
specifically on the comparisons between residential care and
family foster care. The first meta-analysis found that children
in residential care had substantially lower levels of IQ as com-
pared to those in foster families (van Ijzendoorn, Luijk, & Juffer,
2008). A more recent meta-analysis compared residential care
with three other conditions: family foster care, treatment foster
care, and no placement. The authors found that the outcomes of
residential care were often worse than the other alternate forms
of care (Lee, Bright, Svoboda, Fakunmoju, & Barth, 2011).
However, this review only included three studies that compared
between residential care and family foster care, with two studies
demonstrating favorable results for family foster care.
Present Study
The aim of this present meta-analytical study was to examine
the differences in outcomes between children who were placed
in family foster and residential care. We hypothesized that
there would be better outcomes for children in family foster
care as compared to those in residential care. We also expected
the effects to vary as a function of some study characteristics.
Therefore, we examined a list of relevant moderators to
account for the variability across studies, including (1) study
quality, (2) mean age, (3) time in care, (4) gross domestic
product (GDP) per capita for the country where the study was
conducted, and (5) year of publication. These variables are
explained in detail in the Plan of Analyses subsection.
We performed a series of meta-analyses on three outcomes:
internalizing behaviors, externalizing behaviors, and percep-
tion of care. These problematic behaviors were usually used
as outcome measures among the children-in-care population.
Similarly, the perception of care was often used to gauge the
2TRAUMA, VIOLENCE, & ABUSE XX(X)
subjective well-being of the children in care. However, no
meta-analysis has been conducted on these topics among the
children-in-care population so far. We thus attempted to
synthesize the findings for the first time, and we expected that
children in family foster care to have lower levels of proble-
matic behaviors as well as a more positive perception toward
their caregiving environment in comparison with children in
residential care. The findings of the study can then be used to
inform policies and practices in providing care for these dis-
advantaged children in order to enhance positive developments
in the public care system.
Method
Inclusion Criteria
The purpose of the study was to synthesize results from publi-
cations that compared the outcomes of children in residential
and family foster care in the past 20 years (January 1995 and
June 2016). Studies which compared differences between these
two particular types of care were included. For residential care,
we referred to the care modality where children stayed in group
settings with paid staff as the main caretakers (del Valle, 2013).
For family foster care, children were placed in a family setting
where the foster parents, who were usually not related to the
children, were the main caretakers. We focused on the general
children-in-care population in the child welfare system. An
exclusion criterion was applied such that articles on treatment
foster care, such as violence prevention foster care (Berg-
stro¨m & Ho¨jman, 2016), were not included. In other words,
children who were in special care or treatment centers, such as
youth offenders or children with severe mental health prob-
lems, were not the target population of this meta-analysis.
Besides, studies which only reported comparisons between
children-in-care and the general population (Llosada-Gistau,
Montserrat, & Casas, 2015; Monshouwer, Kepper, van den
Eijnden, Koning, & Vollebergh, 2015; White, O’Brien,
Pecora, & Buher, 2015), as opposed to comparisons between
care types, were also excluded.
Among various outcomes, we examined children’s interna-
lizing behaviors, externalizing behaviors, and perception of
care. Specifically, internalizing behaviors included symptoms
such as being withdrawn, somatic complaints, anxiety, and
depression while externalizing behaviors included hyperactiv-
ity, delinquent, or aggressive behaviors. Children’s perceptions
of care included their perceptions, attitudes, or satisfaction with
their experiences in the two different types of placement. Jour-
nal articles and dissertations that were published in English and
Chinese language were included in the search.
Identification of Studies
The search strategy for this study was to locate all studies
comparing residential care with foster family care. First, the
first author (D.L.) conducted a cross-database search using
English database portals (EBSCOhost, ProQuest, PubMed,
Web of Science, Cochrane library, and Google Scholar) and
Chinese database portals (China National Knowledge Infra-
structure [CNKI] and Airiti library, which covers China’s aca-
demic journals, doctoral dissertations, masters’ theses, and
conference proceedings).
As different terms may be used to describe family foster
care and residential care in various studies, we have included
multiple key words for each type of care, including “foster
family,” “home* care,” “foster care,” “surrogate family,”
“surrogate care,” “group care,” “residential care,” “institut*
care,” “congregate care,” and “orphanage.” These key words
were connected using Boolean operators such as “OR” and
“AND.” We also used a combination of key words such as
“type of placement” or “placement type” with “substitute
care,” “out-of-home care,” and “children-in-care.” Similarly,
the key words used in Chinese databases include “family foster
care (Ji Yang Jia Ting)” and “residential care (Fu Li Yuan)” or
“orphanage (Gu Er Yuan).”
