Mental Health Harm to Mothers When a Child Is Taken by Child Protective Services: Health Equity Considerations

Most recent available census data indicate 47,885 young people were living in foster care through the child protection system in Canada in 2011. ¹ Although placement of a child in foster care is a recognized factor influencing children’s health, behaviour, and social trajectories, very little has been documented about its consequences on the health and social outcomes of mothers. ^2,3 Mothers of these children represent a highly marginalized and growing population of caregivers, who are disproportionately poor, racialized, and likely to have also been in foster care as children. ^4,5 Among mothers, Indigenous women experience the highest rates of forced separation from their children, with census data showing Indigenous children comprising over 50% of all children aged 4 years and younger in foster care, while accounting for only 7% of the child population. ⁶

One explanation for inattention to these issues is that mothers most affected are cut off from sources of power in society and face significant social judgment for ‘failing’ in their responsibilities as parents. State structures like the child protection system play a crucial role in this devalorization process through stigmatizing policies that place blame on individual parents for ‘family problems’ that are often the result of systemic and historical deprivations. ^7,8 As a result, empirical research has rarely considered the health and social conditions of this population of mothers, and while we know most are already structurally disadvantaged and vulnerable to poor health prior to loss of children, the health and social harms experienced following removal of children have yet to be systematically documented.

In this issue of the Canadian Journal of Psychiatry, Wall-Wieler et al.’s study ⁹ of the mental health effects of losing a child to foster care helps to fill this void and marks a pioneering step in bringing a population health focus to assess some of the adverse impacts of this system on women’s lives. Drawing on a unique data set from Manitoba, where administrative health and census data have been linked to child protection files for the first time, this team has published the first 2 studies using population-level analyses of health outcomes in this group of mothers. ⁹ This study compares longitudinal mental health diagnoses and treatment among mothers who have lost a child to foster care with mothers who experienced the death of a child.

According to study results, mothers who lost custody of a child to foster care experienced significantly higher rates of depression, substance use, physician visits for mental illness, and prescriptions of psychotropic medications compared to mothers surviving the death of a child. Interpreting these results, authors suggest the disproportionate share of mental health burden among women with children in foster care is likely a reflection of lower social support and a lack of social acknowledgment of grief following this form of loss. Since the analysis could not evaluate the role of exposure per number of children lost, the authors further identify the higher likelihood of compounded grief among the target population due to losing multiple children to this system. In addition, authors note that mothers who experienced a child’s death were more likely to be of higher socioeconomic status, which could be an important factor in facilitating their access to mental health supports outside the public health care system and in turn explain some of the mental health disparity between populations. The study lists several limitations, including potential unmeasured confounding due to the absence of variables accounting for other stressful events in mothers’ lives, such as divorce and intimate partner violence. Moreover, Wall-Wieler et al. ⁹ note that the data did not allow them to adjust for Indigenous identity, and therefore analyses could not directly disentangle the adverse social and economic circumstances resulting from racism and ongoing colonialism that undermine the health and lives of Indigenous peoples in profound ways.

The study’s location of Manitoba presents an imperative to connect findings to the current child protection crisis in Canada, where Indigenous peoples are heavily overrepresented. In Manitoba specifically, the total number of children in care has nearly doubled over the past decade and is among the highest in the world. ¹⁰ More alarmingly, Wall-Wieler et al. ⁹ highlight the racial inequities in Manitoba, where among 10,000 children currently in foster care, nearly 90% are Indigenous children. This deeply troubling reality, increasingly referred to as the Millennial Scoop, ¹¹ marks a striking continuity with past efforts to legitimize government destruction of Indigenous families. ¹² These include the genocidal policies that led to the Residential School System and the Sixties Scoop, as well as other intensifying settler-colonial violence, including theft of land and culture and the documented inequities in the provision of adequate housing, food, income, and educational and health services, which create the enormous challenges faced by Indigenous families in Canada today. ⁸ In this context, Wall-Wieler et al.’s findings ⁹ of worsened maternal mental health following loss of children to Manitoba’s child protection system demonstrate another detrimental impact of Canada’s repeated history of separating Indigenous children from their parents, further exacerbating, at a population level, the ongoing collective and intergenerational traumas experienced by Indigenous peoples. ¹³

