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.     

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.     

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.     

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.     

The health status of foster children

A study of the health care and needs of foster children in the New York City area indicated a prevalence of serious physical, mental and developmental problems. The level of pathology was roughly comparable to that of other disadvantaged child populations.     

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.     

Pediatricians and foster children

The poor state of health and health care of foster children is well documented. The cure lies in the hands of the agencies that administer the foster care system and pay for medical services, and in those of the physicians who provide that care. This study suggests that much of the problem may be solvable. Adequate numbers of pediatricians in Connecticut seem to be committed to caring for foster children, but major impediments remain, including inadequate reimbursement for both primary and specialty health services. The institution of a medical passport can make needed information available and help to establish and promote standards of care. Pediatricians appear willing to take a leadership role in assisting other agencies in developing programs to improve the care of these children; despite the problems in providing medical care to foster children, most pediatricians view it as part of their responsibility to the community and to all children.     

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.     

Parent-child interaction therapy: application of an empirically supported treatment to maltreated children in foster care

One of the more serious problems faced by child welfare services involves the management of children with serious behavioral and mental health problems. Aggressive and defiant foster children are more likely to have multiple foster care placements, require extraordinary social services resources, and have poor short- and long-term mental health outcomes. Interventions that work with challenging foster children and enhance foster parents' skills in managing problem behaviors are necessary. This article presents the successful results of a single case study examining the application of Parent-Child Interaction Therapy (PCIT) with an aggressive young boy and his foster-adoptive parent. PCIT is a dyadic intervention that has been identified as an empirically supported treatment for abused children and for children with different types of behavioral disruption. The application of PCIT to assist foster parents is a promising direction for child welfare services.     

Decision-making around psychotropic medications for children in foster care: Perspectives from foster parents

Background and objectiveChildren in foster care have complex mental health needs and receive high rates of psychotropic medications. Rarely can foster parents make legal decisions about treatment, yet they are intricately involved in the child's life and responsible for the child's safety and well-being. We aimed to conduct the first study of foster parent perspectives on decision-making relevant to the use of psychotropics with children in foster care.MethodsWe conducted semi-structured phone interviews with 13 parents in a small northeastern state who had fostered a child receiving psychotropics in the past 5 years. The state child welfare agency sent information about the study via email to all foster and adoptive parents for whom they had email contact. Interviews queried parents' knowledge and attitudes toward psychotropics, engagement in decisions, and recommendations for the decision-making process. Interview responses were coded and synthesized using mixed inductive and deductive methods in Dedoose software.ResultsChildren came into care on an average of four psychotropics. Parents reported receiving little information about the medications and finding information on their own. Parents acknowledged the potential benefits of medications, yet attitudes were largely against their use. Internal and external pressures for and against the use of medications were described. Many parents felt left out of the decisions and recommended team decisions.ConclusionsEfforts to improve foster parents' knowledge of medications, side effects, and monitoring, as well as team decision protocols, are sorely needed to improve decisions for this population.     

Externalizing problems in young foster children: Prevalence rates,predictors and service use

Objective

Examining the prevalence of externalizing problems, their predictors and mental health service use for these problems by foster children and foster parents in a representative group of foster children aged 3 to 12 in Flanders.

Method

Survey data were collected on 212 foster children, who had been in the foster family for approximately four months. Foster parents filled out a Child Behavior Checklist to measure foster children's externalizing problems. Foster care workers reported on several potential risk variables for externalizing problems and on foster children's and foster parent's mental health service use. Predictors of externalizing problems were identified from a large number of variables using the method of purposeful selection of variables in linear regression.

Results

40.6% of the foster children had externalizing problems. Foster children who were placed because of behavioral problems had more externalizing problems. Only 20.9% of the foster children with externalizing problems and only 13.9% of their foster parents received professional help.

Conclusions

This study showed that externalizing problems are prevalent in this young foster care population, that it is hard to predict which foster children had externalizing problems, and that foster children and their foster parents rarely receive services for these problems. These findings call for a standard protocol of assessment of foster children's externalizing problems. Moreover, from a preventive viewpoint, guidelines are needed to systematically link young foster children with externalizing problems and their foster parents to appropriate services.     

Responsive engagement in mental health services for foster youth transitioning to adulthood

ABSTRACT

As youth near the transition to adulthood and aging out of the foster care system, exposure to stress increases, especially for youth who have less-than-adequate support systems. Although mental health problems among foster youth often continue into adulthood, service use decreases dramatically within a year of turning age 18. Understanding how foster youth experience mental health services as they transition from care provides social workers and other mental health professionals important insight that can lead to specific, targetable strategies. This study sought to explore what situations were helpful in supporting mental health as foster youth transitioned to adulthood. Focus groups and interviews with former foster youth and professionals informed the development of a quantitative instrument, which was used to identify the most supportive and frequently encountered situations former foster youth experienced. Findings indicate the most helpful situations were those in which professionals and mentors were flexible and responsive to their individual needs and trusted their ability to make decisions. Supportive adults who honored their choices and collaborated in decision-making were also helpful. Engaging, empowering, and partnering with transition-age youth may increase the likelihood of positive mental health outcomes for this population, offering implications for family-centered, strengths-based practice.     