The search yielded 2,774 studies (2,563 in English and 211
in Chinese). Studies written in any other languages were
included only if their English versions were available. We also
identified 51 potentially relevant articles by checking through
the reference lists of past review studies, and all studies that
were included in this current meta-analysis. A flowchart of the
literature search process is presented in Figure 1 following
Preferred Reporting Items for Systematic Reviews and
Meta-analysis recommendations (Moher, Liberati, Tetzlaff, &
Altman, 2009). After a review of the abstracts, 152 articles
were included for full-text examination, resulting in 23 studies
that met the inclusion criteria.
Of all articles, 13 examined both internalizing and externaliz-
ing behaviors, with 2 additional articles examining only inter-
nalizing behaviors and 5 articles only on externalizing behaviors.
Five articles examined perception of care. In total, the final
sample that was used in the present study consisted of 23 studies
with 38 effect sizes from one doctoral dissertation and 22 journal
articles published in English language. None of the articles that
were published in the Chinese databases met all inclusion cri-
teria. Table 1 presents thesummaries of the study characteristics.
Data Coding
Data coding was conducted for three separate meta-analyses to
examine the impact of placement in residential care and family
foster care on (1) internalizing problem behaviors, (2) externa-
lizing problem behaviors, and (3) perceptions of care. Each
study was coded at three levels: (a) article, (b) sample, and
(c) effect size. At article and sample level, we coded for the
five variables necessary for moderator analyses (please refer to
Plan of Analyses subsection).
For effect size-level coding, Hedges’s gwas used as the effect
size measure, which is a variation of Cohen’s dthat corrects for
biases due to small sample sizes (Hedges & Olkin, 1985). When
different instruments were used to assess the same construct in
one study (or different informants assessed the same construct),
a mean effect size was computed for the construct and this mean
effect size was used in the final analysis.
Li et al. 3
When a study reported a relationship without any statistics,
we estimated a conservative effect size based on sample size
and an arbitrary pvalue (we used p¼1 if the relationship was
nonsignificant and p¼.05 if the relationship was significant).
If a pvalue was reported as less than a certain value, we used
that value as a conservative estimate. The coding was done
independently by two of the authors. All differences were
discussed until consensus was reached. With regard to inter-
rater reliability, the two authors achieved 93%identical cod-
ing before discussion.
Plan of Analyses
To answer the research questions, three separate meta-analyses
were conducted. Random effects models were tested as hetero-
geneity was assumed due to substantial variations among studies
(e.g., cultural differences and age differences). The following
covariates were included in the meta-regression analysis: (1)
study quality—the overall quality of each study is coded based
on the Newcastle-Ottawa Quality Assessment Scale (NOS).
NOS is a quality assessment tool for observational studies
including case–control and cohort studies. Based on NOS, each
study can be assessed in three broad domains: the selection of the
study groups (e.g., the representativeness of the exposed cohort),
the comparability of the groups (e.g., whether the study controls
for any important confounding factor), and the ascertainment of
either the exposure or outcome of interest (e.g., whether the
assessment of outcome is through independent blind assess-
ment). A score of 5 stars or more out of 9 is considered a good
quality study; (2) age—the mean age of the study sample at the
time of the outcome assessment; (3) gender—the percentage of
girls in the sample; (4) time in care—the average number of
years that children had stayed in public care, including both the
family foster care and residential care. An arbitrary value of 5
years was used to describe long-term outcomes (5 years or more
as compared to less than 5 years); (5) GDP—the GDP per capita
(scaled down by 10,000) of the country where the study was
conducted. It was assumed that the care quality in higher GDP
countries would be better than that in lower GDP countries; (6)
year—the year of publication was used as an estimate of the
study order, specifically the period when the children stayed in
care. It was assumed that the care quality in recent years would
be better than that in earlier years. In a few studies, the publica-
tion year was more than a decade away from when the children
were in care because the outcome data were collected on adults
who were formerly under public care. In such cases, the publi-
cation year was not a good estimate of the chronological order of
the studies; they were thus removed from the meta-regression on
publication year as part of the sensitivity analysis.
Due to the small number of studies included, only one of the
covariates was tested at each time. Meta-regression was only
conducted when the total number of studies included for the
Records identified
through Chinese
database search
(n = 211 )
Additional records
identified by checking
through the reference lists
(n = 51)
Duplicates removed
(n = 1,311)
Records screened
(n =1,514)
Records excluded
(n = 1362)
Full-text articles assessed
for eligibility
(n = 152 )
Full-text articles excluded, due to the following reasons:
•No relevant statistics (n = 39, e.g., no comparison)
•No relevant outcomes (n =74, e.g., results on cognitive
development from The Bucharest Early Intervention Project)
•Special population (n = 16, e.g., the sample only included
children with delinquency problems)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 23)
Records identified
through English
database search
(n = 2,563)
Figure 1. Flowchart of the literature search.
