Mental Health and Substance Use Disorders among Foster Youth Transitioning to Adulthood: Past Research and Future Directions

Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children

OBJECTIVE

This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years.

METHODS

This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex.

RESULTS

Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion.

CONCLUSIONS

This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.

Characteristics of Transition-Age Youth Engaging in Suicidal Behavior

PURPOSE

Suicide rates are markedly high among children with foster care involvement. Transition-age youth (TAY) who age-out of the foster care system are at particularly high risk.

METHODS

Analyzing data from the California Youth Transitions to Adulthood Study (n=727), this paper explores the descriptive characteristics of TAY who engage in suicidal behavior with the goals of better identifying, understanding, and supporting those at risk. We report rates of suicidal ideation and suicide attempt at four interview waves (ages 17, 19, 21, 23) and examine differences in rates by sociodemographic characteristics, past maltreatment, and behavioral health disorders.

RESULTS

At age 17, 42% of California Youth Transitions to Adulthood Study participants had thought of committing suicide and 24% had attempted suicide. Across ages, sexual minority youth reported significantly higher rates of suicidal ideation and behavior than their heterosexual peers. We also found that youth with (1) maltreatment experiences (both before and during foster care); (2) major depressive disorder, anxiety disorder or post-traumatic stress disorder; and (3) alcohol/substance abuse disorders were significantly more likely than their peers without these characteristics/diagnoses to engage in suicidal behavior at certain ages. Youth with comorbid psychiatric and substance use disorders were consistently at elevated risk.

DISCUSSION

Routine screening for suicidal behavior among TAY is important for child welfare service providers to consider. Youth at risk may benefit from more consistent assessment, mental health care, and targeted mental health intervention. Future research is needed to shed light on mechanisms linking certain sociodemographic, experiential, and behavioral health characteristics with suicidal behavior in TAY.

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

A Scoping Review of Factors Associated With the Mental Health of Young People Who Have "Aged Out" of the Child Welfare System

Young people who grow up in care and then exit care around the age of 18 (care-leavers) are a particularly vulnerable group, at increased risk for mental health problems even relative to other care-experienced groups. Yet, little is understood about the factors underpinning this association. We used scoping review methods to synthesize the quantitative and qualitative literature on factors that are associated with mental health problems for care-leavers. Following rigorous methods, we systematically searched three scientific databases spanning psychology and social care and identified 23 peer-reviewed studies for inclusion. This review highlights the heterogeneity of this research, in terms of methodology and topics investigated. Topics included are as follows: pre-care maltreatment, care-related experiences, psychological factors (emotion regulation), social support, education, and adult functioning (e.g., housing, finances, employment). We found mixed and inconsistent findings across research studies. The strongest evidence-base is around the influence of social support upon the mental health of recent care-leavers, though methodological problems are discussed. The field benefits from several large-scale observational and longitudinal research studies. However, there is an over-reliance upon retrospective reporting, and the use of unvalidated measures is common. It is apparent that there are significant gaps in our current understanding of the mental health of care-leavers, in particular around modifiable factors. We discuss potential directions for future empirical research, both in terms of methodology and factors investigated.

A Systematic Review of the Impact of Placement Instability on Emotional and Behavioural Outcomes Among Children in Foster Care

Foster care children are a highly vulnerable population and their experiences in care are considered crucial to their developmental and psychosocial wellbeing. Placement instability has been considered a possible risk factor for developmental difficulties due to its impact on the development of a reparative attachment relationship and sense of relational permanence. The current review synthesises the literature regarding the impact of placement instability on behavioural and mental health outcomes in foster care children. Three major databases and grey literature sources were searched for all relevant quantitative research published by July 2019. Titles and abstracts of 2419 articles were screened following searches, with full texts obtained for 51 studies and 14 included in the final review. All were subject to quality assessment by two independent reviewers. Results indicated that placement instability was a consistent predictor of externalising behaviour in children, although some evidence was counter-indicative in this regard. There was also evidence to suggest a relationship with internalising behaviours, and mental health difficulties, in particular PTSD symptoms. Methodological quality and design varied between studies which limited direct comparisons. Most notably, there was a lack of consensus on how to quantify and measure placement instability and many studies failed to control for potentially confounding care-related variables. The review highlights that instability seems to result in negative psychological outcomes, although the extent of this relationship remains unclear. The review's findings are discussed with reference to research and clinical implications.

How Young Adults with Serious Mental Health Diagnoses Navigate Poverty Post-emancipation: The Complex Roles of Community Mental Health Services & Informal Social Support

Serious mental health diagnoses are prevalent among youth who "age out" of foster care by reaching the maximum age for child welfare service eligibility. Post-emancipation, little is known about how youth engage in community mental health services, or leverage informal social networks, to navigate independence. Twenty emancipating youth completed three interviews over 16 months. All emancipated into poverty; most lived alone and initially connected to adult community mental health teams. Four service use and informal support profiles emerged from analysis: (1) Navigators (n = 2) actively used mental health services and provided limited informal support; Treaders (n = 9) passively used mental health services and heavily exchanged informal support; Survivors (n = 5) used mental health services when in crisis and heavily provided informal support; and Strugglers (n = 4) avoided mental health services and took resources from informal connections. Findings have implications for both child and adult mental health and social service providers.

