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.     

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.     

Former system youth with mental health needs: Routes to adult mental health care, insight, emotions, and mistrust

Objective

Public health concern surrounding the mental health needs of former system youth is escalating. We know very little about mental health service utilization on the other side of the developmental transition to adulthood. The purpose of this study was to explore the mental health service use experiences among former system youth with childhood histories which included mental disorder, use of publicly-funded mental health services, and use of additional public systems of care.

Methods

In-depth face-to-face interviews were conducted with 60 participants currently struggling with mental health difficulties regarding their service use experiences over the transition. Participants were recruited from one Midwestern state. Multi-phase analysis was conducted utilizing immersion/crystallization, constant comparison and concept matrices.

Results

Few participants received continuous mental health care across the transition, with the majority experiencing interruptions or discontinuation of care. Important facilitators of service use emerged, such as physicians, former caseworkers and family. Health clinics and parenting programs emerged as potential entrée points for reconnecting disengaged young adults to mental health services. Insight, mistrust, and emotions emerged as novel factors associated with service utilization among young adults.

Conclusions

Mental health service utilization remains a complicated phenomenon over the developmental transition to adulthood. Future research is needed that closely examines the associations between insight, emotion, mistrust and service use among young adults.     

Caregivers' Endorsement of Barriers to Mental Health Services for Children and Youth in Child Welfare

The purpose of this study was to examine the three most common types of caregivers in the child welfare system (birth parents, relative caregivers, and foster parents), an active child welfare case, caregivers' endorsement of barriers to mental health services and mental health service use by caregivers for the children under their care. The sample consisted of 430 dyads (caregivers and their children). Results indicate that an active child welfare case, provider characteristics, and accessibility of services predicted mental health service use for children. Implications for the child welfare and mental health systems are discussed.     

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.     

Racial/Ethnic Disparities in Mental Health Service Use for Older Foster Youth and Foster Care Alumni

Studies have shown that foster care alumni have disproportionally high rates of poor mental health outcomes compared to the general population. The purpose of this study was to examine differences in mental health service use for Latino, African American, and White youth while in foster care and upon exit from the foster care system. Secondary data were used to identify youth 1 year prior to exiting the foster care system (N?=?934) and 1 year after exit from the foster care system (N?=?433). Racial/ethnic disparities in mental health service use upon exit from the foster care system were found, with Latino youth using the least amount of services after foster care exit. Racial/ethnic service disparities in type of services used were also found. Findings suggest that a lack of support (e.g., mandatory or voluntary) may be significant in overcoming challenges in the continuation or disruption of services.     

Supporting the emotional and psychological well being of sexual minority youth: Youth ideas for action

Gay, lesbian, bisexual and transgender (GLBT) populations are susceptible to stress-related mental health disorders because of daily imposed stigma and prejudice. Yet minimal information exists from the perspective of sexual minority youth about how to support them in managing a challenging social environment during critical stages of development. Through the lens of youth from two geographic communities this study examined what is needed to support GLBT adolescent mental health. The study employed inductive secondary analysis of qualitative and quantitative data gathered through Concept Mapping needs assessments. Findings include 61 unduplicated ideas for support across the two groups of youth; 14 primary themes emerged with 22 stated needs common among both groups. Areas of need in multiple service systems are identified. The importance of the supports for meeting youths' emotional needs varied between the two communities. Ideas generated represent youth ideas for improving conditions which contribute to disparate community supports needed to develop positive emotional and psychological well being. The findings are conceptualized with regard to psychological and physical safety; community impact on emotional well being; schools and psychosocial supports; and access to relevant mental health and health care. Discussion includes implications for practice and policy.     

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.     