4TRAUMA, VIOLENCE, & ABUSE XX(X)
Table 1. Characteristics of the Included Studies.
Study Name
Foster
Care n
Group
Care n
Girl
(%) Country Age
Time in
Care
(Years) Outcome Measure Quality Description
Ahmad, 2005 89 43 48 Iraqi Kurdistan 11 2þINT/EXT CBCL 7 2-Year follow-up on orphans
Ajdukovic
´, 2005 112 263 52 Croatia 13.1 5.4 INT/EXT YSR and CBCL 5 Possibilities for improving the care of children in children’s
homes and foster families’ project
Chapman, 2004 52 15 51 US 10 1þPER Perception on closeness, relatedness, and so
on
4NationalSurveyofChildandAdolescentWell-Being
(NSCAW)
Cheung, 2011 865 107 43 Canada 13 7 EXT Multi-informant measures, SDQ 5 Ontario looking after children project
Damnjanovic, 2011 105 111 53 Serbia 13.8 5.8 INT/PER Depression and Anxiety by SMFQ/SCARED
and PedsQL
4AstudyonSerbianchildwelfaresystem
Damsteegt, 2014 34 57 53 The Netherlands 1.25 1#INT/EXT CBCL 6 International adoption study (adoptee from China)
Delfabbro, 2002 39 12 45 Australia 11.7 2.3 PER Perception on safety, happiness, and so on 4 A 3-year longitudinal study on children in out-of-home care in
South Australia
Dregan, 2012 146 171 51 UK 30 1#INT/EXT Depression by Malaise Inventory/criminal
conviction
71970BritishCohortStudy
Ford, 2007 839 279 40 UK 10.5 2þINT/EXT Emotional/conduct/hyperkinetic disorder by
DAWBA
5Threenationallyrepresentativesurveys
Friedrich, 2005 36 26 26 US 12.3 1.25þEXT Problematic sexualized behavior by CSBI 7 A study on three New York City child welfare agencies
Harden, 2002 30 35 42 US 1.38 1 EXT Toddler behavior checklist 6 A study on African American children in care
Heflinger, 2000 105 77 55 US 12 1þINT/EXT CBCL 6 Children’s program outcome review team
Humphreys, 2015 55 55 50 Romania 12 12 INT/EXT PAPA 8 Bucharest Early Intervention Project (BEIP)
James, 2012 157 157 38 US 10 3þINT/EXT CBCL 7 Propensity score matching on NSCAW
Kang, 2014 40 127 47 South Korea 12.5 8 INT/
EXT/
PER
CBCL, perception on satisfaction,
supervision, affection, and so on
5PanelstudyonKoreanchildreninout-of-homecare
Li, 2011 261 132 52 US 17.5 1þEXT Criminal offense 6 Midwest evaluation of the adult functioning of former foster
youth
Loman, 2013 44 54 55 US 12.9 1#INT/EXT Depression/conduct problem by BASC-2 6 International adoption study (adoptee from Asia, etc.)
Marinkovic, 2007 41 43 55 Serbia 14.8 8 INT/EXT YSR 5 A study on Serbian child welfare system
Nowacki, 2010 27 21 69 Germany 24.8 9 INT BSI 3 A study on adults who grew up in German child welfare
system
Roy, 2000 19 19 37 US 6.7 6.4 INT/EXT Multi-informant measures 7 A study on primary school children
Ryan, 2008 4,113 4,113 46 US 13 4.4 EXT Official arrest record 6 Propensity score matching on admin records from Los
Angeles county
Sim, 2016 153 131 51 Singapore 11.1 4.8 INT/EXT CANS 5 A 1-year follow-up study on children in care
Wilson, 1999 100 100 42 US 11.5 3.23 PER Perception on quality of life, safety, and so
on
4Arandomsampleofout-of-homecarechildreninIllinois
Note. The study name was created by linking the first author last name and the study year with a comma. BASC ¼Behavior Assessment System for Children; BSI ¼Brief Symptom Inventory; CANS ¼The Child and
Adolescent Needs and Strengths; CBCL ¼Child Behavior Checklist; CSBI ¼Child Sexual Behavior Inventory; DAWBA ¼Development and Well-Being Assessment; EXT ¼externalizing; INT ¼internalizing; PAPA ¼
Preschool Age Psychiatric Assessment; PedsQL ¼Pediatric Quality of Life Inventory; PER ¼perception; SCARED ¼Screen for child Anxiety Related Disorders; SDQ ¼Strengths and Difficulties Questionnaire; SMFQ ¼
Short Mood and Feelings Questionnaire; YSR ¼Youth Self Report.
