Do youth in out-of-home care receive recommended mental health and educational services following screening evaluations?

Long-term impact of the Fostering Healthy Futures for Preteens program on suicide-related thoughts and behaviors for youth in out-of-home care: A randomized controlled trial

Youth in out-of-home care are at high risk for suicide-related thoughts and behaviors (STB), yet there are no known efficacious interventions that reduce STB for this population. Fostering Healthy Futures for Preteens (FHF-P) is a 9-month community-based mentoring and skills training preventive intervention for children in out-of-home care. A randomized controlled trial enrolled 156 participants aged 9-11 years who were placed in out-of-home care over the prior year. Participants were 48.9% female, 54.1% Hispanic, 30.1% Black, and 27.1% American Indian. Follow-up interviews, conducted 7-12 years postintervention (85.2% retention rate), asked young adult participants, aged 18-22, to self-report lifetime STB as indexed by non-suicidal self-injury, suicidal thoughts, plans, and/or attempts. There was a nonsignificant reduction in the odds of STB for the intervention group at follow-up (OR = 0.74; CI, 0.32, 1.69). However, FHF-P significantly moderated the effect of baseline STB; control youth who reported baseline STB had 10 times the odds of young adult STB (OR = 10.44, CI, 2.28, 47.78), but there was no increase in the odds of adult-reported STB for intervention youth. Findings suggest that FHF-P buffers the impact of pre-existing STB on young adult STB for care-experienced youth. Further research is needed to identify mechanisms that may reduce STB in this population.

Hard-to-treat or hard-to-catch? Clinical features and therapeutic outcomes of help-seeking foster care youths with mood disorders

Introduction

The high level of emotional problems in youths placed in foster care contrasts with the limited use of evidence-based treatments. This study aims to better characterize the clinical features and therapeutic outcomes of foster care youths with mood disorders.

Methods

A secondary analysis of data collected in the context of a French-Canadian clinical research network on pediatric mood disorders in four sites was conducted to compare three groups of patients with depressive or bipolar disorder: those without exposure to child welfare intervention (WCWI, n = 181), those who received non-placement psychosocial intervention (NPI, n = 62), and those in placement interventions (PI, n = 41).

Results

We observed a very high rate of academic problems in patients in the groups NPI/PI compared to those in the WCWI group. Patients in the PI group had more disruptive behavioral disorders (OR = 6.87, 95% CI [3.25-14.52]), trauma-related disorders (OR = 3.78, 95% CI [1.6-8.94]), and any neurodevelopmental disorders (OR = 2.73, 95% CI [1.36-5.49]) compared to the other groups (NPI/WCWI). Among inpatients, the Clinical Global Impression-Improvement scale and the change in the Children Global Assessment Scale during the hospital stay did not differ across the three groups. We observed a higher prescription rate of antipsychotics in the PI group compared to the NPI/WCWI groups, but no significant difference for antidepressants and mood stabilizers.

Discussion

These findings support the view that, when provided with dedicated support, fostered inpatient youths can improve in a range comparable to other inpatients. Undetected neurodevelopmental disorders and academic problems are likely important contributors of the burden of mood disorders in these youths.

Comprehensive Health Assessment for Children in Out-of-Home Care: An Exploratory Study of Service Needs and Mental Health in a Norwegian Population

A comprehensive model for routine multi-disciplinary health assessment for children in out-of-home care was piloted in a Norwegian region. This paper reports on identified service needs and mental disorders among 196 children (0-17 years) receiving the assessment. Cross-sectional data was extracted from assessment reports. Results show needs across a range of services, with a mean of 2.8 recommended services for children aged 0-6 and 3.3 for children aged 7-17. Mental disorders were identified in 50% of younger children, and 70% of older children. For all children, overall service need was associated with mental disorders, in addition to male gender among younger children. Need for specialized mental health services was associated with mental disorders among younger children and increasing age among older children. The high frequency of service needs and mental disorders illustrate the importance of offering comprehensive health assessments routinely to this high-risk child population and necessitates coordinated service delivery.

Predisposing, Enabling, and Need Factors Associated with Psychotropic Medication and Mental Health Service Use among Children in Out-of-Home Care in the United States: A Scoping Review

This scoping review aimed to identify predisposing, enabling, and need factors associated with the use of mental health services, including psychotropic medications, among children in out-of-home care in the United States. We searched the PsycInfo, SocINDEX, Medline, and Scopus databases, and 22 studies met inclusion criteria and were systematically analyzed. Among the included studies, 7 studies examined predictors associated with taking psychotropic medications, and 16 examined factors associated with using other mental health services. Significant predisposing, enabling, and need factors associated with greater use of mental health services, including psychotropic medications, were identified. The most frequently identified predisposing factors were child race/ethnicity, age, gender, and maltreatment. Important enabling factors were out-of-home placement type and length of care, and need factors included children's mental/behavioral problems. The results provide insight into maximizing factors facilitating children's use of mental health services to address mental health problems of children in out-of-home care. Further, the results imply the importance of the appropriate use of psychotropic medication (e.g., the type and dosage of medications) among children in out-of-home care. The identified factors can inform child welfare agencies and stakeholders on ways to improve access to mental health services and the appropriate use of psychotropic medications among children in out-of-home care in the United States.