Underserved parents,underserved youth: Considering foster parent willingness to foster substance-using adolescents

Adolescents involved with foster care are five times more likely to receive a drug dependence diagnosis when compared to adolescents in the general population. Prior research has shown that substance use is often hidden from providers, negating any chance for treatment and almost guaranteeing poor post-foster care outcomes. There are virtually no studies that examine the willingness (and its determinants) to foster youth with substance abuse problems. The current study conducted a nationally-distributed survey of 752 currently licensed foster care parents that assessed willingness to foster youth overall and by type of drug used, and possible correlates of this decision (e.g., home factors, system factors, and individual foster parent factors such as ratings of perceived difficulty in fostering this population). Overall, willingness to foster a youth involved with alcohol and other drugs (AOD) was contingent upon the types of drugs used. The odds that a parent would foster an AOD-involved youth were significantly increased by being licensed as a treatment foster home, having fostered an AOD-involved youth in the past, having AOD-specific training and past agency-support when needed, and self-efficacy with respect to positive impact. Surprisingly, when religion played a large part in the decision to foster any child, the odds of willingness to foster an AOD-involved youth dropped significantly. These results suggest that a large proportion of AOD-involved youth who find themselves in the foster care system will not have foster families willing to parent them, thereby forcing placement into a variety of congregate care facilities (e.g., residential treatment facilities, group homes). Specific ways in which the system can address these issues to improve placement and permanency efforts are provided.     

The invisibility of adolescent sexual development in foster care: Seriously addressing sexually transmitted infections and access to services

Adolescents residing in foster care are at higher risk for acquiring sexually transmitted infections (STIs) and human immune deficiency virus (HIV) compared to their non-foster care peers. A literature review was conducted to determine whether youth residing in foster care face different barriers to sexual health care compared to their peers in the general population and, if so, what those barriers are. The review revealed barriers common to adolescents in general as well as additional barriers specific to the ecosystem of adolescents in foster care. Systemic issues that decreased access to sexual health services included child welfare policies that were either missing or implemented without fidelity; complicated financial factors; barriers to service utilization; lack of collaboration between child welfare and medical professionals; and limited information provided to foster youth on their sexual health and development. Consent and confidentiality issues that foster youth face in seeking sensitive health services also need to be resolved. More research is needed on how to facilitate development of coherent policies and effective practices that promote sexual health care access for adolescents in foster care.     

Integrating creative art into a community-based mental health program for Asian American transition age youth

This paper advocates for the use of creative art as an adjunct in the delivery of mental health care for Asian American transition age youth in the United States. A case study of a participant in a community-based mental health program called Project FOCUS in Orange County, California details how art was used to assist a young woman to identify and achieve her personal goals, mitigate her emotional and behavioral problems, and reach a sense of overall well-being. The findings in this paper lay the groundwork for future research into how art can be systematically incorporated into community-based mental health programs to facilitate service utilization. Further, this study demonstrates that Asian American transition age youth face mental health challenges typical of their cohorts, despite being putative members of a “model minority.” The use of creative art transcends cultural and language barriers, and empowers Asian American transition age youth to explore their identity and express their emotions, which ultimately promotes their mental well-being.     

Parent-adolescent concordance on perceived need for mental health services and its impact on service use

Mental health service underutilization among African American adolescents is well documented, yet not fully understood. Discordance between adolescents and their parents on perceived need for seeing a counselor for an emotional need or psychiatrist for psychiatric or medical services may help explain low service use among this population. This exploratory, prospective study examined the relationship between parent-adolescent concordance on perceived need for emotional counseling or psychiatric services and mental health service use. The relationships between gender and perceived service need and concordance and adolescent severity of depressive symptoms were also explored. Parent-adolescent dyads (n = 108) receiving community-based adolescent outpatient mental health services responded to interview questions concerning their perception of whether an emotional counselor and a psychiatrist were needed in the past six months. Findings revealed low parent-adolescent concordance on perceived need for an emotional counselor and a psychiatrist. A greater proportion of adolescents reported a need than parents. There was no association between gender and perceived need for an emotional counselor and a psychiatrist. Lower rates of parent-adolescent concordance were found among youth reporting elevated depressive symptoms compared to youth reporting normal range symptoms. Concordant dyads kept a higher number of appointments than discordant dyads. Implications for clinical social work practice and future research are discussed.     