5
particular outcome was larger than six. The Q(the significance
test for observed dispersion), I
2
(the ratio of excess dispersion
to total dispersion), and t(the estimated standard deviation of
the true effect) were reported as indicators of heterogeneity
(Borenstein, Hedges, Higgins, & Rothstein, 2009). Publication
bias was tested for all significant relationships by checking the
funnel plot. The studies will be distributed symmetrically in the
funnel plot around the mean effect size if there is no evidence
of publication bias. We also examined the Egger’s regression
intercept, which was the statistical test for asymmetry of the
funnel plot, to assess the threat of possible bias in the sampling
for publications (Orwin, 1983).
For sensitivity analysis, the jack knife method was used to
assess the impact of the inclusion of transformed and estimated
effect sizes using arbitrary pvalues as well as studies with
extreme effect sizes. Through this procedure, one study was
removed each time to determine whether the overall effect size
is biased by the influence of any one study (Borenstein et al.,
2009). Cohen’s (1992) guidelines for interpreting mean effect
sizes were employed, whereby Hedges’s gof at least .10, .30,
and .50 were considered as small, moderate, and large, respec-
tively. All data analyses were conducted using Comprehensive
Meta-Analysis Version 3.
Results
Internalizing Behaviors
The first meta-analysis included 15 studies with a total of 3,574
children in care. As shown in Figure 2, children from residen-
tial care (n¼1,608) reported higher levels of internalizing
behaviors, with a Hedges’s gof #.30 (95%confidence interval
(CI) [#.41, #.20]), p< .001. There was no evidence of sub-
stantial heterogeneity (Q¼20.42, p¼.12, I
2
¼31.44%,
t¼.11). An examination of the funnel plot showed symme-
trical distribution of studies. Egger’s regression intercept
was 1.02 (p¼.96, two-tailed), indicating no evidence of pub-
lication bias. A sensitivity analysis showed that the result was
not influenced by any individual study.
The results of the meta-regression analyses are presented in
Table 2. The difference in internalizing behaviors between
family foster care and residential care was found to not be
significantly influenced by the age of the sample, percentage
of girls in the sample, and GDP per capita of the country where
the study was conducted. There was a significant moderating
effect for publication year and study quality, in that studies in
recent years and with higher quality ratings reported smaller
differences between residential and family foster care. A sen-
sitivity analysis on publication year showed no changes to the
meta-regression result, by removing the studies using adult
participants (Dregan & Gulliford, 2012; Li, 2011; Nowacki
& Schoelmerich, 2010, where the children were placed in care
as early as in 1970s). There was also a significant effect with
time in care: Studies where children stayed for more than 5
years on average have a larger pooled effect size as compared
to studies where children stayed less than 5 years.
Externalizing Behaviors
The meta-analysis on externalizing behaviors included 18 stud-
ies with a total of 13,048 children in care. As shown in Figure 2,
children from residential care (n¼5,902) reported higher lev-
els of externalizing behaviors than family foster care children
(n¼7,146), with a Hedges’s gof #.33 (95%CI [#.44, #.22]),
p< .001, and substantial heterogeneity (Q¼55.74, p< .01,
I
2
¼69.50%,t¼.19). A sensitivity analysis showed that the
result was not significantly influenced by any individual study.
The distribution of studies is asymmetrical in the funnel
plot, and the Egger’s regression intercept was 1.98 (p< .01,
two-tailed). A detailed examination of the funnel plot showed
that the asymmetry was not due to small study effect. Instead,
there were more small-scale studies with trivial results. Using a
trim and fill method with nine additional studies, the adjusted
effect size would be a higher Hedges’s gof #.55 (95%CI
[#.65, #.41]). A sensitivity analysis was conducted by separ-
ating studies that appeared to be outliers in terms of the
outcomes or moderators. Out of the 18 studies, 2 used a
specific outcome (convictionorarrest)ratherthanamore
generalized externalizing behavior (Dregan & Gulliford,
2012; Ryan, Marshall, Herz, & Hernandez, 2008). Another
three studies used young children (such as 1-year-old) as
study samples (Damsteegt, van IJzendoorn, Out, & Baker-
mans-Kranenburg, 2014; Harden, 2002; Roy, Rutter, &
Pickles, 2000) while majority of the other studies used ado-
lescent samples. After removing the five studies, the funnel
plot became symmetrical with a nonsignificant Egger’s
intercept of .67. The pooled effect size is still significant
for the remaining 13 studies, with a Hedges’s gof #.34
(95%CI [#.45, #.24]), p< .001, and reduced heterogeneity
(Q¼20.65, p¼.06, I
2
¼41.88%,t¼.12).
