European Child & Adolescent Psychiatry

, Volume 23, Issue 1, pp 3–12 | Cite as

Salivary cortisol: a possible biomarker in evaluating stress and effects of interventions in young foster children?

  • Hans W. H. van AndelEmail author
  • Lucres M. C. Jansen
  • Hans Grietens
  • Erik J. Knorth
  • Rutger Jan van der Gaag


Young foster children undergo an early separation from their caregiver(s) and often experience severe stress before placement. However, a considerable part of the children do not show apparent signs of distress, making it difficult for the foster carer to be aware of the amount of stress in their foster child. Potential evidence for using salivary cortisol levels as a dimension to evaluate the amount of stress in young foster children is reviewed. Moreover, the applicability of salivary cortisol in the evaluation of stress-reducing interventions for young foster children is discussed. A systematic review was performed using the databases Medline, Psychinfo, Embase, Ebscohost, and Academic Search Premier. Nine studies were traced in which salivary cortisol was used to measure stress in children placed in family foster care or in adoptive families. Stress in general but also neglect, early loss of a caregiver, a younger age at first placement, and a higher number of placements were associated with an altered hypothalamic–pituitary–adrenal (HPA) axis function in foster children. Moreover, four studies on the effect of stress-reducing interventions on HPA-axis functioning of young foster children were found. These studies suggest that caregiver-based interventions can actually help to normalize the HPA-axis function in foster children, and that such changes co-occur with improved behavioral functioning. Although the results from the papers discussed in this review suggest that diurnal cortisol with a wake up and a bedtime measurement may be a relevant tool to evaluate stress in young foster children, this cannot yet be concluded from the present studies, because statistical data from the studies on foster care and adoption in this review were not robust and researchers used different methods to collect the salivary cortisol. Still, it is noteworthy that all studies did find the same pattern of reduced levels in relation to chronic stress (caused by maltreatment and neglect of the child).


Stress Cortisol Hypothalamus–pituitary–adrenal axis (HPA-axis) Intervention Foster children Family foster care 


Conflict of interest

The authors declare they have no conflict of interest.


