Mental health service utilization and time to care: A comparison of children in traditional foster care and children in kinship care

Existing research indicates that children who are involved with the child welfare system and placed in various forms of out-of-home care experience emotional and behavioral problems. It is also suggested that children placed in kinship care are less likely to receive mental health services than children placed in non-kinship foster homes. This study sought to compare children in non-kinship foster homes to children in kinship care to determine their receipt of mental health services and the time it took for children in kinship care to receive mental health services compared to children in non-kinship foster homes. Using a Cox regression, researchers determined that children in kinship care had a 14% lower likelihood of receipt of mental health services compared to their counterparts in non-kinship foster placements.     

Perceived self-stigma in the utilization of mental health services in foster care and post foster care among foster care alumni

Foster youth experience higher rates of mental health disorders and receive higher rates of mental health services in comparison to the general population. Yet, upon foster care exit, mental health service use drastically declines. Little is known as to the reasons for mental health service decline after foster care exit. However, research studies in the mental health literature have consistently shown that self-stigma and public stigma are significant in mental health service receipt. Studies have also shown that self-stigma affects an adolescent's self-identity, self-efficacy, and interpersonal relationships, which impact self-sufficiency once youth leave foster care. This study explores self-stigma in the utilization of mental health services while in foster care, and whether the stigma developed while in foster care impacts mental health service use upon foster care exit. The role of public stigma in the utilization of mental health services post foster care is also examined. Thirteen former foster youth with a mental health treatment history while in foster care were interviewed. Results show that foster youth experienced self-stigma, which increased the negative impact of mental health service receipt while in foster care. After foster care exit, youth who identified experiencing self-stigma while in foster care tended to discontinue mental health services after foster care exit. In contrast, foster youth who did not identify self-stigma in the receipt of mental health services while in foster care continued accessing services upon foster care exit. Public stigma was not identified as influencing mental health service use post foster care, but was coupled with negative labels, stereotypes, and negative perceptions. Implications for preventive and intervention measures are also discussed/proposed.     

Mental health assessment of infants in foster care

Infants placed in foster care are at high risk for emotional and behavioral problems. Assessment of their mental health must account for their often-adverse life experiences prior to placement and the involvement of multiple systems that shape their lives in lieu of parents' authority. This article presents practice guidelines for infant mental health evaluations with consideration of legal requirements and the unique issues conferred by foster care.     

Continuity of care for youth in foster care with serious emotional disturbances

Continuity of mental health care has long been considered an essential component to the delivery of a high-quality mental health services, particularly for children with special needs. Unfortunately, discontinuities in care are common for children in foster care due in part to placement instability, disruptions in health coverage, and the fragmented health system. This retrospective cohort study examined factors associated with continuity of care for youth (aged 5–17 years) in foster care diagnosed with schizophrenia and bipolar disorder. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Continuity of care was defined as regularity of care—utilization of at least one outpatient mental health visit per month during the year. Multilevel modeling was used to assess the association between individual and contextual-level variables and continuity of care. Of the 952 youth in the study sample, 439 (46.1%) received regular monthly outpatient visits over the 1 year follow-up period. The odds of receipt of regular outpatient treatment were associated with prior outpatient care (odds ratio (OR): 7.43, 95% confidence interval (CI): 2.60–21.20), the presence of a chronic medical illness (OR: 1.45, 95% CI: 0.98–2.16), comorbid anxiety (Or: 1.76, 95% CI 1.22–2.53), or conduct disorder (OR: 1.57, 95% CI: 1.13–2.18), and the use of multiple psychotropic medications as compared to no medications (OR: 1.55, 95% CI: 1.08–2.23). The odds of receiving regular outpatient treatment were higher for youths who resided in suburban areas as compared to metropolitan areas (OR: 1.97, 95% CI: 1.04–3.73) and for those who resided in areas with greater supply of psychiatrists per capita (OR: 1.22, 95% CI: 1.02–1.45). Study findings underscore the need for quality improvement initiatives that improve access to care, care coordination, and continuity of care.     