Meta-regression results using the 13 studies are presented in
Table 3. The results showed that the difference in externalizing
behaviors between family foster care and residential care was
not significantly influenced by the quality of the study, year of
publication, and time in care. A sensitivity analysis on publi-
cation year showed no changes to the meta-regression result, by
removing the studies using adult participants (Dregan & Gul-
liford, 2012; Li, 2011). The moderating effect for GDP was
significant, indicating that studies conducted in high GDP
countries had a smaller pooled effect size. In fact, the Hedges’s
gwas only #.27 (95%CI [#.41, #.14]) among the countries
with high GDP as compared to #.48 (95%CI [#.61, #.34])
among countries with relatively lower GDP based on median
split. There was also a significant moderating effect for age and
percentage of girls in the sample, in that studies with older
participants and studies with more girls had larger pooled effect
sizes.
Perception of Care
The third meta-analysis was on five studies examining the
children’s perception of care. It included 848 children, with
450 from family foster care and 398 from residential care.
6TRAUMA, VIOLENCE, & ABUSE XX(X)
Similarly, it was shown that children from family foster care
had more positive perceptions about care, Hedges’s g¼#.54
(95%CI [#.84, #.24]), p< .001, with considerable heteroge-
neity (Q¼13.00, p¼.01, I
2
¼69.22%).
An examination of the funnel plot showed symmetrical dis-
tribution of studies. Egger’s regression intercept was #.67 (p¼
.82, two-tailed), indicating no evidence of publication bias. A
sensitivity analysis showed that the result was not influenced
by any of the studies. No moderating analyses were conducted
due to the small number of studies included.
Discussion
Overview of Key Findings
This study examined differences between family foster care
and residential care in terms of children’s perceptions and out-
comes. Three separate meta-analyses were conducted using a
total of 23 studies involving 13,630 children in care, with 7,469
from family foster care and 6,161 from residential care. The
results indicated that children in family foster care had consis-
tently better experiences and fewer problems across the three
outcome indicators (i.e., perceptions of care, internalizing, and
externalizing problems) as compared to children in residential
care. The analyses revealed no evidence of publication bias,
indicating that the result is not biased toward small studies with
larger effect sizes.
Internalizing and externalizing behaviors. Compared to studies on
internalizing behaviors, the studies on externalizing behaviors
had more heterogeneity. Moderating factors were found to
differ between the two types of problematic behaviors. For
internalizing behaviors, studies in more recent years with
higher quality ratings and with children who had shorter
length of time in care reported smaller differences between
residential and family foster care. For externalizing
Study name Outc ome Statistics for each study Hedges' s g and 95% CI
Hedges' s Sta ndard
gerrorp-Value
Ahmad, 2005 Externalizing -0.226 0.185 0.222
Ajdukovic , 2005 Externali zing -0.642 0.115 0.000
Cheu ng, 201 1 Exter nal i zing -0 .20 1 0. 103 0.0 50
Dams te egt, 20 14 External i zing 0. 280 0 .2 16 0.195
Drega n, 201 2 Extern al i zi ng -0 .1 49 0.1 41 0.29 2
Ford ,2 00 7 Ext ern al i zi n g -0. 43 0 0.0 83 0.0 00
Fri ed ri ck, 2 005 Ext erna l i zin g 0 .0 52 0.3 83 0 .8 92
Harde n, 2002 Ext erna li zi ng -0.4 01 0.17 6 0. 023
Hef li nge r, 2000 Exte rnal i zin g -0.2 12 0 .172 0. 219
Humph reys, 20 15 E xtern al izi ng -0. 410 0. 191 0 .03 2
James,2012 Externalizing -0.044 0.127 0.729
Kang, 2014 Externali zing -0.413 0.182 0.023
Li, 2011 Externalizi ng -0.508 0. 123 0.000
Loman, 2013 Externalizing -0.459 0.204 0.025
Ma r i n o v i c , 2 0 0 7 E xt e r n a l i z i n g -0 . 4 1 1 0 . 2 1 9 0 . 0 6 0
Roy,2 000 Ext erna l i zi ng -0 .52 8 0.32 4 0 .1 03
Ryan, 20 08 E xterna li zi ng -0. 583 0.0 38 0 .000
Sim, 2016 Externalizing -0.233 0.119 0.051
-0.3 31 0.058 0 .0 00
Ahmad, 2005 Internalizing 0.029 0.185 0.876
Ajdukovic, 2005 Internali zing -0.561 0.115 0.000
Damnj an ovic , 2011 In tern al izi ng -0.4 81 0 .138 0. 000