Childhood maltreatment and mental health problems in a 10-year follow-up study of adolescents in youth residential care: A latent transition analysis

Childhood maltreatment and mental health problems are common among young people placed out-of-home. However, evidence on the impact of maltreatment on the course of mental health problems in at-risk populations is sparse. The aim of this longitudinal study is twofold: (a) describe the course of mental health problems and the shift in symptom patterns among adolescents in youth residential care into young adulthood and (b) assess how childhood maltreatment is related to the course of mental health problems. One hundred and sixty-six adolescents in Swiss youth residential care were followed up into young adulthood (36.1% women; MAge-Baseline = 16.1 years; MAge-Follow-Up = 26.4 years). Latent transition analysis was employed to analyze transitions of symptom patterns and their association with maltreatment exposure. We found three latent classes of mental health problems: a "multiproblem"-class (51.8% baseline; 33.7% follow-up), a "low symptom"-class (39.2% baseline; 60.2% follow-up), and an "externalizing"-class (9.0% baseline; 6.0% follow-up). Individuals in the "multiproblem"-class were likely to transition towards less-complex symptom patterns. Higher severity of self-reported childhood maltreatment was associated with more complex and persistent mental health problems. Our study underlines the need for collaboration between residential and psychiatric care systems within and after care placements, with a specialized focus on trauma-informed interventions and care.

The multifaceted nature of risk behaviour among adolescents-A document analysis of patient and aftercare service providers' records

AIM

The aim of this study was to describe the forms and the prevalence of risk behaviour among adolescents in aftercare services, as well as identify the associated factors and use of services by adolescents.

BACKGROUND

Adolescents in aftercare services represent a vulnerable group that struggles with several aspects of life. The challenges they face are known to accumulate in certain individuals, and the problems that are relevant for this group tend to have an intergenerational nature.

DESIGN

The research applied retrospective document analysis, with the analysed data comprising information on 698 adolescents in aftercare services in one large Finnish city from the fall of 2020.

METHODS

The data were analysed using descriptive statistics and multivariate methods.

RESULTS

Risk behaviour was identified among 616 of the studied adolescents (88.3%), and manifested as substance abuse, reckless sexual behaviour and/or use of money, nicotine use, self-destructive behaviour, delinquency and functional dependencies. Regarding the associations between risk behaviour and background variables, an adolescents' child's clientship in child protection or the child's placement in foster care, adolescent's need for support in parenting, problems with daily rhythm and problems with studying were found to influence the prevalence of risk behaviour. Forms of risk behaviour were also found to be associated with each other. Adolescents displaying risk behaviour commonly did not use the social counsellor, psychiatric outpatient care and study counselling services, even if they would have needed them.

CONCLUSIONS

The interconnections between different forms of risk behaviour mean that this issue should be prioritized when developing aftercare services.

IMPACT

This is the first time that risk behaviour among adolescents in aftercare services has been comprehensively examined. Understanding this phenomenon is key to identifying future research topics, guiding decision-making and helping stakeholders truly understand the needs of these adolescents.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution as the study was based on a document analysis.

Conceptualizing Community Mental Health Service Utilization for BIPOC Youth

Historically, children and adolescents who identify as Black, Indigenous, and other people of Color (BIPOC) have had inequitable access to mental healthcare, and research shows that they are significantly less likely than their white American counterparts to utilize available services. Research identifies barriers that disproportionately impact racially minoritized youth; however, a need remains to examine and change systems and processes that create and maintain racial inequities in mental health service utilization. The current manuscript critically reviews the literature and provides an ecologically based conceptual model synthesizing previous literature relating to BIPOC youth barriers for service utilization. The review emphasizes client (e.g. stigma, system mistrust, childcare needs, help seeking attitudes), provider (e.g. implicit bias, cultural humility, clinician efficacy), structural/organizational (clinic location/proximity to public transportation, hours of operation, wraparound services, accepting Medicaid and other insurance-related issues), and community (e.g. improving experiences in education, the juvenile criminal-legal system, medical, and social service systems) factors that serve as barriers and facilitators contributing to disparities in community mental health service utilization for BIPOC youth. Importantly, we conclude with suggestions for dismantling inequitable systems, increasing accessibility, availability, appropriateness, and acceptability of services, and ultimately reducing disparities in efficacious mental health service utilization for BIPOC youth.

Experiences of the COVID-19 pandemic among young parents with foster care backgrounds: A participatory action PhotoVoice study

The COVID-19 pandemic has had a disproportionate impact on many vulnerable populations, including youth in foster care and parents of young children. In this study, we worked with nine parenting current and former foster youth to share their experiences of the COVID-19 pandemic through photography. Data were collected between January and March 2021 during a series of three virtual PhotoVoice sessions, then transcripts of PhotoVoice sessions and participant-selected captioned photographs were analyzed using thematic analysis. Themes in participants' photographs included 1) Pandemic Parenting and 2) Making the Best of It. Findings indicate the need to expand mental health services, protect essential workers, and ensure young parents receive support navigating medical and social welfare systems and the process of receiving pandemic relief-related benefits.