Children’s Psychosocial Rehabilitation: Clinical Outcomes for Youth with Serious Emotional Disturbance Living in Foster Care

Children living in foster care are an especially vulnerable population who often come to the attention of Medicaid mental health providers. These children experience a high incidence of emotional and behavioral disorders and may have specialized treatment needs related to their living arrangement status. This study assessed whether Children’s Psychosocial Rehabilitation could effectively treat youth with severe emotional and behavioral disorders who live in foster care. Analysis of data from an open trial of 218 clinically-impaired youth, aged 3–18 years, revealed no reliable differences in treatment outcome between foster versus non-foster children, with a trend toward more favorable outcomes for foster youth. Findings justify further study of the effectiveness of this Medicaid-funded service for the treatment of youth in care.     

Specialized foster care and group home care: Similarities and differences in the characteristics of children in care

Until recently, foster children who presented special medical or behavioral problems were largely served in group care environments. Specialized (or “treatment”) foster care has recently been developed to serve some of these challenging children. Although growing evidence points to the special needs of children in foster care, much is still unknown about how children placed in various out-of-home care settings differ from one another. The growth of specialized foster care as an alternative placement to group care, calls for examination of how children in these settings compare on demographic, educational, health, and behavioral characteristics. A cross-sectional mailed survey was distributed to all group care and specialized foster care agencies in a large state to address topics related to children's characteristics. Comparisons point to two groups of very difficult children, with unique mental health and health needs.     

Health and mental health services for children in foster care: the central role of foster parents

It is well documented that children enter foster care with special health and mental health needs and, while in care, those conditions are often exacerbated. However, less attention has been given to foster parents who have the most contact with these children. Results are presented from a national study on the developmental, health and mental health care needs of children in foster care that included foster parents' perspectives and observations. Their role in improving child well being is explained and recommendations for policy, practice and advocacy also are included.     

Mental health interventions for children in foster care: A systematic review

Children in foster care have high rates of adverse childhood experiences and are at risk for mental health problems. These problems can be difficult to ameliorate, creating a need for rigorous intervention research. Previous research suggests that intervening with children in foster care can be challenging for several reasons, including the severity and complexity of their mental health problems, and challenges engaging this often transitory population in mental health services. The goal of this article was to systematically review the intervention research that has been conducted with children in foster care, and to identify future research directions. This review was conducted on mental health interventions for children, ages 0 to 12, in foster care, using ERIC, CINAHL, PsycINFO, PubMed, ProQuest's Dissertation and Theses Database, Social Services Abstracts, and Social Work Abstracts. It was restricted to interventions that are at least “possibly efficacious” (i.e., supported by evidence from at least one randomized controlled trial). Studies were evaluated for risk of bias. Ten interventions were identified, with diverse outcomes, including mental health and physiological. Six interventions were developed for children in foster care. Interventions not developed for children in foster care were typically adapted to the foster context. Most interventions have yet to be rigorously evaluated in community-based settings with children in foster care. Little research has been conducted on child and family engagement within these interventions, and there is a need for more research on moderators of intervention outcomes and subgroups that benefit most from these interventions. In addition, there is no consensus regarding how to adapt interventions to this population. Future research should focus on developing and testing more interventions with this population, rigorously evaluating their effectiveness in community-based settings, determining necessary adaptations, and identifying which interventions work best for whom.     

In their own words: Overcoming barriers during the transition to adulthood for youth with disabilities who experienced foster care

The transition to adulthood can be especially challenging for youth who experience the foster care system. These challenges are magnified for youth with disabilities, who account for at least 40–47% of all children in foster care (Powers et al., 2012). In order to move from a deficit-based to a strength-based approach, this qualitative study focused on understanding the lived experience of transitioning to adulthood for alumni of foster care with disabilities. Semi-structured interviews were conducted with seven young adults who had exited care over a six-month time period. Participants described their journeys from foster care to independence and articulated a vision for a successful adulthood. Key themes that emerged included a desire for stability and personal fulfillment in adult life. Participants also identified common barriers encountered including unmet mental health needs and lack of disability awareness or the implications of mental health diagnosis. Personal strengths that helped overcome those barriers included resilience, advocacy, and self-determination.     

Comparing the health status of low-income children in and out of foster care

Children in foster care face poverty, family dysfunction, neglect, and abuse, with high rates of chronic health, emotional, and developmental problems. This study compared the overall health status of a group of children entering foster care with a group of Medicaid-eligible children living with their parents, matched for age and gender. It identified significantly more health and developmental problems in children in foster care than in the comparison group. Possible contributors to the higher percentage of problems among foster care children may be that the foster children have more problems related to the underlying risk factors resulting in placement, or that the foster care physicians conducted a more comprehensive assessment or had lower clinical thresholds. Further research is necessary to identify and treat the problems of this high-risk group.     

