Summary of the findings
This is the first study to examine the association between parental visitation and depressive symptoms among institutionalized children in Japan. In the present study, we found that father’s visitation was significantly associated with higher depressive symptoms. Secure attachment score was inversely associated with depression score and there was a significant interaction between secure attachment and father’s visitation; children with low secure attachment scores showed higher depression scores when having father’s visitation whereas children with high attachment scores did not.
Household type and depression score
Surprisingly, depression score was highest among children who have both parents and was lowest among orphans. The situation in which they needed to enter an institution even though they have both parents may indicate that the circumstances in their original household (e.g., maltreatment) were more serious than those of children who have one or no parent, so they showed higher depression scores. Among this study’s participants, the frequency of maltreatment children experienced was greater among children who have both parents than orphans (Mean [SD] = 1.5 [1.2] vs. 0.61 [0.96], respectively; data not shown in Tables). Previous studies have shown that maltreated children can easily feel self-blame and responsibility for the institutionalization ; for example, Quas et al.  have shown that abuse severity was positively associated with self-blame among sexually abused children, which could be a psychological burden for these children. There is also a study pointing out the possibility that inconsistent contact with parents can be more stressful than having no contact, as it can cause ambiguous loss which disturbs the grieving process from moving forward .
Association between visitation and depression score
A positive association was observed between father’s visitation and depression score, while there was no significant association between mother’s visitation and depression score. Although it is considered that visitation can be the primary intervention for maintaining parent-child relationships , our results showed a higher psychological burden among children having father’s visitation. Given that Moyers et al.  have found that 63% of children who took foster placements had contact with someone who was detrimental to them (e.g., a perpetrator of abuse) after 1 year of the placement, and they were more likely to have difficulty in expressing their emotion, a relationship with parents could affect the association and be reflected in a heightened depression score. Although data on the perpetrator of abuse was available only for 223 children, we certificated that the association was still significant when we exclude children who had been abused by their father (coefficient = 2.4, 95% CI = 0.23, 4.7, p = 0.031; data not shown in Tables). Given that many of the children had experienced a complex history of maltreatment (e.g., the dual burden of neglect from the mother and physical abuse from the father), future study should address this point (i.e., impact of visitation by perpetrator) using data with much bigger and detailed sample. As another possible situation, although there was no interaction between father’s visitation and household type (i.e., single-father household vs. household with both parents) (Appendix), it is possible that children who have frequent father’s visitation tend to experience less support from their mother and reflected in higher depressive symptoms. Since the total number of visits was not associated with depression score, considerable attention should be paid to the quality of each visitation.
Although it was of borderline significance, visitation by grandparents, other relatives, and friends was associated with lowered depression score. This is consistent with the finding by Simsek et al.  that children having regular contact with their parents or relatives showed fewer internalizing problems, although they did not analyze the association separately for contacts with parents and relatives. This finding may indicate that child welfare should concern the involvement not only of parents but also of extended family members and friends (i.e., any people who care for the children regardless of the blood relationship), so that children would feel supported. Future study should focus not only on parents but also on other close adults.
For children who only have a mother, mother’s visitation was protective against their depressive symptoms (Appendix). This is consistent with a previous study that showed that frequent contact with the biological mother was associated with lower levels of depression, although this was a marginal association among children in foster care . The present data showed that frequency of maltreatment was lower among single-mother households than households with both parents (Mean [SD] = 1.5 [1.2] vs. 1.2 [1.1], respectively; data not shown in Tables). Considering that single-mother households are more likely to have economic disadvantages in Japan , it may reflect the result of reluctantly-decided institutionalization in single-mother households. This speculation needs to be tested with more detailed data.
Interaction effect of attachment security
As for the association with attachment, there was a significant interaction between the secure attachment score and father’s visitation on depressive symptoms; children who have low secure attachment scores showed higher levels of depression when having father’s visitation, whereas those with high scores did not (Fig. 1). This is in line with a previous study, which showed that children with stronger attachment were less likely to take psychiatric medication among children in foster care . They also reported that frequent contact with mother was associated with stronger attachment to their mother, although they targeted families in which reunification is a goal. Given that secure attachment relationships enhanced the child’s coping capacities toward stress , children with higher secure attachment would have a more stable mental status even if they regard visitation as a stressor.
The authors expected that children who have a high secure attachment would show decreased depression scores when having father’s visitation. However, it should be noted that the depression score remained at the same level when having father’s visitation among children with high secure attachment compared to children who have no visitation. Given that 54% of institutionalized children and 82% of children who have experienced maltreatment are supposed to have a disorganized style of attachment as stated in the Introduction [34, 35], children who had a higher secure attachment score in this study (i.e., the highest tertile among the participants) did not seem to have formed a secure attachment, which is comparable to that of healthy population.
Strengths and limitations
This study extends earlier research on mental health among institutionalized children in several ways. One of the strengths of the study is the sample size. Compared to previous studies conducted with institutionalized children, which had sample sizes that were relatively small of around 100–200 [1,2,3,4], this study collected a larger sample size. Another strength was that this study was conducted on a multisite basis, from rural to urban areas across Japan.
The current study has several important limitations. First, the cross-sectional design of the study prevented us from making causal inferences. Second, although many variables were included as covariates, we did not have data on several variables that could have better explained the studied association, such as the diverse history of adverse experiences that each child has. As for the type and perpetrator of maltreatment, we did not have a large enough sample size for stratifying the analysis (e.g., only 20 had experienced sexual abuse), and many of the children had experienced a complex history of maltreatment, which may have different impacts on depression among children. Third, we used the IWMS in this study to assess attachment style; observational or representational procedures are desirable for assessing childhood attachment. Fourth, since this is a retrospective study, we only analyzed the number of visitations. Future studies should examine not only the quantity but also the quality of visitations and how children perceived their parental visitation. For example, in the U.S., there are organizations to monitor and assess the quality of the visitation before reunification (i.e., supervised visitation), and a study showed that children who had more consistent and frequent visitation showed better mental health status .