Health Risk Behavior of Youth in Foster Care

PROBLEM:    Many adolescent health problems are predominantly caused by risk behavior. Foster adolescents have disproportionately poor health; therefore, identification of risk behavior is critical.
METHOD:    Data from a larger study were analyzed to investigate the health risk behavior of 56 youth in foster care using the Child Health and Illness Profile–Adolescent Edition.
FINDINGS:    Data indicated that youth in foster care had some increased risk behavior when compared with a normative adolescent population. Younger adolescents and those in relative placement had less risky behavior. Risk behavior was increased for youth in foster care when they were in group homes, had experienced a parental death, or had a history of physical or emotional abuse or attempted suicide.
CONCLUSIONS:    These results point to areas of strength and vulnerability for youth in foster care and suggest areas for clinicians and caregivers of these adolescents to focus interventions towards harm reduction and enhancement of resiliency.     

Pioneering the Psychiatric Nurse Role in Foster Care

Older youth served in the foster care system have elevated rates of mental health disorders and are high users of mental health services, yet concerns have been raised about the quality of this care. This paper describes the details of a psychiatric nurse's work within a multidisciplinary team to address gaps in care for older youth with psychiatric disorders. We describe the process, outcomes, and lessons learned in developing and piloting a psychiatric nurse intervention for older youth in the foster care system as part of a multidimensional treatment foster care program. Our experiences support further work to develop a role for nursing to improve the quality of mental health treatment in foster care.     

Are Restrictiveness of Care Decisions Based on Youth Level of Need? A Multilevel Model Analysis of Placement Levels Using the Child and Adolescent Needs and Strengths Assessment

Youth entering into the foster care system face many challenges, not the least of which is finding an appropriate placement in which their behavioral and emotional needs can be addressed. This secondary data analysis of foster youth placed in residential care and treatment foster care will study the connection between youths’ scores on a functional assessment and level of placement in the child welfare system using a multilevel model analysis. Data were obtained from an online case management system operated by a state child serving system. The dataset included information for 9,893 youth within 295 residential and foster care provider agencies, with 23,853 functional assessments at multiple time points. Initial findings show a linear relationship between scores on a functional assessment and a placement’s level of restrictiveness; all of the level 2 program variables were significantly associated with the total CANS score for a youth at intake. These findings support prior literature and least restrictive placement policies.     

The health of shelter-based foster youth

There is a lack of information on the health needs of foster care adolescents in emergency shelters or group homes. The purpose of this study was to conduct an assessment of access to health care among shelter-based foster care adolescents in Baltimore, Maryland. The health passports of all the foster care youth staying at two emergency shelters had data extracted to a standardized chart audit tool. In addition, semistructured interviews were conducted with 15 of the adolescents and five shelter staff. Of the 84 passports, only nine (10.7%) had documented up-to-date immunizations, and only one (1.2%) had documented purified protein derivative (PPD) application and reading. A total of 11 (13.1%) met the criteria for significant delay in recommended follow-up to care. Major themes of the interviews revealed that shelter staff and youth were unaware of specific health care recommendations, or were unable to obtain needed health care due to insurance problems or prolonged waiting for appointment times. The results of this health passport audit indicate that shelter-based foster care youth suffer from worse access to health care than do comparable nonshelter-based foster care youth from the same city. Specific public health nursing recommendations are made for improving health supervision for these vulnerable youth.     

From homeless to hopeless and healthless?: the health impacts of housing challenges among former foster care youth transitioning to adulthood in California

A childhood history of placement in the foster care system makes the emerging adult period more complicated and problematic in a variety of ways including meeting basic needs, such as housing and health. We conducted focus groups with 31 former foster youth in San Francisco and Oakland, California to explore their housing and health care circumstances since "aging out" of the foster care system. Five key themes were identified: 1) housing circumstances have direct and indirect impacts on access to health care; 2) housing instability can impede the flow of information between social services staff and youth; 3) housing circumstances and health care differed for men and women; 4) service agency rules and structures may be developmentally mismatched with participant needs; and 5) emerging adults experience repercussions of institutional life including the suspicion of authority and mistrust of medical providers.     