Dams te egt , 201 4 Inte rna l i zi ng -0.0 24 0.2 15 0.91 1
Drega n, 201 2 In te rna l i zi ng -0.1 02 0.1 54 0.50 6
Ford ,2 00 7 In te rna l i zi ng -0. 42 0 0.1 06 0. 000
Hef li nge r, 2000 In tern al izi ng -0.4 21 0 .181 0. 020
Humph reys, 20 15 I nt ernal i zin g -0 .08 8 0. 189 0.6 41
James,2012 Internalizing -0.388 0.138 0.005
Kang, 2014 Internalizing -0.299 0.181 0.099
Loman,2014 Internali zing -0.122 0.202 0.546
Ma r i n o v i c , 2 0 0 7 I n t e r n a l i z i n g - 0 . 2 2 1 0 . 2 1 7 0 . 3 0 8
Nowac ki, 2 010 Int erna li zi ng -0 .64 1 0. 294 0.0 29
Roy,2 000 In te rnal izi n g -0.57 3 0.32 9 0 .0 82
Sim, 2016 Internalizing -0.186 0.119 0.119
-0.3 04 0.052 0 .0 00
Chap man, 200 4 P erc ept io n -0 .13 9 0. 164 0.3 97
Damnj an ovic , 2011 Per cep ti on -0. 862 0.14 2 0. 000
Del fa bbro, 20 02 Per cep ti on -1. 240 0.6 10 0. 042
Kang, 2014 Perception -0.408 0.182 0.025
Wi ls on, 19 99 Pe rcepti on -0.5 59 0.1 44 0.0 00
-0.5 39 0.151 0 .0 00
-1.00 -0 .5 0 0.00 0.50 1.00
Figure 2. Forest plots by study names and outcomes.
Li et al. 7
behaviors, the results showed that studies conducted in higher
GDP countries with younger participants and more boys had
smaller pooled effect size. In other words, the gap in inter-
nalizing behaviors between foster and residential care became
larger when children stayed in care for a longer period of time.
In contrast, the effect on externalizing behaviors is more
influenced by age and gender of the sample rather than time
in care. The result is consistent with gender and developmen-
tal studies in that males usually have higher levels of exter-
nalizing behaviors, and such behaviors may continue from
childhood and peak at adolescence with some acute symptoms
such as offending (Bongers, Koot, Van Der Ende, & Verhulst,
2004; Broidy et al., 2003; Moffitt, 1993).
With regard to the contributing factors of the year of
publication and the GDP of the country, the differences
between foster and residential care were smaller for more
recent studies on internalizingbehaviorandforthosecon-
ducted in more developed countries on externalizing beha-
vior. An explanation may lie in the recent development and
implementation of changes toward improving the quality of
out-of-home care in some countries. For example, it was
found that in recent years that residential care in both
Germany and the Netherlands has been more focused toward
the development and funding of small-scale group homes
with increasing professionalization of staff (Hardera, Zeller,
Lo´pez, Ko¨ngeter, & Knorth, 2013).
Additionally, it may be inferred from published statistic
reports that developed countries with higher GDP have a
more fine-grained understanding of the characteristics of
their out-of-home care population: Statistics on out-of-
home care in Australia, United Kingdom, and United States
are more detailed, thematically organized, and publicly
accessible as compared to less developed countries. This may
enable them to be more targeted in their reforms for the out-
of-home care sector. A better quality of care may mitigate
some of the negative effects that could arise due to care type,
hence reducing the differences between residential and fam-
ily foster care. Another explanation for these differences may
lie in that the rationale for placement type is different across
time and countries. For example, it was found that more
children aged 3 years and below were placed into residential
care in countries with lower GDP, who then subsequently
developed more serious attachment and behavioral problems
(Browne, 2005).
Perceptions of care. The analysis on children’s perceptions about
care showed that children in family foster care had more favor-
able perceptions about their placement, with a large effect size
being observed. In other words, children in foster families
reported higher levels of satisfaction with care settings and
caregivers, higher levels of feelings of safety, and so forth
(Delfabbro et al., 2002). Children’s opinions toward care are
important as it may be related to their development and well-
being. Increased feelings of safety have been postulated to
allow children to focus more on school tasks and thus lead to
increased scores on academic outcomes (Ratner et al., 2006).