A Balancing Act: How Professionals in the Foster Care System Balance the Harm of Intimate Partner Violence as Compared to the Harm of Child Removal

The striking prevalence of child exposure to intimate partner violence (IPV) and its associated adverse health outcomes necessitates a robust response from professionals who must grapple with the ethical dilemma of how to serve and support children in these circumstances. In 2020, 42 participants from four different professional backgrounds (attorneys, nonprofit leadership, licensed therapists, and social workers) were interviewed or participated in a focus group discussion. All groups acknowledged the shortfalls of current intervention practices, which often result in child removal. Group 1, which included social workers that work for children's legal services, minor's counsel, and Los Angeles Department of Child and Family Services social workers, were more conflicted in their recommendations for change. Some Group 1 participants recommended more training, while others thought more training would make little difference and recommended more substantial changes to prevent child removal when possible. Group 2, which included parents' counsel, and Group 3, which included social workers, attorneys, and nonprofit leadership at IPV nonprofits, were more closely aligned in their recommendations, primarily focusing on systemic changes to the child welfare system. Participants whose employment required them to advocate for parents tend to view child removal from a non-offending parent as harmful for both the child and IPV survivor. These findings illuminate how the perspectives of these diverse participants are influenced by their professional and personal experiences.

Screening and Assessment of Suicidal Behavior in Transition-Age Youth with Foster Care Involvement

Transition-age youth with foster care involvement (TAY, ages 17-22) are at heightened risk for suicidal behavior. Despite this, mental health screenings are not standardized across child welfare (CW) systems and existing assessment tools are not designed for use with this specific population. As such, TAY are unlikely to be adequately screened for suicide risk and connected with needed services. In this paper, we sought to identify screening and assessment tools that could be effective for use with TAY in CW settings. Using PubMed and PsycINFO, we conducted a search of the current literature to identify some of the most commonly used screening and assessment tools for youth. We then narrowed our focus to those tools that met predefined inclusion criteria indicating appropriateness of use for TAY in CW settings. As a result of this process, we identified one brief screening tool (the ASQ) and four assessments (the SIQ-JR, the C-SSRS, the SHBQ, and the SPS) that demonstrated specific promise for use with TAY. The strengths and limitations of the tools are discussed in detail, as well as the ways that each could be used most effectively in CW settings. We highlight three key points intended to guide social work practice and policy: (1) systematic, routine assessment of mental health and suicide risk across CW settings is critical; (2) the protocol for assessing suicidal behavior in TAY must account for the wide variations in context and service provision; and (3) CW workers administering assessments must be thoughtfully trained on risk identification and the protocol implementation.

Intervention development to improve foster youth mental health by targeting coping self-efficacy and help-seeking

This study articulates the iterative development of an intervention called Strengthening Youth Networks and Coping (SYNC), which is designed to target coping self-efficacy and help-seeking intentions and behaviors among youth in foster care. The overarching goal is to design an intervention that will be a feasible and acceptable enhancement to existing child welfare services, and that will address modifiable determinants among adolescents involved in child welfare system that are related to elevated risk for mental health challenges, limited support network capacity, and service disengagement after exiting foster care. In this paper, we describe our initial needs assessment, explain how we selected proximal intervention mechanisms (i.e., intermediate outcomes) to target, and outline the preliminary intervention development process, including ongoing insights we received from a research advisory group including members with lived experience. Next, we report and discuss the initial acceptability pre-testing data collected from youth (N = 30) as well as feasibility data collected from providers (N = 82), results from which were used to refine the SYNC intervention framework prior to robust efficacy testing. Findings highlight the need and importance of targeting youth coping and help-seeking, integrating programming within existing transition services, delivering this content in a group-based format that includes near-peer mentors and facilitators with lived experience, and developing options that work for the heterogeneous population of young people in foster care. The results also highlight the key objective of capturing youth's interests prior to enrolling in the program (e.g., language used in recruitment materials), holding their interest throughout the program (e.g., creating opportunities for youth to engage with other youth with similar experiences), and suggestions to encourage youth's engagement and participation. This paper articulates the value of this intervention development approach, and the sequential phases of this intervention development process as well as the results, which may be useful to applied researchers and practitioners working with youth in foster care and other priority populations.

Negative experiences, social exclusion and unwanted attention on social media: exploring the association with adolescent alcohol use

BACKGROUND

Adolescents' presence on Social Media (SoMe) facilitates peer connections making them susceptible to peer-influences and approval. Negative experiences on SoMe can affect adolescent stress and wellbeing, impelling their use of alcohol. This paper provides a novel understanding of the relationship between negative experiences on SoMe and key indicators of alcohol use in adolescents.

METHODS

Data was collected from upper secondary school students (n = 3528, ages 16-19, 45% boys) in Bergen (Norway) using a web-based questionnaire during school-hours in 2020 and 2021. Dependent variables were alcohol consumption, binge drinking and scoring ≥ 2 points on the CRAFFT instrument screening for substance use problems in adolescents. Independent variables were two scales indicating "negative acts and exclusion" and "unwanted attention from others". Covariates included age, gender, country of birth and subjective socioeconomic status. Results are presented as relative risk ratios (RRR), odds ratios (OR) and incidence rate ratios (IRR) with 95% confidence intervals.

RESULTS

Using multinomial logistic regression models, "negative acts and exclusion" and "unwanted attention" were positively associated with trying alcohol (OR: 1.50 (95% CI 1.28-1.76) and 1.86 (95% CI 1.66-2.09) respectively, both p ≤ 0.001), with frequency and amount of alcohol consumed. Findings from logistic regression models indicated that "negative acts and exclusion" and "unwanted attention" were positively associated with i. CRAFFT-caseness (OR: 2.13 and 1.86) and ii. frequent binge drinking (OR: 1.55 and 1.89).

CONCLUSION

Both exclusion and unwanted attention on SoMe were associated with indicators of problematic drinking, including frequency, quantity, and consequences related to alcohol.