Outcomes of a model care coordination program for adults with mental illness under guardianship/conservatorship

Adults with serious and persistent mental illnesses, such as schizophrenia, schizoaffective disorder, and bipolar disorder, who are under guardianship/conservatorship, may experience health care, social, financial, and housing concerns, which can be addressed by care coordination programs. In such programs, providers assist with communication across service sectors, assistance with monitoring of psychiatric care, and support with practical needs. Such programs are understudied in the context of guardianship/conservatorship. Through a review of electronic records for 217 consumers who were enrolled in a model program continuously for 3 years or more, we examined trends before and after enrollment in a model care coordination program for adults with serious and persistent mental illnesses under guardianship/conservatorship. We sought to describe the number of days and rates of hospitalization, emergency room visits, and arrests before and after receiving program services. Comparing utilization among consumers three years pre- to three years post-enrollment, we identified statistically significant reductions in hospitalizations and imprisonment, but no change in state hospitalizations. We also saw some (non-significant) reduction in emergency room visits. Findings provide preliminary evidence of effectiveness of the model program; future efforts could expand its reach to more adults with serious and persistent mental illnesses.     

The need for educational assessment of children entering foster care

Comprehensive medical and mental health evaluations of children in foster care are recommended within 30 days of entering care. What constitutes a comprehensive evaluation has yet to be established. This study examines the need to include educational assessment as a component of the comprehensive evaluation. Rates of achievement and language problems for Arkansas school-age children are compared with rates of medical and psychiatric disorders to assess the relative need for including educational assessment.     

The impact of mental health issues, substance use, and exposure to victimization on pregnancy rates among a sample of youth with past-year foster care placement

The purpose of this study is to (1) compare youth entering substance abuse treatment with and without a history of foster care placement to determine any differences in mental health, substance use, and exposure to victimization, and (2) determine if mental health, substance use, and/or exposure to victimization predict past pregnancy among the sample with a history of foster care placement. The pooled dataset consisted of 17,124 adolescents (12-17 years of age) who completed the Global Appraisal of Individual Needs at intake for substance abuse treatment in 2009. Of these, 366 (2.1%) reported having been in foster care in the past year. When compared with a non-foster care sample, the foster care sample reported significantly higher internal mental distress scores, behavior complexity scores, and general victimization scores, after controlling for race, gender, and level of care. Problems associated with substance use did not differ between groups, though regular tobacco use was present at a higher rate in the foster care sample. Multivariate logistic regression results revealed that, within the foster care sample, internal mental distress and gender predicted past pregnancy. There may be room for intervention within substance abuse treatment centers for youth with a history of foster care, who may be at risk for pregnancy if their levels of internal mental distress are high.     

Mental health and behavioral problems of youth in the child welfare system: residential treatment centers compared to therapeutic foster care in the Odyssey Project population

This is the first multisite, prospective study of behavioral and mental health disorders of youth in residential treatment centers (RTC) and therapeutic foster care (TFC), and the first study to compare the two. This study addressed two questions in a sample of 22 agencies in 13 states: (1) how prevalent were emotional and behavioral disorders in the youth admitted to RTCs and TFC?, and (2) were the youth in RTCs significantly more likely to be disturbed than youth served in TFCs? Data were drawn from the Time 1 phase of the longitudinal national "Odyssey Project" developed by the Child Welfare League of America (1995). Measures included an extensive child and family characteristics form (CFC) and the Child Behavior Checklist (CBCL). The results revealed extremely high levels of behavioral and mental health disorders in the sample as a whole, well above the norms for a non-child welfare population. The prevalence of disorder in the RTC population was substantially greater than in the TFC population.     

Foster care and Medicaid managed care

Children in the foster care system are often dependent on Medicaid for health care. These children, however, have more complex health care needs than the typical child receiving Medicaid. States are implementing Medicaid managed care programs as a way to control escalating costs while providing necessary services. This article reviews the issues surrounding delivery of managed health care services to children in foster care and describes several solutions.     