Reducing transfers of children in family foster care through onsite mental health interventions

This article describes a successful pilot project in New York City that effectively reduced the number of transfers or replacements of children in family foster care through the placement of mental health clinicians onsite at two foster care agencies.     

Mental health service utilization in children adopted from US foster care,US private agencies and foreign countries: Data from the 2007 National Survey of Adoption Parents (NSAP)

Aims

In this analysis, we (1) described the rate of mental health service utilization for children from domestic foster care adoption, domestic private adoption, and international adoption and (2) analyzed the effect of common risk factors on mental health service utilization.

Data

As part of the 2007 National Survey on Adoptive Parents (NSAP), parents with children 5–17 years old (N = 1722) were asked if their children had received mental health services and how helpful these services were. Parents also provided data on the children's demographics and likelihood of pre-adoption adversity (e.g., abuse).

Results

For boys, mental health services were utilized by 52.4% of domestic foster care adoptees, 41.0% domestic private adoptees, and 40.0% of international adoptees. For girls, the corresponding rates were 36.3%, 24.8%, and 30.9% respectively. Parents reported that the services were very helpful for about half of the children. Logistic regression analyses showed that adoptees from domestic foster care were more likely than international adoptees to have received mental health services, but there was no difference between domestic private adoptees and international adoptees. Older age at placement, older age at assessment, having special health care needs, and being male all increased the odds for having received mental health services.     

Abused children and foster care—the need for specialist resources

Estimates vary on how many abused and neglected children are admitted to care and how many children in care are there because of abuse and neglect. Nevertheless, it is important to examine their special needs and the problems they present to carers. Although research findings are difficult to interpret, there is enough evidence to show that abused and neglected children in care have special needs in three particular areas: education, health and social behaviour. The evidence is available from research into children in care and research into child maltreatment. Children in care run the risk of disrupted educational careers; abused and neglected children have additional problems in school. Many children in care have a patchy and neglected medical history; abused and neglected children are seriously at risk of further ill-health. Abused and neglected children have been shown to have behaviour problems that jeopardize their relationships with peers and adults; they run the risk of placement breakdown. Foster care of abused and neglected children is a specialist and demanding task, requiring knowledge of, and sensitivity to special needs. Because many abused and neglected children return to their parents, foster carers also need to include the natural family in their task. High expectations of these foster carers, however, should not lead to exploitation but rather an enhancing of fostering assessment, preparation, support and training.     

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.     

Predisposition to seek mental health care among Black males transitioning from foster care

This study examined the predisposition to seek mental health care in the future for personal and mental health problems among Black males transitioning from the foster care system (n=74). Results of simultaneous multiple regression analysis showed that custody status, diagnosis of a DSM-IV psychiatric disorder, and emotional control contributed significantly to the prediction of Black male's predisposition to seek mental health care. Specifically, Black males who were still in foster care were more predisposed to seek mental health care, whereas those diagnosed with a DSM-IV psychiatric disorder and who adhered more to the norm of emotional control were less predisposed to seek mental health care. Implications for mental health service delivery are discussed.     

Predictors of foster care exits to permanency: A competing risks analysis of reunification, guardianship, and adoption

Although foster care is intended to be temporary, and policy explicitly requires permanency outcomes, many children experience lengthy stays and exit foster care without a permanent family. This study sought to identify which child and placement characteristics were important predictors of exit to three types of permanency outcomes: reunification, guardianship, and adoption. A sample of 3351 children who entered foster care in 2006 was observed for 30 to 42 months. Permanency outcomes were analyzed using competing risks survival analysis. Children exited foster care to different types of permanency at different rates and frequencies. Reunification occurred most quickly and frequently. Guardianship was second in terms of median duration but third in frequency. Adoption was the second most common exit but had the longest median duration. One in four children remained in foster care or exited without permanency. While patterns varied by type of permanency, three major categories of important predictors were identified: 1) demographic characteristics of age at entry and race, 2) clinical needs related to children's disabilities and mental health problems, and 3) continuity and connections represented by kin placements, sibling placements, early stability, and absence of runaway events. Implications for practice, policy, and research are discussed.     

Health supervision of children in foster care.

The 1971--74 survey of the health needs and services provided to New York City children in foster care indicates a failure of the Medicaid program to ensure adequate routine care and treatment.