Mental disorders among adults formerly in out-of-home care: a systematic review and meta-analysis of longitudinal studies

While children and adolescents placed in child welfare or juvenile justice out-of-home care show higher prevalence rates of mental disorders compared to the general population, it remains unclear whether this pattern persists into adulthood. A quantitative synthesis of existing studies is lacking. The aim of this meta-analysis was to estimate the prevalence rates for mental disorders among adults with a foster or residential child welfare or juvenile justice care history, comparing them where possible to rates among the general population. PubMed, PsycInfo, EMBASE, and Web of Science were systematically searched for epidemiological studies published up to 28 October 2020. Nineteen studies, totaling 604,257 participants, met our inclusion criteria. Random-effects models were used for prevalence rates and odds ratios (OR) of mental disorders, and study quality was rated. A prevalence rate of 30% [95% CI (23.36, 37.36)] for any mental disorder in adults with a child welfare care history was found (3-17% for specific disorders). A prevalence rate of 45% [95% CI (42.38, 47.38)] for any mental disorder was found in adults with a juvenile justice care history (6-66% for specific disorders). For out-of-home placement history, adult mental disorders were significantly higher than in the general population (OR = 1.33-2.76). Studies differed in terms of methodology and the disorder groups considered, so heterogeneity between effect sizes ranged from low to high. Our findings suggest that the high risk that mental health issues will persist in adults with an out-of-home placement history needs to be taken seriously in the transition from adolescence to adulthood. The care systems involved need to collaborate and to be aware of these risks.

The impact of COVID-19 on campus-based support programs serving students with foster care experience: Focus groups with administrators and students

The onset of the Coronavirus disease (COVID-19) pandemic forced higher education institutions to abruptly transition to remote services and online learning. Students with a foster care background are a subgroup of students who have been particularly hard hit by the pandemic, as were the campus-based programs (CSPs) designed to support them. The purpose of this study was to learn about the impact of the pandemic on CSPs and CSP participants. Focus groups were conducted with CSP administrators and separately with CSP students from two- and four-year colleges in California. The first theme that emerged from the data focused on challenges exacerbated by the pandemic, with six subthemes zeroing in on breaks in social connections, academic disruptions, technology woes, gaps in basic needs, employment challenges, and the toll on mental health. The second theme described participants' responses, including their creative and collaborative actions. Administrators quickly adapted service delivery, formed partnerships with new units and organizations to ensure students' needs were met, and found creative ways to stay connected with students during a time of pervasive isolation. Students talked about their own efforts to access resources, connect with peers, and use of strategies to manage challenges such as burnout and depression. A second subtheme highlighted the ways participants displayed resilience, such as creating boundaries to manage their own self-care and leaning on each other for support. The findings from this study increase our understanding of the experiences students faced during the pandemic and shed light on implications moving forward to support students with foster care histories in higher education.

"Just being there, like a shoulder to lean on": Resilience and Mental Health among Older Youth in and Aged out of Foster Care during COVID-19

Disasters share a common potential for significant ecological and psychosocial disruption at the individual, community, and societal levels, and are especially harmful to members of social groups in vulnerable situations, including youth in foster care and those recently emancipated from care. These young people are susceptible to mental health challenges and understanding their resiliency is key to mitigating pandemic-related harms. This qualitative study aims to (1) understand how the COVID-19 pandemic affected the mental health of older youth between the ages of 18 and 23 (M = 20.5 years, S.D. = 1.7 years), currently in or aged out of foster care (M = 5.9 years in care, S.D. = 4.4 years), and experiencing mental health challenges, and (2) gain insight into the resiliency that supports young people in dealing with these challenges. Twenty-six young people (77% female-identifying, 38% White, 27% Hispanic) in the USA participated in in-depth interviews. Salient themes include: 1) supportive relationships, 2) adaptive coping skills and mindsets, and 3) environmental, institutional, and social supports. Results amplify the voices of these young people concerning the impact of COVID-19 on their mental health and foreground the dynamic strategies they are using to alleviate their distress.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-022-00498-7.

The association between treated psychiatric and neurodevelopmental disorders and out-of-home care among Finnish children born in 1997

Comprehensive overviews of the use of psychiatric services among children and adolescents placed in out-of-home care (OHC) by child welfare authorities are scarce. We examine specialized service use for psychiatric and neurodevelopmental disorders among children and adolescents in a total population involving children in OHC. We used the longitudinal administrative data of a complete Finnish birth cohort 1997 (N = 57,174). We estimated risk ratios (RRs) for a range of diagnosed psychiatric and neurodevelopmental disorders among children in OHC. We also estimated RRs for OHC among those with diagnosed disorders. We used descriptive methods to explore the timing of first entry into OHC relative to the first diagnosis. Among children in OHC, 61.9% were diagnosed with any psychiatric or neurodevelopmental disorder, compared with 18.0% among those never in OHC (RR: 3.7; 95% CI 3.6-3.8). The most common diagnosed disorders among children in OHC were depression and anxiety disorders, neurodevelopmental disorders, and oppositional defiant disorder/conduct disorder (ODD/CD). Among all children with any diagnosis, 18.1% experienced OHC, compared with 2.5% among those without a diagnosis (RR: 7.4; 95% CI 6.9-7.9). Of those diagnosed with self-harm and suicidality, ODD/CD, substance-related disorders, and psychotic and bipolar disorders, 43.5-61.2% experienced OHC. Of the children in OHC receiving psychiatric services, half were diagnosed before first placement in OHC. The majority of children with experience in OHC were diagnosed with psychiatric or neurodevelopmental disorders. They comprised a significant proportion of individuals treated for severe and complex psychiatric disorders and self-harm.