Voices of foster youths: problems and ideas for change

INTRODUCTION: Foster care youth are innocent victims of both abusive parents and the foster care system that inadequately prepares them to transition to independent living in adulthood. OBJECTIVE: The purpose of this study was to identify the characteristics leading to a lack of self-sufficiency and economic independence as perceived by foster care youths. METHOD: This grounded theory study involved structured and unstructured interviews with 16 persons who had aged out of the foster care system and were living independently. Constant comparative analysis of responses to open-ended questions allowed for identifying and coding of emerging themes, and the relationships among categories associated with the foster care experience. RESULTS: Five major themes emerged from the analysis of the data, including It's From My Past, No Place to Call Home, Broken Promises, The System Failed Us, and Ideas for Change. CONCLUSIONS: The unique perspectives and observations of foster care youth should serve as the basis for developing policies and programs that can assist in acquiring knowledge and skills critical for their successful transition to independence.     

Where Do Youth in Foster Care Receive Information About Preventing Unplanned Pregnancy and Sexually Transmitted Infections?

Adolescents in foster care are at risk for unplanned pregnancy and sexually transmitted infections, including HIV infection. A study using a qualitative method was conducted to describe how and where foster youth receive reproductive health and risk reduction information to prevent pregnancy and sexually transmitted infections. Participants also were asked to describe their relationship with their primary health care provider while they were in foster care. Nineteen young adults, recently emancipated from foster care, participated in individual interviews. Using grounded theory as the method of analysis, three thematic categories were generated: discomfort visiting and disclosing, receiving and not receiving the bare essentials, and learning prevention from community others. Recommendations include primary health care providers providing a confidential space for foster youth to disclose sexual activity and more opportunities for foster youth to receive reproductive and risk prevention information in the school setting.     

. . . on Foster Care International Society of Psychiatric-Mental Health Nurses

PROBLEM:  Mental health problems are particularly widespread for foster children. There are approximately 700,000 youth in foster care and nonfamily settings in the United States. The mean entry age is 3 years. The average stay is 2 years. Experts estimate that between 30% and 85% of youngsters in out-of-home care have significant emotional disturbances. Foster care children represent 5% of Medicaid enrollees but use approximately 40% of Medicaid funds. A substantial number of these children have psychological problems so serious that they require residential placement. Adolescents living with foster parents or in group homes have about four times the rate of serious psychiatric disorders than those living with their own families (2009a). Despite this level of need, less than one-third of children in the child protective system are receiving mental health services (2009a).
SOURCES:  Child psychiatric nurse advocates from the Association of Child and Adolescent Psychiatric Nurses Division of the International Society of Psychiatric-Mental Health Nurses compiled this position statement for adoption by the Board of Directors as the Association's formal statement on the plight of children and adolescents in foster care.
CONCLUSIONS:  Areas that need to be addressed include (a) lack of consistent and comprehensive service planning; (b) communications across agencies and with the youth, their foster parents, and key stakeholders; (c) use of evidence-based interventions to prevent and reduce the incidence of disability; (d) education of child welfare case workers about mental and emotional therapeutic management; and (e) education of foster parents and youth about mental health issues and appropriate treatments.     

Rationale for a new direction in foster youth substance use disorder prevention

Background: Of the 463 000 children residing in United States foster care, 29 000 annually exit the system because they have “aged out,” are thus dropped from supportive services, and become responsible for their own housing, finances and health needs. Given histories of maltreatment, housing instability and parental substance use, youth preparing to exit care are at substantial risk of developing substance use disorders. Unfortunately, access to services is often limited, both before and after exit from care. Methods: With the goal of developing a relevant substance use intervention for these youth, focus groups were conducted with foster care staff, administrators and parents to assess the feasibility of potential approaches. Results: Participants identified several population-specific barriers to delivering adapted intervention models developed for normative populations. They expressed concerns about foster youth developing, then quickly ending, relationships with interventionists, as well as admitting to substance use, given foster care program sanctions for such behavior. Group members stressed the importance of tailoring interventions, using creative, motivational procedures. Conclusions: Foster youth seem to encounter unique barriers to receiving adequate care. In light of these results, a novel, engaging approach to overcoming these barriers is also presented.     

