Our findings indicate that adolescents in institutional care facilities had experienced significantly greater emotional and behavioral problems than those living in the community. The institutional sample had consistently higher rates, not only of Externalizing, but Internalizing, Social Problems, Attention Problems, and Thought Problems, as well as discrete DSM-oriented scales, suggesting that labeling of institutional youth as simply aggressive and delinquent contributes to their further marginalization and does not comprehensively address their mental health needs [27
]. The youth in particular themselves reported far more problem behaviors on all three domains: Total, Externalizing, and Internalizing Problem scores.
First, the prevalence of Total Problems scores in the clinical range by youth, caregiver/parent, and teacher reports were: 47, 15.1, and 20.5%, in the institutional versus 10.1, 7.5, and 9.5%, for the community sample, respectively (p < 0.05). Far more problems were endorsed by self-reports by adolescents in institutional care. There was no significant effect of gender on Total Problems scores by informant or institutional versus community sources.
Second, youths in institutional care reported for more Internalizing Problems than evident by caregiver or teacher assessments. To raise awareness among caregivers and teachers of the distress and warning signs of internalizing concerns for helping the youth when they face such problems would be an important consideration in planning primary prevention as well as specialty mental health care services to address them. In fact, the youth in the institutional care sample reported higher scores on all three subsyndrome categories that comprise the Internalizing Problems scale (Anxious/Depressed, Withdrawn/Depressed and Somatic Complaints) or the three DSM-oriented scales that reflect internalizing-type problems (Affective, Anxiety, and Somatic). Findings of heightened internalizing concerns for institutionalized adolescent are consisted with studies from other developing countries [4
Third, the youth in institutions also suffer from far more externalizing problems as reported by self-report than by means of teacher or caregiver assessments. In a previous study in Turkey, Coskun [13
] compared the emotional and behavior problems of 438 students ages 9–14 years from three types of schools (boarding, bussing, and regular catchment) in rural Ankara, and investigated the environmental and psychological predictors of academic success. The families were living in poverty and the youth were living away from their families for education and were under State protection. The YSR self and TRF teacher reports were used to measure the emotional and behavior problems. The boarding school students were the most disadvantaged among the three groups in terms of behavior problems, social support and school adjustment. Their results showed that the primary (grades 1–5) boarding school students' total adjustment scores were lower and their problem behavior scores were higher than those of the secondary (grades 6−8) boarding school students. The lower socio-economic status, rural residence, and residing far away from parents brought significant disadvantages.
Fourth, in terms of utilization of specialty care services, even though the prevalence of problem behaviors was high among adolescents in institutional care, only 2.4% received any speciality mental health services. The service utilization among the community sample was 0.3% in the mental health profile study reflecting lack of availability of services for the representative national population with almost non-existent mental health services in rural regions in the country [20
]. There is therefore an unmet need for mental health services both at the national scale as well as in terms of targeted services for youth in institutional care in Turkey. The lack of services for the institutional care youth is particularly disconcerting given the high prevalence of self and informant reported problems.
The prevalence of behavioral disturbance among community school-aged youth has been estimated at 7–20% [6
]. A longitudinal community study by Costello et al. [14
] assessed the prevalence and development of mental disorders among 1,420 youth from age 9–16 years; the 3-month prevalence of any disorder averaged 13.3% during the study period, with 36.7% of participants (31% of girls and 42% of boys) having at least one mental disorder. The authors concluded that the risk of having a single mental disorder was much higher than point estimates would in fact suggest.
Findings from studies of child welfare samples in more developed countries may not necessarily be comparable to the community-based circumstances in a developing country, nevertheless also indicate a high prevalence rate of 47.9% [9
]. In this respect, previous studies support the view that as many 80% of youths involved with child welfare agencies have emotional or behavioral disorders, developmental delays, or other indications of need for mental health services [22
]. These numbers suggest that youth in child welfare settings have over twice the rate of emotional and behavior problems found for community-based samples. Despite the estimate that one half of the welfare population had clinically significant emotional or behavioral problems, only one-fourth of this group received any mental health care [9
]. The gap between need for and receipt of services is significant both on our own sample and the other samples. Although this gap parallels a similar proportion of unmet need for the general population, the magnitude is much greater due to an estimated prevalence that is 2.5 times greater in the child welfare population. Practical issues such as health care costs and overburdened care systems require more effective targeting of individuals exhibiting emotional and behavior problems [26
The findings of our study also underscore the effects of fatalistic beliefs, lack of supportive caregiving, and the poor problem solving abilities as being powerful predictors of adolescents' emotional and behavioral problems. Previous research has also examined the effect of fatalism, the belief in external control over life chances, as a risk factor in particular for development of adolescent depression [31
]. The higher rate of self-reported internalizing problems in terms of affective, anxiety and somatic concerns, by adolescents support the hypothesis (not directly tested by the present research) that the youth felt helpless over their life chances and control over their lives, otherwise externally unrecognized by key informants. It has been hypothesized that adolescents who demonstrate greater fatalism would be at higher risk for emotional and behavioral problems [31
]. Consistent with research on young adolescents, the results also indicate that caregivers play a crucial role in mitigating problem behaviors [19
]. Adolescents are more likely to have trusting relationships with caregivers who are consistent and nurturing. Adolescents reared in a high quality caregiving ecology are placed on a positive developmental path that has the potential to produce long-term positive outcomes [7
Although these findings regarding the quality of the caregiving environment have long been emphasized, implementation of reforms has lacked substantively behind in many developing countries. The World Health Organization has recently launched the new Gap Action Programme (mhGAP) which aims at scaling up services for mental disorders especially for low and middle income developing countries. For the first time, the mhGAP has emphasized child mental health and child development as a major goal [44
]. In the absence of family and community-centered services that are urgently needed, caregiver training and support remain critical steps. In planning for preventive mental health services interventions that improve problem solving skills and decrease fatalistic beliefs among adolescents in residential care are likely to be important nodal points given their important protective effects. It was notable also that both tobacco and alcohol use were additional important negative predictors of mental health in particular among adolescents in institutional care. Our results again support research suggesting that substance use and dependence are associated with behavioral problems [15
] and this seems also to hold true for middle income developing countries.