Mental Health Service Urgency in Children's Mental Health: Factors Impacting the Need for Expedited Services

Delayed access to mental health services for children and adolescents has been linked to an increased risk of harm and nonattendance to scheduled appointments. While studies suggest that the lack of standardized assessments for prioritizing individuals has contributed to long wait times, the inconsistent use of assessments across service sectors in Ontario continues to persist. This has contributed to a paucity of information surrounding which children and adolescents may require urgent mental health services. Using a large secondary data set, this study examined whether service sector (e.g., school), and other individual client characteristics (e.g., age, sex, legal guardianship, interpersonal and school conflict) predicted greater mental health service urgency in 61,448 children and adolescents assessed using the interRAI Child and Youth Mental Health Screener. Binary logistic regression revealed that all predictors, except for sector, showed a significant effect on service urgency. Findings are instrumental in prioritization, reducing the likelihood that children with acute needs remain on waitlists.

Mental disorders into adulthood among adolescents placed in residential care: A prospective 10-year follow-up study

BACKGROUND

Child welfare and juvenile justice placed youths show high levels of psychosocial burden and high rates of mental disorders. It remains unclear how mental disorders develop into adulthood in these populations. The aim was to present the rates of mental disorders in adolescence and adulthood in child welfare and juvenile justice samples and to examine their mental health trajectories from adolescence into adulthood.

METHODS

Seventy adolescents in shared residential care, placed by child welfare (n = 52, mean age = 15 years) or juvenile justice (n = 18, mean age = 17 years) authorities, were followed up into adulthood (child welfare: mean age = 25 years; juvenile justice: mean age = 27 years). Mental disorders were assessed based on the International Classification of Diseases 10th Revision diagnoses at baseline and at follow-up. Epidemiological information on mental disorders was presented for each group. Bivariate correlations and structural equation modeling for the relationship of mental disorders were performed.

RESULTS

In the total sample, prevalence rates of 73% and 86% for any mental disorder were found in adolescence (child welfare: 70%; juvenile justice: 83%) and adulthood (child welfare: 83%; juvenile justice: 94%) respectively. General psychopathology was found to be stable from adolescence into adulthood in both samples.

CONCLUSIONS

Our findings showed high prevalence rates and a high stability of general psychopathology into adulthood among child welfare and juvenile justice adolescents in Swiss residential care. Therefore, continuity of mental health care and well-prepared transitions into adulthood for such individuals is highly warranted.

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

OBJECTIVE

This study used Medicaid claims to compare the prevalence of mental health disorders (MHDs) and developmental disorders (DDs) between foster and nonfoster youth.

METHODS

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.

RESULTS

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.

CONCLUSION

Children in foster care had significantly higher rates of mental health and DD diagnoses compared with children not in foster care.

Dialectical behaviour therapy 'Skills for Living' for young people leaving care: A qualitative exploration of participants' experiences

It is acknowledged that care leavers experience an accelerated transition into adulthood, despite often having complex psychosocial needs with limited support networks. The 'Skills for Living' programme was designed to improve the psychological wellbeing of care leavers and offers an adapted Dialectical Behaviour Therapy skills group as its primary intervention. This paper provides a qualitative evaluation of the programme. Semi-structured interviews were undertaken with 10 participants, and the data were analysed using thematic analysis (Braun & Clarke, 2006). Four key themes emerged: 'Initial Apprehension and Reluctance to Participate', 'Connection, Understanding and Validation', 'Confidence with Social Skills', and 'Emotional Acceptance and Self-Soothing'. Clinical implications and recommendations are discussed.

Purpose Formulation, Coalition Building, and Evidence Use in Public-Academic Partnerships: Web-Based Survey Study

Background

Partnerships between academic institutions and public care agencies (public–academic partnerships [PAPs]) can promote effective policy making and care delivery. Public care agencies are often engaged in PAPs for evidence-informed policy making in health care. Previous research has reported essential partnership contextual factors and mechanisms that promote evidence-based policy making and practice in health care. However, the studies have not yet informed whether public care agency leaders’ and academic researchers’ perceptions of partnership purpose formulation and coalition building evolve through the PAP life cycle and whether public care agency leaders’ use of research evidence differs through life cycle stages.

Objective

This exploratory study aims to focus on PAPs designed to improve youth mental health and well-being outcomes. This study also aims to identify public care agency leaders’ and academic researchers’ perceptions of PAP purpose formulation (structure, goals, primary function, and agenda-setting process) and coalition building (mutual benefits, trust, convener’s role, member role clarity, and conflict management) by PAP life cycle stage and examine whether public care agency leaders’ use of research evidence differs according to the perception of PAP purpose formulation and coalition building through the PAP life cycle.

Methods

A web-based survey of PAP experience was conducted by recruiting academic researchers (n=40) and public care agency leaders (n=26) who were engaged in PAPs for the past 10 years. Public care agency leaders additionally participated in the survey of the Structured Interview for Evidence Use scale (n=48).

Results

Most public care agency leaders and academic researchers in PAPs formed, matured, and sustained perceived their PAP as having purpose formulation context well aligned with their organizational purpose formulation context, pursuing mutual benefits, having leadership representation and role clarity, having a higher level of trust, and knowing how to handle conflicts. Most PAPs across all life cycle stages crystallized another issue to focus, but not all PAPs with issue crystallization had purpose reformulation. Public care agency leaders who trusted academic researchers in their PAP had greater use of research evidence. Public care agency leaders in PAPs that had gone through new issue crystallization also showed greater use of research evidence compared with those that had not.