  1. 1.
    Levine S (1983) A psychobiological approach to the ontogeny of coping. In: Garmezy N, Rutter M (eds) Stress, coping and development in children. McGraw Hill, New York, pp 107–131Google Scholar
  2. 2.
    Levine S, Stanton ME (1990) The hormonal consequences of mother-infant contact. In: Barnar K, Brazelton TB (eds) Touch: The foundation of experience. International Universities Press, Madison, pp 165–194Google Scholar
  3. 3.
    Suomi SJ (1999) Attachment in rhesus monkey. In: Cassidy J, Shaver PR (eds) Handbook of attachment: Theory, research, and clinical applications. Guilford, New York, pp 181–197Google Scholar
  4. 4.
    Gunnar MR, Donzella B (2002) Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology 27:1999–2020CrossRefGoogle Scholar
  5. 5.
    Strijker J, Knorth EJ (2009) Factors associated with the adjustment of foster children in the Netherlands. Am J Orthopsychiatry 79:421–429CrossRefPubMedGoogle Scholar
  6. 6.
    Stovall-McClough KC, Dozier M (2000) The development of attachment in new relations: single subject analysis for 10 foster infants. Dev Psychopathol 12:133–156CrossRefGoogle Scholar
  7. 7.
    Dozier M, Peloso E, Lindheim O, Gordon MK, Manni M, Sepulveda S, Ackerman J (2006) Developing evidence-based interventions for foster children: an example of a randomised clinical trial with infants and toddlers. J Soc Issues 62:767–785CrossRefGoogle Scholar
  8. 8.
    Dozier M, Levine S, Eldreth D, Stovall-McClough KC (2002) Intervening with foster infants’ caregivers: targeting three critical needs. Infant Ment Health J 23:541–554CrossRefGoogle Scholar
  9. 9.
    Fisher PA, Gunnar MR, Chamberlain P, Reid JB (2000) Preventive intervention for maltreated preschoolers: impact on children’s behaviour, neuroendocrine activity and foster parent functioning. J Am Acad Child Adolesc Psychiatry 39:1356–1364CrossRefPubMedGoogle Scholar
  10. 10.
    Cicchetti D, Gunnar RM (2008) Integrating biological measures into the design and evaluation of preventive interventions. Dev Psychopathol 20:737–743PubMedGoogle Scholar
  11. 11.
    Gunnar MR, Vazquez DM (2001) Low cortisol and a flattening of expected daytime rhythm: potential indices of risk in human development. Dev Psychopathol 13:515–538CrossRefPubMedGoogle Scholar
  12. 12.
    Luijk PCM, Saridjan N, Tharner A, Van IJzendoorn MH, Bakermans-Kranenburg MJ, Jaddoe VWV, Hofman A, Verhulst FC, Tiemeier H (2009) Attachment, depression and cortisol: deviant patterns in insecure-resistant and disorganised infants. Dev Psychobiol 52:441–452CrossRefGoogle Scholar
  13. 13.
    Carlson M, Earls F (1997) Psychological and neuroendocrinological sequelae of early social deprivation in institutionalized children in Romania. Ann NY Acad Sci 807:419–428CrossRefPubMedGoogle Scholar
  14. 14.
    Gunnar MR, Morison SJ, Chisholm K, Schuder M (2001) Salivary cortisol levels in children adopted from Romanian orphanages. Dev Psychopathol 13:611–628CrossRefPubMedGoogle Scholar
  15. 15.
    Cicchetti D, Rogosch FA (2001) The impact of child maltreatment and psychopathology on neuroendocrine functioning. Dev Psychopathol 13:783–804PubMedGoogle Scholar
  16. 16.
    Linares LO, Stovall-McClough KC, Li M, Morin N, Silva R, Albert A, Cloitre M (2007) Salivary cortisol in foster children: a pilot study. Child Abus Negl 32:665–670CrossRefGoogle Scholar
  17. 17.
    Heim C, Ehlert U, Hellhammer DK (2000) The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology 25:1–35CrossRefPubMedGoogle Scholar
  18. 18.
    Vanyukov MM, Moss HB, Plail JA, Blackson T, Mezzich AC, Tarter RE (1993) Antisocial symptoms in preadolescent boys and their parents: associations with cortisol. J Abnorm Psychol 37:239–249Google Scholar
  19. 19.
    McBurnett K, Lahey BB, Rathouz PJ, Loeber R (2000) Low salivary cortisol and persistent aggression in boys referred for disruptive behaviour. Arch Gen Psychiatry 57:38–43CrossRefPubMedGoogle Scholar
  20. 20.
    Yehuda R, Bierer LM, Schmeidler J, Aferiat DH, Breslau I, Dolan S (2000) Low cortisol and risk for PTSD in adult offspring of holocaust survivors. Am J Psychiatry 157:1252–1259CrossRefPubMedGoogle Scholar
  21. 21.
    Greeson JKP, Briggs EC, Kisiel CL, Layne CM, Ake GS III, Ko SJ, Gerrity ET, Steinberg AM, Howard ML, Pynoos RS, Fairbank JA (2012) Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network. Child Welf 90:91–108Google Scholar
  22. 22.
    Walker RF, Ryad-Fahmy D, Reid GF (1978) Adrenal status assessed by direct radio-immuno-assay of cortisol in whole saliva and parotid saliva. Clin Chem 24:1460–1463PubMedGoogle Scholar
  23. 23.
    Stams GJJM, Juffer F, Rispens J, Hoksbergen RAC (2000) The development and adjustment of 7-year-old children adopted in infancy. J Child Psychol Psychiatry 41:1025–1037CrossRefPubMedGoogle Scholar
  24. 24.
    Lloyd EC, Barth RP (2011) Developmental outcomes after 5 years for foster children returned home, remaining in care, or adopted. Child Youth Serv Rev 33:1383–1391CrossRefGoogle Scholar
  25. 25.
    Bernard K, Butzin-Dozier Z, Rittenhouse J, Dozier M (2010) Cortisol production patterns in young children living with birth parents vs children placed in foster care following involvement of child protective services. Arch Pediatr Adolesc Med 164:438–443CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Dozier M, Manni M, Gordon MK, Peloso E, Gunnar MR, Stovall-McClough K, Eldreth D, Levine S (2006) Foster children’s diurnal production of cortisol: an exploratory study. Child Maltreatment 11:189–197CrossRefPubMedGoogle Scholar
  27. 27.
    Fisher PA, Stoolmiller M (2008) Intervention effects on foster parent stress: associations with child cortisol levels. Dev Psychopathol 20:1003–1021CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
    Gunnar MR, Frenn K, Wewerka SS, Van Ryzin MJ (2008) Moderate versus severe life stress: associations with stress reactivity and regulation in 10–12 year old children. Psychoneuroendocrinology 34:62–75CrossRefPubMedCentralPubMedGoogle Scholar
