Non-foster Youth Research Articles

Psychotropic Medication Prescribing: Youth in Foster Care Compared with Other Medicaid Enrollees.

Objective: To compare the prevalence of psychotropic medication prescriptions among youth in foster care with those among nonfoster youth on Medicaid. Methods: Children ages 1-18 years in a region of a large southern state who were enrolled in their respective Medicaid plan for at least 30 days between 2014 and 2016 and had at least one health care claim were included. Medicaid prescription claims were categorized by class: alpha agonists, anxiolytics, antidepressants, antipsychotics, mood stabilizers, and stimulants. Primary mental health (MH) or developmental disorder (DD) diagnostic groups were identified for each class. Analyses included chi-square tests, t-tests, Wilcoxon sign rank tests, and logistic regression. Results: A total of 388,914 nonfoster and 8426 children in foster care were included. Overall, 8% of nonfoster and 35% of foster youth were dispensed at least one prescription for a psychotropic medication. Prevalence was higher for youth in care within each drug class and, with one exception, across all age groups. Among children prescribed a psychotropic medication, the mean number of drug classes prescribed was 1.4 (SD 0.8) and 2.9 (SD 1.4) for nonfoster and foster youth, respectively (p < 0.000). Except for anxiolytics and mood stabilizers, more children in foster care were prescribed psychotropic medications without an MH or DD diagnosis. Finally, children in foster care experienced 6.8 (95% CI: 6.5-7.2) times higher odds of being prescribed a psychotropic medication than their nonfoster peers, after controlling for age group, gender, and number of mental and developmental diagnoses. Conclusions: Across all age groups, children in foster care on Medicaid were prescribed psychotropic medications disproportionately more than their nonfoster peers on Medicaid. In addition, children in foster care were significantly more likely to be prescribed psychotropic medication absent an MH or DD diagnosis.

Mental Health and Developmental Disorder Diagnoses of Foster and Nonfoster Children Enrolled in Medicaid.

This study used Medicaid claims to compare the prevalence of mental health disorders (MHDs) and developmental disorders (DDs) between foster and nonfoster youth. Medicaid claims data were used to identify MHDs and DDs. Diagnosis codes were categorized into 16 MHD and 8 DD groups. Children were enrolled in their respective Medicaid plan for at least 30 days and had at least 1 health care encounter generating a claim. Prevalence was compared between children in foster care and children not in foster care overall and by age group. Logistic regression was used to compare the odds of having an MHD or DD diagnosis. Of the 8706 children in foster care, 20.1% had an MHD compared with 9.7% of the 392,815 nonfoster children. Overall, the 5 most prevalent MHD and DD conditions among foster youth were attention-deficit/hyperactivity disorder (ADHD) (11.0%), miscellaneous (9.3%), bipolar disorders (5.6%), communication disorders (5.4%), and depressive disorders (5.1%). The 5 most prevalent conditions among children not in foster care were ADHD (6.1%); communication disorders (3.0%); disruptive, impulse control, and conduct disorders (2.7%); specific learning disorders (2.5%); and trauma and stressor-related disorders (2.4%). Anxiety was significantly higher among nonfoster children. The prevalence of the most common conditions by age group is reported. Overall, children in foster care had 2.5 and 2.3 times higher odds of having an MHD or DD diagnosis, respectively. Children in foster care had significantly higher rates of mental health and DD diagnoses compared with children not in foster care.

Foster youth and at-risk non-foster youth: A propensity score and structural equation modeling analysis

Foster youth and youth who grow up in poverty are at risk for experiencing difficulties in adulthood. However, youth in foster care may be at a greater disadvantage due to additional stressors associated with being removed from home and placed into care. Much of the research assessing outcomes associated with foster care compare foster youth to other youth in care or to youth in the general population. In the current study, we used propensity scores and careful sampling to closely match a sample of 17-year-old foster youth (N = 332) with a group of 17-year-old high-risk youth (N = 83) who had not experienced foster care to evaluate them on risk and protective factors associated with various outcomes in adulthood. A well-fitting structural equation model (SEM) indicated that compared to high risk youth who have never been in foster care, youth in foster care experience higher rates of incarceration, homelessness, early parenthood, and referral to drug and/or alcohol treatment as well as lower levels of education attainment. An interaction between foster care status and gender significantly predicted incarceration. Males in foster care were more likely to experience incarceration compared to other youth. These experiences predict further difficulties in adulthood. Implications for youth currently in care are discussed.