Trajectories of mental health services for youth in foster care with attention deficit hyperactivity disorder

Youth in foster care with Attention Deficit Hyperactivity Disorder (ADHD) often have significant needs for mental health services. The degree to which youth taking medication for ADHD use mental health services in relation to sibling co-placement and their level of need over time is unclear. To examine these issues, caregivers (N = 54) provided information on youth mental health service use across an 18-month study period. Results show that siblings living apart had a higher probability of mental health service use. For youth with higher CBCL scores, probability of mental health service use was both high and stable over time. However, youth with lower CBCL scores showed a decrease in probability of mental health service use over time. The sustained commitment to receipt of mental health services among youth with ADHD is something all behavioral health providers who work with foster care involved youth can benefit from, as well as the youth themselves.

The Role of Social Services in Reunified Custodial Grandfamilies

Social services, including the child welfare system, are often heavily involved in situations where children are returned to the care of their parents, after being raised in kinship care by their grandparents. While previous research has highlighted custodial grandparents' service needs and the challenges they experience when accessing services and working with social service professionals, few studies have examined social services in the context of reunifying grandfamilies. Informed by bioecological theory, the aim of this qualitative study was to examine custodial grandmothers' perceptions of the role of social services in the process of their grandchildren being reunified with a biological parent. Semi-structured, in-depth interviews were conducted with a purposeful sample of 16 custodial grandmothers whose grandchildren had experienced reunification. Findings from a grounded theory analysis revealed grandmothers' perceptions that having a strong connection with a responsive caseworker facilitated successful reunification, as did ongoing efforts to address the parental issues that had resulted in the grandmother assuming a custodial role. Unfortunately, grandmothers also perceived barriers to successful reunification. These included having their perspectives dismissed by caseworkers and judges as well as the child welfare system prioritizing reunification, often to the perceived detriment of their grandchildren. Implications for policy and practice with reunifying grandfamilies are addressed.

Impact of geographic access to primary care providers on pediatric behavioral health screening

Behavioral Health (BH) screening is critical for early diagnosis and treatment of pediatric mental disorders. The objective of this study was to assess the impact of geographic access to primary care providers (PCP) on pediatric BH screening in children with different race/ethnicity. A retrospective cohort study was conducted using the 2013-2016 administrative claims data from a large pediatric Medicaid Managed Care Plan that have been linked to 2010 US Census data and the 2017 National Provider Identifier (NPI) Registry. Geographic access was defined as the actual travel distance to nearest PCP and the PCP density within 10-mile travel radius from each individual's residence. Stratified multivariate logistic regression was conducted to examine the association between the geographic access to PCP and the likelihood of receiving screening for behavioral disorders within each racial/ethnic group. BH screening rate was 12.6% among 402,655 children and adolescents who met the inclusion criteria. Multivariable analysis stratified by individual race/ethnicity revealed that Hispanic and Black children were more vulnerable to the geographic access barriers than their non-Hispanic White counterparts. The increase in travel distance to the nearest PCP was negatively associated with screening uptake only among Hispanics (10-20 miles vs. 0-10 miles: OR = 0.78, 95% CI [0.71-0.86]; 20-30 miles vs. 0-10 miles: OR = 0.35, 95% CI [0.23-0.54]). In a subgroup that had access to at least one PCP within 10 miles of travel distance, the variation in PCP density had a greater impact on the screening uptake among Hispanics and Blacks than that in non-Hispanic Whites.

Using Positive Emotion Training With Maltreated Youths to Reduce Anger Bias and Physical Aggression

Maltreated youths often overinterpret anger in others' emotional expressions, particularly expressions that are ambiguous, and this "anger bias" is associated with aggressive behavior. In the current experiment, we tested the effect of an emotion-training intervention on anger bias and subsequent aggression. Eighty-four youths, ages 8 to 17, who had been removed from home because of maltreatment and had screened positive for aggressive tendencies, served as participants. Over 4 days, youths completed positive emotion training, a computerized program in which youths classify emotional expressions. Youths in the treatment condition received feedback to encourage their recognition of happiness over anger in ambiguous expressions. Physical aggression up to 1 week posttraining was assessed on the basis of self- and staff reports. The intervention was effective in reducing youths' anger bias and somewhat so in reducing aggression-the latter of-which occurred infrequently, limiting power. Results offer direction for developmental research and cost-effective interventions for maltreated youths at risk for aggression and future justice-system involvement.