The present study also underscores the importance of negative impact of abuse and neglect on the emergence of emotional and behavioral problems in affected children. This finding is consistent with previous research documenting the impact of maltreatment during childhood that leads to higher incidence of physical, emotional and behavioral as well as cognitive problems [10
]. Our results are also consistent with findings of previous studies which indicate that the risk of psychopathology may be mitigated in children that remain in contact with a parent or a parental figure, obtain social support, or benefit from improved competencies in an orphanage [35
]. Specifically, our findings support the observation that the youth who experience early maltreatment, family disruption, and lack of family contact, have higher risk of psychopathology. In contrast, the risk of psychopathology seems lower when adolescents remain in contact with their birth family with protective effect of family relationships, positive early care experiences, and higher likelihood of remaining in contact with their families.
The results of this study should be viewed in the light of a number of limitations. Because of the cross-sectional nature of this study, it is difficult to draw conclusions about a causal inferential relation between institutional rearing and mental health problems. Despite the limitations of the cross-sectional design, our national sampling frame both with respect to representative institutional and community care samples, enables us to describe meaningful prevalence estimates and explores the predictors of mental health among of institutionalized adolescents in Turkey. As our prior local validation studies of CBCL, TRF and YSR refer to factor analytic evaluation by Confimatory Factor Analysis (CFA) on the instruments' eight-factor measurement structure, the cross-national application of the 90th percentile cut-off criterion for Turkish samples, based on the original US manual is presumptive and calls for future comparison of data from local clinical and community groups using under the curve (AUC) analysis. In assessing predictive factors in institutional care, we chose to multiple correlations between emotional/behavioral problems and independent variables for institutionalized adolescents. Our results were presented without adjustment for alpha values and should be interpreted with caution.
Despite some limitations, a major strength of this study is its relatively large sample size, good response rates in view of current declining rates in many studies, and use of measures with multiple informants. This study is in fact one of very few investigations that provides empirical comparison of adolescent self-reports with other key informants in institutional care in a developing country setting.
Policy and clinical care implications
The documentation of the topography of protective and risk factors among adolescents is a necessary but not sufficient step for eliciting policy reforms to end the institutional care of adolescents in the twenty-first century in Turkey. Whereas the national policies in Turkey, among other countries, ought to be geared to abolish institutional care proper, in the interim, there remains an urgent need for interventions based on identified risk and protective factors serving the needs of the youth. The goal of this project was to promote policies favoring family-centered care and support, prevention of family separation, and promotion of development of therapeutic counseling services to prevent families at risk of child abandonment. A broad perspective is needed to provide community-based care aimed at families to prevent breakdown (found 68.9% in our study) and to support those in need. When this is not possible, making placement decisions has remained complex. For adolescents already in the institutional care system, and especially for those youngsters who have entered the system earlier and stayed for longer period of time without experiencing family life, it has been difficult to make the transition that could adopt them into family life. At this time, there is a need to create high quality safe environments and child friendly care within the social welfare system. These reforms need to evaluate and organize care systems, provide caregiver training, scrutinize and maintain high standards of conduct and support. There is also a need for rights based advocacy to strengthen and promote the well-being of children and adolescents. Although, as also in many other countries, Turkey is a signatory to the U.N. Convention of the Rights of the Child, implementation of a rights based framework has lagged behind the adoption of the convention. This study provides empirical evidence relevant to the mission of the GAP project [44
] with respect to urgently addressing disparities in particular with respect to development of child mental health services. The youth's voices in particular need to be taken into consideration.
As this study also attests, the youth in institutional care continue to face a challenging journey and may be unable to overcome the otherwise permanent obstacles that hinder their optimal development. All those involved in care of youngsters, including professionals, parents, teachers and other members of the community, have important obligations to promote their rights. Although Turkey is currently moving towards a child protection policy that prioritizes placing young children in family-centered care, many adolescents in institutions continue to experience disruptions in their development. These adolescents are likely to require special services to help them to develop problem solving skills, therapy to help decrease fatalistic beliefs and substance abuse. Successful evidence-based prevention programs will require careful assessment of adolescents' needs, development of culturally consistent interventions that are appropriate for these needs, and an integration of adolescent psychosocial health and social policy. The use of standardized self-reports can cost-effectively provide clinicians with appropriate norms against which individual adolescents' problem scores can be evaluated. Although the aforementioned legislation and policy emphasize the goal of family reunification as much as that of adoption, the number of adolescents who returned to their biological parents in Turkey in recent years has not risen appreciably.