Characterization of Chronic Multiclass Psychotropic Polypharmacy and Psychotherapy in Foster Care Youth in a State Medicaid Population.

Foster youth have higher rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy compared with nonfoster youth. However, less is known about the extent of multiclass psychotropic polypharmacy after adjusting for patient factors associated with psychotropic medication use OBJECTIVES: To (a) compare psychotropic medication use and psychotherapy use by youth in foster care to those not in foster care in the Oklahoma Medicaid population across various sociodemographic and clinical factors, and (b) determine if patient-related characteristics are associated with high levels of concurrent multiclass psychotropic polypharmacy. This cross-sectional, retrospective analysis was conducted using paid prescription, outpatient, and inpatient Oklahoma Medicaid administrative claims from calendar year 2016. Foster youth and adolescents aged 20 years or younger were identified (n = 9,325) and compared with the general Oklahoma Medicaid population of the same age (n = 639,868). Descriptive statistics highlight baseline demographic and clinical differences between the 2 groups. Multivariable logistic regression was used to determine if covariates were associated with concurrent multiclass psychotropic polypharmacy. A subgroup analysis of foster youth taking at least 1 psychotropic medication was also performed to determine factors associated with the highest level of concurrent multiclass psychotropic polypharmacy. Foster care was associated with higher odds of concurrent multiclass psychotropic polypharmacy regardless of presence of psychotherapy. Among the subgroup of foster youth taking at least 1 psychotropic medication, attention deficit hyperactivity disorder medications were the most commonly prescribed medication class, followed by antidepressants and anxiolytics when use was not chronic. However, at the highest level of chronic multiclass psychotropic polypharmacy (4-5 chronic concurrent medications), antipsychotics rose to the top, and anxiolytics were the least likely to be prescribed. Overall, the foster care population had the highest proportion of individuals with concurrent multiclass psychotropic polypharmacy (9.2% vs. 1.9%, P < 0.0001). The highest level of chronic multiclass psychotropic polypharmacy was more likely to occur in males (OR = 1.66, 95% CI = 1.40-1.96) and patients living in group homes (OR = 4.13, 95% CI = 2.02-8.44) or foster homes (OR = 1.66, 95% CI = 1.25-2.19). Being overweight or obese was associated with an 83% higher odds of being at the highest level of concurrent multiclass psychotropic polypharmacy (95% CI = 1.27-2.64). Despite higher psychotherapy use, high rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy in foster youth remain a concern for policymakers. Patterns observed at different levels of concurrent multiclass psychotropic polypharmacy may be key to identifying youth who require additional monitoring. Future research exploring factors associated with higher levels of psychotropic concurrent multiclass psychotropic polypharmacy in foster youth can lead to actionable interventions and important policy changes. This project was funded through the CHIP Health Services Initiative. Keast, Tidmore, and Lambert report contractual employment for the Oklahoma Health Care Authority. Nesser is an employee of the Oklahoma Health Care Authority, and Shropshire is an employee of the Oklahoma Department of Human Services. Keast discloses unrelated research grant funding from AbbVie, Amgen, Otsuka, and Purdue Pharma. Tidmore discloses unrelated research grant funding from Amgen and Otsuka. The remaining authors have no relevant disclosures or conflicts of interest to declare. Posters based on this study were presented at AMCP Nexus 2017; October 16-19, 2017; Grapevine, TX, and at the AMCP Annual Meeting 2018; April 23-26, 2018; Boston, MA.

Psychological Security in At-Risk Youth: Attachment, Emotion Regulation, and PTSD Symptom Severity

Post-traumatic stress disorder (PTSD) may be influenced by attachment insecurities and dysfunctional emotion regulation strategies in children at risk for mental health difficulties, such as children in foster care or in low socioeconomic status (SES) homes. Yet relatively little research exists on attachment and emotion regulation in at-risk adolescents, including in youth with foster care experience. We examined attachment dimensions (attachment avoidance and attachment anxiety) and emotion regulation strategies (expressive emotion suppression and cognitive reappraisal) as predictors of PTSD symptom severity in a sample of 17-year-olds in foster care (n = 146) compared to a low SES sample of 17-year-olds with no foster care experience (n = 83). Greater attachment avoidance and greater attachment anxiety were associated with higher PTSD symptom severity scores regardless of foster care status. Cognitive reappraisal was associated with less severe PTSD symptoms for foster and non-foster youth. Policy and practice implications for at-risk youth’s rights to psychological security are discussed.

After Child Maltreatment: The Importance of Voice for Youth in Foster Care.