A Positive Youth Development Approach to Improving Mental Health Outcomes for Maltreated Children in Foster Care: Replication and Extension of an RCT of the Fostering Healthy Futures Program

Preventing the negative impact of maltreatment on children's mental health requires interventions to be contextually sensitive, grounded in theory and research, and effective in reaching and retaining children and families. This study replicates and extends previous findings of the Fostering Healthy Futures (FHF) program, a 30-week mentoring and skills group intervention for preadolescent maltreated children in foster care. Participants included 426 children recently placed in out-of-home care who were randomized to intervention or control conditions. Outcomes measured 6-10 months postintervention included a multi-informant (child, caregiver, teacher) index of mental health problems as well as measures of posttraumatic stress symptoms, dissociative symptoms, quality of life, and use of mental health services and psychotropic medications. There were high rates of program initiation, retention, and engagement; 95% of those randomized to FHF started the program, 92% completed it, and over 85% of the mentoring visits and skills groups were attended. The FHF program demonstrated significant impact in reducing mental health symptomatology, especially trauma symptoms, and mental health service utilization. These program effects were consistent across almost all subgroups, suggesting that FHF confers benefit for diverse children. Results indicate that positive youth development programming is highly acceptable to children and families and that it can positively impact trauma and its sequelae.

The Needs of Foster Children and How to Satisfy Them: A Systematic Review of the Literature

Family foster care deeply influences the needs of children and how these are satisfied. To increase our knowledge of foster children’s needs and how these are conceptualized, this paper presents a systematic literature review. Sixty-four empirical articles from six databases were reviewed and categorized (inter-rater agreement K = .78) into four categories: medical, belongingness, psychological and self-actualization needs. The results give a complete overview of needs that are specific to foster children, and what can be implemented to satisfy these needs. This study shows psychological needs are studied more often compared to the other categories, which specially relates to much attention for mental health problems. Furthermore, most articles focus on how to satisfy the needs of foster children and provide no definition or concrete conceptualization of needs. Strikingly, many articles focus on children’s problems instead of their needs, and some even use these terms interchangeably. This review illustrates that future research should employ a proper conceptualization of needs, which could also initiate a shift in thinking about needs instead of problems.

Services according to mental health needs for youth in foster care? - A multi-informant study

BACKGROUND

Foster children have a high risk of mental disorders. This has contributed to increased international attention to service utilization for youth in foster care. The aim of this study is to examine whether youth in foster care receive services according to need, by using a multi-informant design.

METHOD

Detailed information on the type and frequency of service use during the last 2 years and on youth mental health were collected from foster youths and their carers in Norway (n = 405, aged 11-17 years) through online questionnaires. Mental health was assessed with the Strengths and Difficulties Questionnaire. Statistical analyses were conducted using descriptive statistics and log-binominal regressions.

RESULTS

In total, 48.8% of foster youths showed evidence of mental health problems, and 74.5% of foster families had contact with services. Increased mental health problems and living in non-kin foster care were associated with more service use. Youths with mental health problems had twice the probability of receiving services from the child and adolescent mental health service (CAMHS) and primary health care services compared to youths without problems. However, 57.0% of youths with carer-reported mental health problems did not have contact with CAMHS.

CONCLUSIONS

Service use among foster youths was associated with service need rather than demographic and placement characteristics. The majority of youths with mental health problems did not receive services from CAMHS. However, many of them were in contact with primary health care services.

Utilization of Mental Health Services and Mental Health Status Among Children Placed in Out-of-Home Care: A Parallel Process Latent Growth Modeling Approach

This longitudinal study examined the parallel trajectories of mental health service use and mental health status among children placed in Florida out-of-home care. The results of growth curve modeling suggested that children with greater mental health problems initially received more mental health services. Initial child mental health status, however, had no effect on subsequent service provision when all outpatient mental health services were included. When specific types of mental health services, such as basic outpatient, targeted case management, and intensive mental health services were examined, results suggested that children with compromised functioning during the baseline period received more intensive mental health services over time. However, this increased provision of intensive mental health services did not improve mental health status, rather it was significantly associated with progressively worse mental health functioning. These findings underscore the need for regular comprehensive mental health assessments focusing on specific needs of the child.

Suicidality among preadolescent maltreated children in foster care

This study sought to determine the prevalence of suicidal ideation, plans, and attempts among 515 preadolescent (aged 9-11 years) maltreated children who entered foster care within the prior year. Over a quarter (26.4%) of the children had a history of suicidality according to their own and/or their caregiver's report, 4.1% of whom were imminently suicidal. In bivariate analyses, children at higher risk of suicidality tended to be younger, non-Hispanic, abused, and to have experienced multiple types of maltreatment, more referrals to child welfare, more household transitions, and a longer length of time in foster care. There were no gender differences. Multiple regression analyses found physical abuse and chronicity of maltreatment to be the most robust predictors of suicidality. It is critically important that these high-risk children are screened for suicidality before adolescence and that caregivers and professionals are informed of their risk status so that they may implement mental health treatment, monitoring, and harm reduction measures.