  29. 29.
    Van den Dries L, Juffer F, Van IJzendoorn MH, Bakermans-Kranenburg MJ (2010) Infants’ physical and cognitive development after international adoption from foster care or institutions in China. J Devel Behav Pediatr 31:144–150CrossRefGoogle Scholar
  30. 30.
    Dozier M, Peloso E, Lewis E, Laurenceau J, Levine S (2008) Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. Dev Psychopathol 20:845–859CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Fisher PA, Stoolmiller M, Gunnar MR, Burraston BO (2007) Effects of a therapeutic intervention for foster preschoolers on diurnal cortisol activity. Psychoneuroendocrinology 32:892–905CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Patterson GR, Reid JB, Dishion TJ (1992) A social learning approach for antisocial boys. Castalia, EugeneGoogle Scholar
  33. 33.
    Fisher PA, Gunnar MR, Dozier M, Bruce J, Pears KC (2006) Effects of therapeutic interventions for foster children on behavioural problems, caregiver attachment and stress regulatory neural systems. Ann NY Acad Sci 1094:215–225CrossRefPubMedGoogle Scholar
  34. 34.
    Ainsworth MDS, Blehar M, Waters E, Wall S (1978) Patterns of attachment: a psychological study of the strange situation. Lawrence Erlbaum Associates, HillsdaleGoogle Scholar
  35. 35.
    Fisher PA, Van Ryzin M, Gunnar MR (2011) Mitigating HPA-axis dysregulation associated with placement changes in foster care. Psychoneuroendocrinology 36:531–539CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Tirella GT, Tickle-Degen L, Miller LC, Bedell G (2012) Parent strategies for addressing the needs of their newly adopted child. Phys Occup Ther in Pediatr 32:97–110CrossRefGoogle Scholar
  37. 37.
    Pierrehumbert B, Torrisi R, Glatz N, Dimitrova N, Heinrichs M, Halfon O (2009) The influence of attachment on perceived stress and cortisol response to acute stress in women sexually abused in childhood or adolescence. Psychoneuroendocrinology 34:924–938CrossRefPubMedGoogle Scholar
  38. 38.
    Gunnar MR, Talge NM, Herrera A (2009) Stressor paradigms in developmental studies: what does and does not work to produce mean increases in salivary cortisol. Psychoneuroendocrinology 34:953–967CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.
    Brand S, Wilhelm FH, Kossowsky J, Holsboer-Trachsler E, Schneider S (2011) Children suffering from separation anxiety disorder (SAD) show increased HPA-axis activity compared with healthy controls. J Psychiatr Res 45:452–459CrossRefPubMedGoogle Scholar
  40. 40.
    Sapolsky RM, Meany MJ (1986) Maturation of the adrenocortical stress response: neuroendocrine control mechanisms and the stress hyporesponsive period. Brain Res Rev 11:65–76CrossRefGoogle Scholar
  41. 41.
    Rosenfeld P, Suchecki D, Levine S (1992) Multifactorial regulation of the hypothalamic–pituitary–adrenal axis during development. Neurosci Biobehav Rev 16:553–568CrossRefPubMedGoogle Scholar
  42. 42.
    Smotherman WP, Bell RW (1980) Maternal mediation of early experience. In: Bell RW, Smotherman WP (eds) Maternal influences and early behavior. SP Medical and Scientific Books, New York, pp 201–210CrossRefGoogle Scholar
  43. 43.
    Antonini SR, Jorge SM, Moreira AC (2000) The emergence of salivary cortisol circadian rhythm and its relationship to sleep activity in preterm infants. Clin Endocrinol 52:423–426CrossRefGoogle Scholar
  44. 44.
    Edwards S, Clow A, Evans P, Hucklebridge F (2001) Exploration of the awakening cortisol response in relation to diurnal cortisol secretory activity. Life Sci 68:2093–2103CrossRefPubMedGoogle Scholar
  45. 45.
    Kiess W, Meidert A, Dressendorfer RA, Schriever K, Kessler U, Konig A, Schwarz HP, Strasburger CJ (1995) Salivary cortisol levels throughout childhood and adolescence: relation with age, pubertal stage, and weight. Pediatr Res 37:502–506CrossRefPubMedGoogle Scholar
  46. 46.
    Larson M, White BP, Cochran A, Donzella B, Gunnar MR (1998) Dampening of the cortisol response to handling at 3 months in human infants and its relation to sleep, circadian cortisol activity, and behavioural distress. Dev Psychobiol 33:327–337CrossRefPubMedGoogle Scholar
  47. 47.
    Lewis M, Ramsay DS (1995) Developmental change in infants’ responses to stress. Child Dev 66:657–670CrossRefPubMedGoogle Scholar
  48. 48.
    Price DA, Close GC, Fielding BA (1983) Age of appearance of circadian rhythm in salivary cortisol values in infancy. Arch Dis Child 58:454–456CrossRefPubMedGoogle Scholar
  49. 49.
    Santiago LB, Jorge SM, Moreira AC (1996) Longitudinal evaluation of the development of salivary cortisol circadian rhythm in infancy. Clin Endocrinol 44:157–161CrossRefGoogle Scholar
  50. 50.
    Spangler G, Grossmann KE (1993) Biobehavioral organization in securely and insecurely attached infants. Child Devel 64:1439–1450CrossRefGoogle Scholar
  51. 51.
    Hansen AM, Garde AH, Persson R (2008) Sources of biological and methodological variation in salivary cortisol and their impact on measurement among healthy adults: a review. Scan J clin lab invest 68:448–458CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Hans W. H. van Andel
    • 1
    Email author
  • Lucres M. C. Jansen
    • 2
  • Hans Grietens
    • 3
  • Erik J. Knorth
    • 3
  • Rutger Jan van der Gaag
    • 4
  1. 1.Department of Child and Adolescent Psychiatry and Developmental DisordersDimence Mental Health CareDeventerThe Netherlands
  2. 2.Department of Child and Adolescent PsychiatryVU University Medical Center (VUmc) AmsterdamDuivendrechtThe Netherlands
  3. 3.Department of Special Needs Education and Youth CareUniversity of GroningenGroningenThe Netherlands
  4. 4.St. Radboud & Karakter UCN Child and Adolescent PsychiatryUniversity Medical CentreNijmegenThe Netherlands

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