Once social services steps in to protect children from violence and neglect in their homes, many youth become wards of the specialized juvenile or family court that assists in child protection (e.g., the dependency court). Some of these children will be ordered into foster care. Within this "dependency system," such children often feel a lack of voice. This study tests the prediction that foster youth who perceive having more opportunity for voice, even indirectly via a representative, more favorably rate the dependency system. Adolescents (n = 110), aged 17 years, involved in foster care and age-matched nonfoster youth rated "how good or bad the foster care/dependency court is for foster youth." The foster youth were also asked about their interactions with the court and with their attorney representatives. Foster and nonfoster youth did not significantly differ in dependency system ratings when considered at the overall group level. However, foster and nonfoster youth ratings significantly differed when foster youth's views of relevant prior legal experiences (e.g., frequency of child-attorney contact, quality of attorney representation) were taken into account: Youth with the highest perceived quality of experiences indicated more positive views than any other group. The importance of perceived quality of experience adds insight into mechanisms for improving adolescents' feelings of voice in the legal system.

Variations in Outcomes Between Foster and Non-foster Youth Following Sex and Relationship Education

Teen pregnancy is associated with increased risk of school dropout, employment challenges and long-term poverty; these risks are exacerbated for foster youth who are at elevated risk for teen pregnancy. Sex education and relationship education can facilitate the development of attitudes and skills associated with behaviors that reduce risky sexual behaviors. However, research on sex education with foster youth is limited as is research exploring the potential benefits of combining relationship education with sex education. This study examines variations in the experiences and outcomes of non-foster youth (n = 160) and foster youth (n = 165) who participated in a federally funded teen pregnancy prevention program that included both relationship and sex education. Path analysis models examined the relationship between several exogenous variables (i.e., youth characteristics, pre-program risky sexual behavior, program experience) and three endogenous variables (i.e., post-program perceived change in intercourse, condom use, and contraceptive use intentions). Multi-group analyses were used with foster youth status as a moderator to determine if the model was invariant by foster youth status. Although foster youth entered programming with elevated rates of risky sexual behavior, both groups reported positive program experiences and safer sexual behavior intentions post-programming. Regardless of their elevated rates of risky sexual behavior prior to receiving programming, foster youth, like non-foster youth, may benefit from both relationship and sex education. For foster youth specifically, their positive program experience and reduced intentions to engage in risky sexual behaviors is an encouraging finding that contrasts with existing literature.

School-related experiences of adolescents in foster care: A comparison with their high-school peers.

Although adolescents in foster care are known to be more at risk for school-related academic challenges, there is a paucity of research on their school-related experiences, such as victimization and relationships with teachers, compared with their same-age peers not in care. The aim of this article is to compare foster-care adolescents and their schoolmates on data that was drawn from the statewide representative California Healthy Kids survey and includes 165,815 nonfoster youth and 706 foster youth in 9th and 11th grades. Findings indicate a consistent pattern: After controlling for age, gender and race, adolescents in foster care have lower (self-reported) academic achievements and experiences that are more negative in school compared with their peers. However, hierarchical regression equations indicate that after controlling for background and school experiences, there were no significant differences in academic achievements between foster care youth and their high school peers. This finding may reflect that in-school experiences are responsible for many of the more negative academic outcomes experienced by foster youth. (PsycINFO Database Record

Instability in the lives of foster and nonfoster youth: Mental health impediments and attachment insecurities

Foster youth are at risk for negative mental health and psychosocial outcomes, including when they are on the brink of emancipation from care into self-sustained adulthood. Factors believed to affect outcomes among foster youth include residential and school instability. Although frequent moves to new homes and schools are common for youth living in poverty, instability for foster youth involves not only changing homes and schools but often also changes in caregivers, thus putting foster youth at risk for disrupted attachment relationships. For the current study, structural equation models examined links between instability, mental health problems, and attachment insecurities in foster and at-risk nonfoster youth. A model containing instability provided a better fit to the data than a model containing foster care status only. Group comparisons revealed that instability was associated with posttraumatic stress disorder symptoms for foster but not nonfoster youth. Implications of instability in the lives of foster youth are discussed.

4.27 Gender Differences in Service Utilization Among Youth Adopted From Foster Care

Foster and adopted youth receive more mental health services than the normative. Although research on nonfoster youth has indicated that females use these services to a greater extent than males, contradictory results have emerged from research examining whether male or female foster youth use these services. Given the high overall rates of service use among foster youth, it is imperative to identify a gender gap, if it exists, to ensure that all youth receive the treatment they need.