Similarly, children who were more satisfied with their place-
ment were reported to display fewer problematic behaviors
(Cheung, Goodman, Leckie, & Jenkins, 2011). However, chil-
dren in care usually have no say in the decision-making process
with regard to their placement (Unrau, 2007). In particular, the
rationale for placement is usually based on adult assessment of
children’s risk factors and needs, and these reasons may not be
adequately explained to the children (Khoo, Skoog, & Dalin,
2012; Scholte, 1998). Therefore, efforts should be made in the
child welfare system to include the voices of children in order
to enable appropriate placements and support in order to
improve their quality of life (Fox & Berrick, 2007).
Comparisons With Previous Reviews
To the best of our knowledge, no previous meta-analysis has
compared children with long-term placement in foster and resi-
dential care. A similar analysis was found in a recent review by
Lee, Bright, Svoboda, Fakunmoju, and Barth (2011), who com-
pared residential care with family foster care and treatment
foster care and concluded that outcomes of residential (group)
care were generally worse than family foster care. However,
the analysis on family foster care in Lee’s review was made up
of only three studies with varying stay length and treatment.
Generalizability of Conclusions
The studies included in this review covered a great variation of
children with regard to age, country, and time in care. How-
ever, majority of these studies examined children’s outcomes
of both genders in their adolescence and the majority of these
children stayed in care for more than 1 year. More than half of
Table 2. Meta-Regression on Internalizing Behaviors.
Moderator Variable BSEp
Study quality .09 .04 .01
Age .001 .01 .95
Percentage of girls in sample .45 .40 .26
GDP/10,000 #.02 .02 .48
Time in care #.20 .09 .03
Year .02 .01 .02
Note. As the covariates were not measured on the same scale, the coefficients
are not comparable. SE ¼standard error; GDP ¼gross domestic product.
Table 3. Meta-Regression on Externalizing Behaviors.
Moderator Variable BSEp
Study quality .07 .05 .22
Age #.04 .02 .09
Percentage of girls in sample #1.38 .75 .08
GDP/10,000 .05 .03 .06
Time in care #.12 .12 .33
Year .01 .01 .71
Note. As the covariates were not measured on the same scale, the coefficients
are not comparable. SE ¼standard error; GDP ¼gross domestic product.
8TRAUMA, VIOLENCE, & ABUSE XX(X)
the studies were conducted in Western countries such as United
States and United Kingdom. For problematic behaviors, major-
ity of the studies used the Child Behavior Checklist (CBCL) or
the Youth Self Report (YSR) as the outcome measure. In stud-
ies not using CBCL/YSR, the outcome measure for internaliz-
ing behavior is usually an established scale of depression or
anxiety. Sensitivity analysis on the outcome measure showed
that results did not differ significantly. In contrast, the mea-
surement of externalizing behaviors varied greatly for some
of the studies, such as the use of criminal convictions in
two studies. Further analysis showed that studies that uti-
lized a very young sample or criminal convictions as the
outcome measure for externalizing behavior appeared to be
outliers as compared to other studies. Therefore, the find-
ings on problematic behaviors can be considered general-
izable to studies with adolescent children in care where
outcomes are measured on a general internalizing/externa-
lizing framework. More evidence is needed to support the
usage of outcomes for young children and administrative
official data (e.g., criminal convictions) as proxies for
externalizing outcomes.
As for perception of care, although the results of the analysis
on perception were based on five studies, four of these studies
used a representative sample of teenage children. The sensitiv-
ity analysis also revealed a stable estimated effect size even
with the removal of any one study from the analysis. To some
extent, the pooled finding is representative of adolescent chil-
dren’s perceptions of residential care and family foster care.
Potential Bias and Limitations
The major limitation of this meta-analysis lies in the methodo-
logical differences between included studies. Specifically, the
placement of children into different types of care was not ran-
dom. Based on past studies, children in residential care usually
entered the system at an older age and with higher psycholo-
gical and behavioral needs. Therefore, meta-analysis con-
ducted using studies with a convenient or representative
sample may mistakenly reinforce differences in children’s pro-
files in care, although these differences may have existed from
entry into care and are not resultant from care. Similarly, the
included studies usually did not differentiate children who were
admitted primarily for treatment and those admitted primarily
for care. Although we excluded studies on treatment efficacies
to focus solely on the comparisons between different types of
care, it is unclear to what extent treatments were still provided
to these children in different settings. At present, the diverse
methodologies contribute to great difficulties in comparing the
results across studies—this situation needs to be improved and
more clarity is needed in terms of the criteria and efficacy of
placement modes in order to help policy makers and practi-
tioners to make better decisions.