Conclusions

To promote public care agency leaders’ use of research evidence, focusing on developing trusting partnerships and continuously crystallizing PAP issues are important.

International Registered Report Identifier (IRRID)

RR2-10.2196/14382

Der Verlauf von psychischen Problemen bei fremdplatzierten Kindern und Jugendlichen bis in deren Erwachsenenalter

Zusammenfassung. Theoretischer Hintergrund: Fremdplatzierte Kinder und Jugendliche sind psychisch hoch belastet, jedoch ist der Verlauf von psychischen Problemen bis in deren Erwachsenenalter weitgehend unbekannt. Fragestellung: Die Prävalenz und der Verlauf von psychischen Problemen bei fremdplatzierten Kindern und Jugendlichen bis ins Erwachsenenalter wurden in dieser Studie untersucht und mögliche Prädiktoren identifiziert. Methode: 164 Kinder und Jugendliche wurden während der Fremdplatzierung und im Erwachsenenalter längsschnittlich mittels Selbstbeurteilungsfragebogen auf psychische Gesamtauffälligkeit, internalisierende und externalisierende Probleme untersucht. Ergebnisse: 62.2 % der Kinder und Jugendlichen zeigten auffällige Werte für die Gesamtauffälligkeit wohingegen es im Erwachsenenalter noch 35.7 % waren. Die stärksten Prädiktoren für die jeweiligen Skalen im Erwachsenenalter waren die psychischen Probleme im Kindes- und Jugendalter. Mädchen zeigten eine erhöhte Wahrscheinlichkeit für internalisierende Probleme im Erwachsenenalter im Vergleich zu Jungen. Diskussion und Schlussfolgerung: Die psychischen Probleme bei fremdplatzierten Kindern und Jugendlichen verringerten sich bis ins junge Erwachsenenalter, dennoch blieb ein beachtlicher Teil chronisch auffällig. Implikationen für die Forschung und Praxis werden diskutiert.

A Systematic Review of Mental Health Disorders of Children in Foster Care

OBJECTIVES

This article summarizes the rate of mental health disorders of foster children, the specific types of disorders faced by this population, and how factors such as type of abuse or placement variables can affect mental health outcomes.

METHOD

A search in PsycInfo Ovid, EMBASE Elsevier, and Cochrane Library Wiley resulted in 5,042 manuscripts that were independently reviewed by two authors, yielding 25 articles.

INCLUSION CRITERIA

Published in or after 2000, written in English, and having a population sample of foster children (ages 0-18) in Western countries including the United States, Norway, Australia, and Canada.

RESULTS

Foster children have higher rates of mental health disorders than those of the general population. The most common diagnoses include oppositional defiant disorder/conduct disorder, major depressive disorder, post-traumatic stress disorder, and reactive attachment disorder. Variables such as type of maltreatment and type of placement predicted mental health outcomes.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Children in foster care experience more mental health disorders, as a response to either the circumstances that led to being removed from their homes or the experience of being placed in foster care. These results demonstrate the necessity for providers to consider mental health issues when caring for children in foster care and to perform appropriate screenings and assessments. With adequate trauma-informed training, providers can quickly become comfortable and competent in identifying mental health needs of children in foster care who have experienced trauma.

Protocol for a systematic review of policies, programs or interventions designed to improve health and wellbeing of young people leaving the out-of-home care system

BACKGROUND

Relative to their counterparts in the general population, young people who leave, or transition out of, out-of-home (OOHC) arrangements commonly experience poorer outcomes across a range of indicators, including higher rates of homelessness, unemployment, reliance on public assistance, physical and mental health problems and contact with the criminal justice system. The age at which young people transition from OOHC varies between and within some countries, but for most, formal support ceases between the ages of 18 and 21. Programs designed to support transitions are generally available to young people toward the end of their OOHC placement, although some can extend beyond. They often encourage the development of skills required for continued engagement in education, obtaining employment, maintaining housing and general life skills. Little is known about the effectiveness of these programs or of extended care policies that raise the age at which support remains available to young people after leaving OOHC. This systematic review will seek to identify programs and/or interventions that improve outcomes for youth transitioning from the OOHC system into adult living arrangements.

METHODS

This review will identify programs, interventions and policies that seek to improve health and wellbeing of this population that have been tested using robust controlled methods. Primary outcomes of interest are homelessness, health, education, employment, exposure to violence and risky behaviour. Secondary outcomes are relationships and life skills. We will search, from January 1990 onwards, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Cochrane CENTRAL, SocINDEX, Sociological Abstracts, Social Services Abstracts, NHS Economic Evaluation Database and Health Technology Assessment. Grey literature will be identified through searching websites and databases, e.g. clearing houses, government agencies and organisations known to be undertaking or consolidating research on this topic area. Two reviewers will independently screen all title and abstracts and full text articles with conflicts to be resolved by a third reviewer. Data extraction will be undertaken by pairs of review authors, with one reviewer checking the results of the other. If more than one study with suitable data can be identified, we plan to undertake both fixed-effects and random-effects meta-analyses and intend to present the random-effects result if there is no indication of funnel plot asymmetry. Risk of bias will be assessed using tools appropriate to the study methodology. Quality of evidence across studies will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

DISCUSSION

Previous reviews were unable to identify any programs or interventions, backed by methodologically rigorous research, that improve outcomes for this population. This review seeks to update this previous work, taking into account changes in the provision of extended care, which is now available in some jurisdictions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020146999.