“It's really overwhelming”: Parent and service provider perspectives of parents aging out of foster care

Rates of pregnancy and parenthood among current and former foster youth are two to three times higher than non-foster youth peers. Repeat pregnancies among young mothers aging out of foster care also occur at higher rates than peers not involved with the child welfare system. Furthermore, mothers aging out of foster care demonstrate high levels of parenting stress and risk for child maltreatment. Indeed, this population is in significant need of help; however, beyond anecdotal evidence, little is known about the needs and day-to day experiences of this population. In order to tailor interventions to meet the needs of parents aging out, the perspectives of stakeholders must be taken into account. Using qualitative data gathered from separate small group interviews with parents aging out and service providers, this study examined participants' perceptions of parents' daily experiences, strengths, and needs. Findings indicated that parents aging out face overwhelming adversity and stress with little outside financial, emotional, or parenting support from family or friends. Yet, parents also expressed motivation to be good parents, resilience, and the desire to gain effective parenting skills. Although similar themes arose among parent and provider interviews, perceptions differed. Parents expressed hope and optimism in providing for their children while providers expressed systemic failure in preparing parents for independent living. Based on these findings, we conclude that parenting interventions specific to parents aging out may need to address three fundamental and key components: basic needs, social support, and effective parenting techniques.

Fostering Relationships with Children Who are “Too Much to Handle”

Parenting yields unique challenges for adolescent-aged foster youth. Given their age, past trauma, lack of social support, and lack of resources, foster youth are at increased risk for mental health problems, substance abuse, and homelessness compared with nonfoster youth. Many pregnant and parenting adolescent-aged foster youth are at high risk for perpetuating the same dynamics that they themselves experienced, specifically of having their children placed in foster care. This intergenerational trauma cycle will likely continue without interventions focused on the psychological, emotional, developmental, and social experiences of both parents and children. Moreover, interventions must also focus on those implementing the interventions and working with these youth. Staff working with foster youth have high burnout and turnover rates, resulting in inconsistent service provision and disrupted relationships for the youth. Fostering Relationships is a free, theory-based resource that works toward addressing the aforementioned challenges by promoting the development of healthy relationships between foster youth and staff, and between foster youth and their children. This paper uses a case example, a review of the literature, and discussion of underlying theory to detail the need for relationship-focused intervention and the benefits of fostering relationships in supporting staff and pregnant and parenting foster youth.

Improving Social Work Practice with Foster Adolescents: Examining Readiness for Independence

All young people encounter developmental challenges as they make transitions from adolescence to adulthood. Adolescents in the child welfare system experience additional struggles since they suffer from child abuse/neglect, separation from their biological family, and placement instability in out-of-home care. Using reliable measures and face-to-face interviews with 152 randomly selected foster adolescents, this study found that a majority of adolescents who remained in care until late adolescence (a) had severe emotional or behavioral problems, (b) demonstrated poor reading skills compared to non-foster youth in the general population, and (c) had limited job opportunities. Practice implications are discussed and recommendations for future research are outlined.

Improving Education Outcomes for Children in Foster Care: Intervention by an Education Liaison

Children in foster care represent one of the most vulnerable, academically at risk populations in the United States. Aside from lower standardized achievement test scores, higher grade retention numbers, and a greater dropout rate than non-foster youth, between 30% to 50% of children in foster care are placed in special education programs, generally related to either a learning disability or an emotional disturbance. This study investigated the effectiveness on school performance of an education liaison from the school system who worked with social workers to resolve educational barriers to learning and achieving. Advocacy by the education liaison led to positive results in terms of school performance of foster youth. Recommendations are made for better addressing the educational needs of children in foster care.

The Influence of Mentoring on the Peer Relationships of Foster Youth in Relative and Nonrelative Care

The influence of a mentoring program (Big Brothers-Big Sisters) on the peer relationships of foster youth in relative and nonrelative care was examined. Youth were randomly assigned to either the treatment or control condition, and changes in their peer relationships were assessed after 18 months. Foster parents were more likely than nonfoster parents to report that their child showed improved social skills, as well as greater comfort and trust interacting with others, as a result of the intervention. In addition, whereas the peer relationships of all nonfoster youth (N = 90) remained stable, treatment foster youth (N = 90) reported improvements in prosocial and self-esteem enhancing support, and control foster youth showed decrements over time. When the foster youth were differentiated further on the basis of their placement, a pattern of findings emerged in which treatment youth in relative foster care reported slight improvements in prosocial support, whereas treatment youth in nonrelative foster care ...