Pregnancy risk among older youth transitioning out of foster care

Youth served in the foster care system have higher rates of pregnancy than general population youth; yet we have little information about risk and protective factors to target in order to prevent early pregnancy in this population. We assessed early pregnancy risk and protective factors known for general population adolescents for their relevance to youth in the foster care system. Using data from a longitudinal study of 325 older youth from the foster care system, we examined bivariate and multivariate relationships between these factors and pregnancy between ages 17 and 19 using logistic regression. Models examined the risk for early parenting separately by gender. The pregnancy rate increased by 300% between ages 17 and 19. At 19, 55% of females had been pregnant, while 23% of males had fathered a child. Although this study assessed multiple known factors, few were significant for this high risk group. Females who were not sexually active at age 17 were less likely to become pregnant, but those who reported using birth control were as likely to become pregnant as those who did not. Also, females with a history of arrest were more likely to have a pregnancy between 17 and 19. Males who left the foster care system before their 19th birthday were more likely to make someone pregnant. Youth from the foster care system are at exceptional risk of early pregnancy, regardless of their maltreatment history, religiosity, school connectedness, or academic achievement, particularly in the years between 17 and 19. This high risk group needs pregnancy prevention interventions and access to effective birth control.     

Better Futures: A validated model for increasing postsecondary preparation and participation of youth in foster care with mental health challenges

Higher education participation rates of young people in foster care are dramatically lower than their level of postsecondary education aspiration. Increasing attention to this disparity has stimulated policy and practice enhancements, however rigorously validated models for promoting postsecondary preparation and participation have not existed for young people in foster care, including those with mental health conditions. This article describes Better Futures, which is the first such model to be experimentally validated as effective for increasing the higher education participation and other related outcomes of young people in foster care with mental health challenges. Better Futures features a four day on-campus Summer Institute, coaching provided to youth by older peers who are in college and have shared experiences around foster care and/or mental health, and workshops that bring together youth, coaches and guest speakers for information sharing and mutual support. This article includes the theoretical and component features of the Better Futures model, findings related to intervention fidelity, participants' evaluation of the program, and discussion of implications for future model refinement and research.     

Child-related dimensions of placement stability in treatment foster care

Research shows increasing numbers of emotionally disturbed children entering foster care nationwide. As a result, there is growing interest in a special form of foster care known as therapeutic or treatment foster care. However, little information is currently available on the kinds of children who can benefit from this form of mental health care or on interactions between child characteristics and placement outcome. This paper begins to address this deficit in the knowledge base by proposing five psychosoical dimensions of child functioning associated with placement stability and outcome in treatment foster care. Current theory and research regarding each dimension are presented along with clinical examples.     

Intersection of homelessness and mental health: A mixed methods study of young adults who accessed psychiatric emergency services

Young adults who experience homelessness have high rates of mental disorders, yet low rates of outpatient mental health service use. This mixed methods study examined the intersection of homelessness and mental health in a sample of 54 young adults (ages 18–25) who were hospitalized on a short-term, inpatient psychiatric unit. Nearly half (n = 26) reported being homeless in the prior year and more than a quarter were homeless at the time of admission (n = 15). Qualitative analyses identified key factors that contributed to both mental health problems and homelessness including disrupted support networks, fragile family relationships, foster care involvement, substance use and traumatic events. Homelessness was both a facilitator and a barrier to successfully accessing mental health services to manage mental health symptoms. Findings highlight the interconnection of homelessness and mental health and their common relationship with additional underlying risk factors. Providers across service settings need to recognize the overlap of client populations and provide integrated, trauma informed care to address housing instability, mental health, and substance use together.     

Improving access to health care for foster children: the Illinois model

Children in foster care have lower health status than do their peers and limited access to health care. The Illinois Department of Children and Family Services developed HealthWorks, a separate primary care preferred provider system for children in foster care. This study compared claims data for children in HealthWorks with children not enrolled in HealthWorks and with children in Aid to Families with Dependent Children (AFDC) who had never entered foster care. Children enrolled in HealthWorks were more likely than were other children to receive all of the services except general inpatient hospitalizations. They had greater odds of receiving general exams and physicians' services and were more likely to visit the emergency room than children who were not enrolled. They were more likely to receive all of the measured services when compared with children receiving Medicaid through AFDC.