Health and education passport and the role of the foster care public health nurse

AIM

The aim of this study is to explore the practical use of Health and Education Passport (HEP) for children in foster care and the role of the Foster Care Public Health Nurse (FCPHN) in tracking health and education records.

BACKGROUND

Children in foster care have complex health problems and experience frequent changes in home and school placements that result in gaps documentation. California mandates an HEP for every child in foster care.

DESIGN

Utilizing an online survey, PHNs describe their agency's use of the HEP, reported how they obtain health and education records for the HEP.

RESULTS

Social workers, PHNs and mental health providers were main HEP users, less so for foster parents and youth who age out of foster care. The HEP was used at medical and dental visits. PHNs reported little to no participation in updating educators. The HEP may be most useful when the child moves to a new placement or school.

CONCLUSION

The HEP is a critical document that ties a fragmented health history together.

RELEVANCE TO CLINICAL PRACTICE

This study describes the foster care PHN role in updating the HEP and accessing health services and establishing a medical home.

Internal conversations, self-reliance and social support in emerging adults transitioning from out-of-home care: An interpretative phenomenological study

Young people transitioning from out-of-home care frequently have a history of maltreatment and multiple psychosocial challenges. 'Survivalist self-reliance' - thought to involve social disconnection from others, and reluctance to seek support - provides one coping strategy. However, little is known about the self-reliant young person's own reflexive interpretations of social relationships and support during transition. This qualitative study addresses the question: In the context of transitioning from out-of-home care, what reflexive meanings do 'avowedly' self-reliant individuals attribute to current social support and social relationships? Participants were four avowedly self-reliant young adults in transition from care, each with a history of maltreatment and multiple adversities. In this secondary analysis, data were from semi-structured interviews utilizing Margaret Archer's internal conversations interview framework. Data were analyzed using Interpretative Phenomenological Analysis (IPA). Three thematic contexts were identified in which social support was salient: (a) current thoughts and active memories of both the birth family and foster families; (b) the importance of socializing; and (c) perceptions of formal services. There was evidence of cognitive reappraisal (a known amenable resilience factor) and selective engagement with social support, despite the strong overall stance of self-reliance. The findings suggest a more nuanced approach to our understanding of 'survivalist self-reliance'.

Experience of child welfare services and long-term adult mental health outcomes: a scoping review

PURPOSE

This is the first comprehensive review of empirical research that investigated the association between receipt of child welfare services and adult mental health outcomes. The review summarised the results of studies about mental health outcomes of adults with a history of child welfare involvement.

METHODS

A scoping review methodology was used to search five electronic databases (MEDLINE, EMBASE, PsychINFO, IBSS, Social Policy and Practice). Studies were included if they examined any child welfare exposure (including receipt of services while remaining at home/being placed in care) and adult mental health status.

RESULTS

In total 4591 records were retrieved, of which 55 met the eligibility criteria. Overall, receipt of child welfare services was associated with an increased risk of adult mental ill-health, suicide attempt and completed suicide. Results regarding potential moderating factors, such as gender and care-related experiences, were mixed. Relatively few studies investigated the reasons for requiring child welfare services, the experience of abuse or neglect or the adult outcomes of child welfare service users who remained in their own homes. Mental ill-health was defined and measured heterogeneously and details about the nature and type of welfare service utilisation were lacking.

CONCLUSION

There is a need for detailed, longitudinal studies to better understand the relative contribution of pre-existing adversity versus experiences during and after exposure to child welfare services on adult mental health outcomes. More standardised measures of mental ill-health and greater detail from authors on specific care exposure are also needed.

Emancipated Foster Youth and Intimate Partner Violence: An Exploration of Risk and Protective Factors

Due to their high rates of parental maltreatment and violence exposure, youth in the foster care system are considered particularly vulnerable to experiencing intimate partner violence (IPV) in adolescence and young adulthood. Those who have emancipated from foster care may be at a heightened risk, as they are significantly more likely to struggle in a variety of critical domains (i.e., mental health, substance use, and delinquency). This longitudinal study is the first to explore the impact of demographic, individual, family, and foster care system factors on IPV involvement for foster care alumni at age 23/24. Analyses were conducted on three waves of quantitative data from the Midwest Evaluation of the Adult Functioning of Former Foster Youth (the Midwest Study). We find that approximately 21% of the young adults in our sample were involved in some type of IPV at age 23/24, with bidirectional violence the most commonly reported form. Males were more likely than females to report IPV victimization, whereas females were more likely than males to report IPV perpetration and bidirectional violence. Young adults who reported parental IPV prior to foster care entry were more likely to be involved in bidirectionally violent partnerships than nonviolent partnerships in young adulthood, as were young adults who reported neglect by a foster caregiver and those who reported greater placement instability while in the foster care system. Anxiety at baseline increased the odds of IPV perpetration at age 23/24, and posttraumatic stress disorder (PTSD) at baseline decreased the odds of IPV perpetration at age 23/24. Understanding the characteristics and experiences that place these young adults at risk for IPV will allow for more effective and targeted prevention efforts.