Exposing challenges in transitioning post residential mental health treatment: The case of the “Poster child”

A case report is employed that illustrates the need for residential mental health treatment (RT) and the need for continuation of support post RT. Children and youth with moderate-to-severe mental health needs that require intensive treatment in a safe setting for a duration of several months might access RT. RT is sometimes the treatment of choice, and, in fact, is the best treatment option for some youth regardless of whether the youth is in the care of the family or child welfare authorities. However, mental health needs do not stop after discharge from RT. A continuation of supports and continuation of contact with a mental health professional may provide stability that can foster the youths’ progress in education and interpersonal relationships that are significantly affected by the mental health disorders but are simultaneously essential for transitioning to adulthood.     

Residential Care from a Child's Perspective

In 1991, the author, drawing from his fourteen years of work in residential treatment, created a fictitious child named Gus E. Studelmeyer and asked him to write about his experiences in residential care. Gus, 13, lived in a residential treatment center for boys. The essay, "What Do I Think About Residential Treatment: A Child's Perspective" won a national award and was subsequently published in this journal (Volume 9, Number 3 1992). As a result, Gus was asked to keep on writing. In chapter 11 (RTCY, Summer, 1993), Gus tantrums and processes the incident with a counselor. In the following chapter, Gus confronts the issue of foster care. Gus was created to help child care professionals better empathize with, and care for, children and families in residential treatment.     

Outside the margins: youth who are different and their special health care needs

Some adolescents have differences, not of their own choosing, that require different approaches to clinical assessment and care. These adolescents are often marginalized from their peer group, and of-ten isolated in general. Awareness of the differences in health risks that these youth face, and their challenges in the successful mastery of developmental tasks is important to the clinician who serves them. Health care professionals must avoid three things in their efforts to help these groups of young people: judging, preaching, or becoming an agent of social control, even though such efforts maybe well meaning. This article addresses some of the unique needs of gay, lesbian, and bisexual youth; homeless adolescents; foster care youth; and youth who have disabilities.     

Family Involvement in Treatment Foster Care

Child mental health policy and practice has increasingly embraced family-driven practice which promotes family involvement in all aspects of planning and service delivery. While evidence for positive outcomes related to family involvement is mounting in traditional residential treatment, there is little information about family involvement in treatment foster care. This study provides data on family involvement in a statewide randomized trial of treatment foster care. The types of family involvement, factors associated with such involvement, and placement outcomes were examined. Nearly 80% of youth experienced recent family contact and/or family participation in treatment planning. Implications for research, policy, and practice to increase understanding the role of family involvement are discussed.     

Minority youth in foster care: managed care and access to mental health treatment

BACKGROUND: Public sector mental health treatment has been transformed in recent years by the advent of managed care, but investigators of managed care policy have not yet focused on ethnic minority children, especially those involved with the child welfare system. Because of an overrepresentation of high-need minority children, foster care in particular is important to consider. OBJECTIVES: The present study examined children placed in foster care and documented differences between minority children and youth (black persons, Hispanic persons, and white persons) in use of mental health services. The primary concern of the study was to consider whether there were differences in access to services or service use among the groups in the transition to capitated managed care. MATERIALS AND METHODS: Medicaid claims and encounter data for two experimental managed care sites and one comparison fee-for-service site are used in a "difference-in-difference" analysis to estimate a changes in inpatient, outpatient, and residential treatment center (RTC) utilization, controlling for patient characteristics. RESULTS: The study finds persistent declines in inpatient and outpatient use for all ethnic groups, persistent under-representation of Hispanic persons and black persons in treatment regardless of managed care, and greater use of RTCs by black persons and Hispanic persons that is attributable in part to managed care. CONCLUSIONS: Black and Hispanic children received more rather than less mental health care under capitated managed care. The significance of this shift, largely increased in use of RTCs, however, cannot be determined at present, as the effectiveness of treatment delivered in RTCs is not known.     