Findings from this study are important in advancing an understanding of the mental health experiences of mothers involved with the child protection system, an economically and racially marginalized population so far neglected by health researchers. Significantly, they bring attention to an underappreciated layer of mental health inequity, one that could add to intergenerational trauma and the disadvantages already faced by mothers who come into contact with this system, as well as create barriers to reunification with children. These findings are supported by qualitative research describing the loss of a child to foster care as a powerful and unique type of adversity with potential long-term implications for women’s well-being. Among studies examining women’s mental health during this period, this type of loss has been identified as an unrecognized form of institutional trauma, which may exacerbate or lead to the development of posttraumatic stress, as well as contribute to other mental health issues, including depression and anxiety. ^{14 –17} In my own qualitative research, mothers noted how the trauma and mental health distress they experienced due to child removal went unrecognized by the health and social service institutions they interacted with, which not only deepened women’s social isolation but also compounded their extensive trauma histories. These experiences led to further traumatization and mental distress in encounters with the child protection system, which were also complicated by accounts of debilitating panic and worry about children’s state of well-being in foster care. ¹⁵ Women also described the loss of a child to foster care as a stigmatizing loss, which had consequences across a wide range of areas, including derailing women’s sense of agency in moving forward with life ambitions, including employment, and negatively affecting formation and quality of relationships. Social marginalization consistently characterized women’s experiences, and rare peer-led opportunities to be with other mothers involved with this system were pivotal in mitigating isolation and providing space for healing, support, and community organizing around these issues.

There is a strong need for further research in this area, across multiple fields of scholarship. In undertaking this work, public health researchers and providers need to contextualize the experiences and needs of mothers in the child protection population within a broader health equity framework. In Canada, the most frequent reason for child protection investigations is neglect, which is closely linked to poverty. As such, poor and racialized families are significantly more likely to encounter the child protection system, have children removed, and, once in foster care, have lower rates of reunification. ^{5,18 –20} In highlighting the hardships of mothers, a focus on health problems should not detract from the priority of remedying social and racial inequities, which bring families into contact with child protection in the first place. Also, in seeking to better understand and address the health effects of this system on mothers, it is important to carefully guard against pathologizing women’s institutional trauma and exhaustive stress from poverty and not create additional barriers to reunification with children.

A rethinking of the child protection system’s response to mothers who use drugs is also imperative, and influential stakeholders in the health sector are well positioned to challenge the paradigm that has long equated maternal drug use with inadequate mothering. In illuminating a new paradigm, one core action for health equity should address the forced removal of drug-exposed newborns from mothers at birth. In Manitoba, 15% of all children in out-of-home placement were removed from their mothers at birth. ²¹ This is a common course of action in Canadian hospitals with detrimental effects on mother-infant bonding, attachment, and developmental health trajectories. ^22,23 Research demonstrates that outcomes are better for infants who remain with their mothers at birth, with evidence pointing to decreases in neonatal intensive care admissions and lengths of stay, improvement in breastfeeding outcomes, and increases in maternal custody of infants at discharge. ^24,25 Cases of neonatal abstinence syndrome have also been shown to be more often effectively managed with infants in close proximity to mothers in ‘rooming-in’ hospital programs, with 1 recent study demonstrating a sustained decrease in average length of infant hospital stay (22.4 to 5.9 days), a reduction in infants treated with morphine (98% to 14%), and savings in hospitalization expenditure (from $44,824 to $10,289). ²⁶ This far more dignified approach not only is evidence based but also sends the powerful message to mothers that they are capable of parenting.

Findings by Wall-Wieler et al. ⁹ provide some insight into the mental health effects for mothers, offering another challenge to the flawed belief that separating families fosters healthy communities. In line with the Assembly of Manitoba Chiefs’ call for dismantling the current child protection system, a fundamental shift is required away from seeing this system as a primary source for keeping children safe. Part of this shift requires educating people about the traumatic consequences of foster care for children and for parents. Findings from 1 study using administrative data from 15,000 children in the United States suggest that children kept with their parents, even within homes facing significant adversity, had a tendency for better social outcomes than those placed in foster care. ²⁷ More studies in this vein are needed that focus on alternatives to parent-child separation, including services to support and enhance the home environments and communities for the purpose of preserving families.

Children are overwhelmingly better off in their families, and their best interests lie in their right to maintain family bonds. To reverse the crisis of Indigenous children in foster care, a core concern is the full implementation of Jordan’s Principle, which to date has only been narrowly and inconsistently applied. This federal court order is meant to ensure equitable funding for child and family services on reserves and is one critical mechanism to support children’s right to remain in their families and address the root causes of displacement. ²⁸ More broadly, rather than privileging the child protection system’s authority to remove children, more meaningful efforts by clinicians, public health officials, and policy makers are needed to eliminate the upstream political and socioeconomic harms to families, as well as pave a way forward for transformation of this system into one that truly supports families, and works unrelentingly to keep them together.