Homelessness and Children's Use of Mental Health Services: A Population-Based Study

This study examined whether children who become homeless differ from other low-income children in their mental health service use before and after their first homeless episode, and to what extent homelessness is associated with an increased likelihood of mental health service use. Differences between children with and without new onset of sheltered homelessness in the use of mental health services emerged following homelessness and widened over time. Sheltered homelessness and foster care placement history were associated with increased odds of receiving inpatient and ambulatory mental health services. Findings underscore the importance of collaborations between homeless assistance, foster care, and mental healthcare in efforts to mitigate family homelessness and collateral needs among homeless children.     

The Role of Social Support in the Transition From Foster Care to Emerging Adulthood

Many youth leave foster care with disrupted relationships with their family and others in their social networks. Previous research has documented the severe adversity that former foster youth face in the transition to young adulthood. Perhaps some difficulties are at least partially related to a lack of social support that results from frayed relationships. This article reviews the literature on social support, particularly as it relates to foster youth, for the purpose of examining the role that formal and informal supports play in the transition to adulthood. The implications of this literature for successful transitions for former foster youth are discussed, as well as ways child welfare workers can engage youth and their families, and help them develop supportive social networks.     

Youth with Serious Mental Health Disorders: Wraparound as a Promising Intervention in New Zealand

Youth with serious mental health disorders present with a complexity of challenges for the mental health system, schools, youth justice, care and protection, and their communities. Research shows their needs are best achieved by providing coordinated intensive, multidisciplinary, and individualised services. This article outlines the prevalence and characteristics of youth with serious mental health disorders. It also discusses community‐based interventions used in New Zealand and their limitations. It introduces Wraparound, an intensive individualised coordination and care planning process as a promising practice for youth with serious mental health disorders and their families. Key principles and phases underpinning the Wraparound process are presented along with a case vignette to exemplify the process. Its theory of change, the challenges experienced in practice, and a brief overview of the evidence‐base are also discussed.     

Stepping Down and Stepping In: Youth's Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care

Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth's perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n = 8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.     

Referrals, language proficiency, and enrolment for children's mental health services

Alberta Health Services maintains a database of children, adolescents and adults referred to the child and adolescent mental health and psychiatry intake service. In this study, we sought to systematically assess the impact, if any, of English language proficiency on enrolment of children for mental health services. Specifically, we assessed the extent to which children referred for mental health services were enrolled. In doing so, we categorized our sample (12,143) as English Proficient (EP), or Less English Proficient (LEP). Overall, we found that LEP children were significantly less likely to be enrolled compared to EP children. This disparity in enrolment was only present when other variables were not taken into account. English Proficiency is an important factor for some subgroups.     

Police encounters among a community sample of children and youth accessing mental health services

Generally, within the Canadian context, scholarship on police encounters with persons living with mental illness has focused on the experiences of adults and not children and youth. In this article, we present preliminary work of a secondary data analysis of intake statistics collected over a 5-year period (2009–2014) and a thematic content analysis of qualitative intake notes collected over a 2-year period (2009–2011) about police involvement among a community sample of children and youth accessing mental health services. Of 8,920 intakes completed, 1,449 children and youth, birth to 24 years old, had had police involvement at the time of accessing mental health services. Over the 5 years, the average number of young people with police involvement at the time of accessing mental health services was 16%, or one in six children and youth. Analysis of the qualitative intake notes revealed two main reasons for police involvement: (1) support in the home for a distressed child, and (2) concerns about a child’s conduct and behaviors in the community. The implications for social work practice and future research are discussed.     

The Family and Social Networks of Recently Discharged Foster Youth

Many youth leave foster care with disrupted relationships with family and others in their social networks. Previous research has documented the severe adversity that former foster youth face in the transition to young adulthood. Some of these difficulties are at least partially related to a lack of social support that results from frayed relationships. The purpose of this research was to examine the role that social support plays in the transition to adulthood. It was hypothesized that foster youth with higher levels of social support would make more successful adaptations to early adulthood than youth without that support. Ninety-seven former foster youth were followed for 2 years. Youth reported low levels of “feeling close to parents,” but higher levels of “closeness” were expressed for other relatives. Findings were mixed. Organizational involvement and having many “close” friends were associated with better outcomes. On the other hand, family contact and family support was inversely associated with resiliency. The implications of these findings are discussed.