The second concern with regard to drawing conclusions
concerning residential care is the lack of data on the differences
between types of residential care. Some studies distinguished
between group home and institutions, where the latter referred
to institutes with more than 20 beds (Vogel, 1999). Some stud-
ies compared different types of group homes, where in certain
SOS Children’s Villages, they lived in group homes together
with caregivers in a family-like setting (Ajdukovic´ & Franz,
2005). Originally, there were plans to code the size of residen-
tial care (e.g., number of beds), but majority of the studies did
not report such information. This information could contribute
to within-subject variations and thus should be reported in
future studies.
Another limitation lies in the fact that the moderators (pub-
lication year and GDP) that were used to infer the quality of
care were measured with some imprecision. For example, there
is always a lapse of time between data collection and publica-
tion, and the length may vary among studies. Similarly, the
quality of care may differ between cities or between urban and
rural areas within the same country. Using a country’s GDP to
estimate the quality of care was thus also a source of potential
bias. Nevertheless, the present meta-analyses results showed a
promising effect of professionalization of care. Future studies
should report the quality of care on a standardized format, so
that a more accurate measure can be used in the synthesis and
comparison of results.
Implications and Conclusion
Taken together, the findings in this study suggest that it might
be beneficial to invest in the development of family foster care
services, despite the reduction of supposed advantages of fam-
ily foster care over residential care pertaining to outcomes that
were likely to have been brought about with improvements in
care conditions, the rising affluence of various societies, as
well as more advanced research methods. The results demon-
strate considerable robust effects of poorer behavioral and psy-
chosocial outcomes for children placed in residential homes as
compared to those in family foster care. These results imply
that family foster care offers better caring environment, possi-
bly due to the provision of more individualized, stable, and
responsive caregiving and the provision of a safer, more
home-like environment as compared to residential homes.
Furthermore, preliminary research on the interaction effects
between resilience and placement type indicated that family
foster care might facilitate much better outcomes for children
with resilience as compared with residential care (Sim, Li, &
Chu, 2016)—such results provide food for thought about the
social capital that we invest in our children in care and whether
placement options can augment these. Hence, policy efforts
should be made to promote the placement of children removed
from families into family foster care as compared to placing
them in residential homes. More resources should also be allo-
cated to increase the pool of foster caregivers and to provide the
necessary support and training.
However, not all children, because of their experiences, may
be able to cope with close relationships in a substitute family,
and there has to be a consideration of particular circumstances
of institutions and social structures in different communities
(see Nowacki & Schoelmerich, 2010); hence, it would be
Li et al. 9
prudent to continually have some residential care facilities that
are made available for children who are in severe, acute distress
and those who are not coping well in family foster care for
various reasons. It is worthy to note that in the current study,
the gap between outcomes in residential and family foster care
was reduced in studies published in more recent time and by the
GDP of the country. This finding may indicate that there is
space for the substantial improvement of the quality of care
and environment offered in residential homes. More research
has to be done to identify which aspects of residential care
carry the benefits and which carry the risks. Some suggestions
from past studies have indicated that smaller child-to-caregiver
ratios and increased training and professionalization of care-
giving staff will be helpful directions to pursue. The physical
living conditions such as the provision of facilities and the
structural building layouts of residential homes should also
be looked into to provide a feeling of safety and warmth for
the child. In addition to training and upgrading, adequate
resources have to be allocated for the proper monitoring of
these care institutions in order to ensure optimal functioning.
Furthermore, more integrated and professionalized assess-
ment at the point of entry into the out-of-home care system is
needed, including the need to take into account the opinion of
the child. The provision of an age-appropriate explanation for
the child to understand the placement decision can be consid-
ered, so as to facilitate better adjustment of the child to the
new environment.
Negative effects of childhood maltreatment can be enduring
and these effects may be cumulative in leading to greater
inequality in later years of life. The current meta-analytic study
shows that care placement types do play a role in mitigating
some negative consequences of childhood maltreatment,
although the extent of this mitigation on other outcomes not
included in this study remains to be determined.
Declaration of Conflicting Interests
The author(s) declared no potential conflict of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Dongdong Li,PhD,isaprincipalresearchspecialistintheCentrefor
Research on Rehabilitation and Protection, Ministry of Social and
Family Development (MSF), Singapore. Her research involves the
study of child protection issues and youth offender rehabilitation. She
also studies media effects on child development.
Grace S. Chng,PhD,isaseniorresearchspecialistatMSFexamining
issues of youth offender rehabilitation, child welfare and child protec-
tion. Her interests lie mainly in family and child development domains.
Chi Meng Chu, PhD, is the senior principal clinical and forensic
psychologist, and a deputy director at MSF, Singapore. He is also
an adjunct associate professor with the National University of Singa-
pore. His research interests include youth offending and child protec-
tion issues.
12 TRAUMA, VIOLENCE, & ABUSE XX(X)