Youth Worker Job Description and Self-Evaluation Compendium

ABSTRACT

Milieu Therapy, as a psychosocial modality, deals intensively with all aspects of a young person's life. When treatment staff have an idea of what a youth lacks, through the therapeutic use of daily events, staff help the youth with integration (into the residence), individuation (self-direction) and separation (discharge). With the development of emotional trust in staff youth interactions treatment becomes possible; and therefore, the role and function of the child and youth care worker can be defined and evaluated. This article discusses a training and evaluation model, employed at Haydon Youth Services, Oshawa, Ontario. The compendium has as its focus, staff strengths and weaknesses, with a view to skills building. This is part B of the compendium. Part A appears prior to this article and is titled: “Training Youth Workers in Residential Treatment.”     

Treatment Motivation and Living Group Climate in German Youth Prison: A Validation of the German Adolescent Treatment Motivation Questionnaire

Treatment motivation is one of the basic requirements for successful treatment and rehabilitation in youth detention. Treatment motivation is often presumed, but rarely assessed, because there is a lack of reliable and valid measurement instruments to investigate treatment motivation in detained youth, especially in Germany. The Adolescent Treatment Motivation Questionnaire (ATMQ) provides insight into the treatment motivation of young prisoners. The present study examined the construct validity and reliability of the German ATMQ in a sample of 76 German delinquents. A confirmatory factor analysis showed a good fit to the data, indicating construct validity. Cronbach’s alpha reliability coefficients were good. Concurrent validity was supported by significant relations between treatment motivation and living group climate. The German ATMQ (8 items) can be used to assess treatment motivation in judicial and forensic psychiatric care in order to improve treatment motivation.     

Overweight and Obesity Among Youth Entering Residential Care: Prevalence and Correlates

Little is known about the prevalence of clinical weight problems for youth living in residential care. Therefore, this study examined the prevalence and correlates of overweight and obesity in a large sample of youth (N = 1709) entering a residential care program. Results indicated that 48% of youth were overweight or obese at the time of intake, which is much higher than national pediatric rates. Females had higher rates of overweight/obesity, as did youth referred from moderately restrictive placements such as foster care. Youth who were overweight/obese had greater internalizing symptoms at intake. Clinical and research implications are discussed.     

Effect on Health Care Costs for Adolescents Receiving Adjunctive Internet-Delivered Cognitive-Behavioral Therapy: Results of a Randomized Controlled Trial

The economic burden of pediatric chronic pain is high, with an estimated annual cost of $19.5 billion. Little is known about whether psychological treatment for pediatric chronic pain can alter health care utilization for youth. The primary aim of this secondary data analysis was to evaluate the effect of adjunctive internet cognitive-behavioral therapy intervention or adjunctive internet education on health care-related economic costs in a cohort of adolescents with chronic pain recruited from interdisciplinary pain clinics across the United States. For the full sample, health care expenditures significantly decreased from the year before the intervention to the year after the intervention. Results indicated that the rate of change in health care costs over time was not significantly different between the internet cognitive-behavioral therapy intervention and adjunctive internet education groups. Further research is needed to replicate these findings and determine patterns and drivers of health care costs for youth with chronic pain evaluated in interdisciplinary pain clinics and whether psychological treatments can alter these patterns. This trial was registered at clinicaltrials.gov (identifier NCT01316471).

Fostering health in the foster care maze

The fastest growing population of children in foster care today is quite young, and many of these children have significant health care needs. The General Accounting Office (GAO) reported that children in foster care "are among the most vulnerable individuals in the welfare population" (GAO, 1995, p. 1). Poverty, increased homelessness, substance abuse, and a rise in the incidence of persons with HIV all contribute to the problems faced by these children. The Caring Communities for Children in Foster Care Project, funded by the Maternal Child Health Bureau Integrated Services Medical Home Initiative with the American Academy of Pediatrics (AAP), investigated the availability of comprehensive health care services for children in foster care. The AAP recommends that pediatricians serve as the primary health care provider for children in foster care and also as consultants to child welfare agencies. Pediatric nurses play a crucial role in providing health care services to children in foster care. With an increased understanding of the potential physical and mental health care needs of children in foster care and the important role of foster parents, pediatric nurses can increase the likelihood of positive health outcomes for children in foster care.