Long-term benefits of providing transitional services to youth aging-out of the child welfare system: Evidence from a cohort of young people who use drugs in Vancouver, Canada

BACKGROUND

Youth aging-out of the child welfare system (CWS) experience numerous vulnerabilities including, elevated rates of substance use and substance use disorders. Calls to improve services to transition youth to independence are common; however, evidence of the long-term impacts associated with transitional service utilization is scarce. Further, existing services frequently lack appropriate supports for substance using youth and it is unknown if youth are able to access such services. In the present study, we assess the relationship between transitional service utilization and health and social outcomes among a cohort of people who use drugs (PWUD) that aged-out of the CWS.

METHODS

Data were obtained from two harmonized cohorts of PWUD in Vancouver, Canada. Those who reported aging-out were asked about service utilization, availability, barriers, and interest across seven categories of transitional services. Multivariable logistic regression analyses were conducted to assess the relationship between having previously utilized transitional services and current health and social outcomes.

RESULTS

Between December 2014 and November 2017, 217 PWUD reported having previously aged-out of the CWS. Across service categories, reported service utilization prevalence ranged from 16.6-61.8% while unmet demand ranged from 64.8-78.4%. In multivariable analyses, compared to individuals who utilized ≤1 service while aging-out, having utilized 4-7 services was significantly associated with reduced odds of current homelessness (adjusted odds ratio [AOR]=0.29) and engaging in daily drug use (AOR=0.35) (both p<0.05).

CONCLUSION

Findings suggest that this understudied high-risk population of PWUD and aged-out of the CWS experience long-term benefits associated with transitional service utilization and are interested and willing to engage in these services. However, given high unmet demand, findings also highlight considerable gaps in service delivery and support calls for extending the age of emancipation for all youth in the CWS and in particular, for additional harm reduction and substance use supports embedded into service models.

Mental Health Management Among Older Youth in Foster Care: Service Utilization and Preparedness

PURPOSE

The aim of the study was to document mental health service use (counseling and medication) among youth in foster care, examine how prepared they feel to manage their mental health, and investigate predictors of service use and preparedness.

METHODS

The study includes a representative sample of youth in California foster care at age 17 years who participated in in-person, structured interviews (n = 727). Survey measures captured youth characteristics, their mental health service use, and their level of preparedness to manage their mental health. Data from a child welfare worker survey were used to capture county-level service availability, helpfulness, and coordination. Binary and ordered logistic regression were used to predict mental health service use and preparedness.

RESULTS

Youth reported high rates of mental health service use and one-fifth of the sample reported feeling less than prepared to manage their mental health. Youth who screened positive for mental disorders were less prepared than their peers to manage their mental health. Physical (odds ratio [OR] = 1.44; p < .05) and sexual abuse (OR = 2.04; p < .001) predicted past year use of counseling. Sexual abuse also predicted medication use (OR = 1.97; p < .01). Youth who identified as 100% heterosexual were less likely than non-100% heterosexual peers to use counseling (OR = .58; p < .05). The results also suggest geographic variation in use. Finally, caseworkers' perception of greater helpfulness of services in the county they worked predicted greater mental health preparedness (OR = 1.23; p < .05).

CONCLUSIONS

Mental health service use remains high among youth in foster care. Youth with particular characteristics may benefit from interventions aimed at preparing them for managing their mental health in adulthood.

Exploring college student identity among young people with foster care histories and mental health challenges

Young adults with foster care histories experience unique barriers to success in postsecondary academic settings, including higher rates of mental health challenges. This study reports the perspectives of college students with foster care histories and self-identified mental health concerns (N=18) about how these factors relate to their post-secondary academic experiences. Study participants describe managing their mental health amid other academic and life stressors, share their perspectives on campus-based support and help-seeking experiences, and highlight the need for acknowledgement of their foster care identities in conjunction with their developing college student identities. Participants make a case for programming to help with managing challenges related to overwhelming emotions in response to compounding stressors, balancing self-reliance with help-seeking when needed, and developing interpersonal relationships that reduce feelings of otherness in the campus context. Recommendations for improving student experiences include mental health services provided by people familiar with the lived experience of foster care, access to foster student-specific programs providing social, emotional, and academic support, and campus-wide efforts improve the conditions for academic success in the face of difficult personal histories and elevated mental health challenges.

Meeting the Developmental Needs of Young Adults Diagnosed with Serious Mental Health Challenges: the Emerge Model

Adult providers struggle to engage 18-25-year olds despite high rates of serious mental health challenges observed among this age group. A new model, called "Emerge," combines the intensive outreach and multidisciplinary team-based approach used in Assertive Community Treatment with Positive Youth Development principles and practices used in the Transition to Independence Process Model. Emerge bridges youth and adult services, focuses on supporting transition-to-adulthood milestone achievement, and is a sister team to Coordinated Specialty Care for recent psychosis onset. This paper describes Emerge components, practices, and findings from a feasibility pilot study using agency administrative data. Most prevalent goals were employment and social support/relationship related. The majority made progress on individual goals, engaged in employment and education, and experienced decreased psychiatric hospitalizations. Community mental health policy and practice implications are discussed, including funding blending of evidence-based practices for those transitioning to adulthood with youth-onset serious mental health conditions.

A Comparison Study of Primary Care Utilization and Mental Health Disorder Diagnoses Among Children In and Out of Foster Care on Medicaid

The purpose of this study was to compare the utilization of primary care services and presence of mental health disorder diagnoses among children in foster care to children on Medicaid not in foster care in a large health system. The data for this study were analyzed from a clinical database of a multipractice pediatric health system in Houston, Texas. The sample included more than 95 000 children covered by Medicaid who had at least one primary care visit during the 2-year study period. The results of the study demonstrated that children not in foster care had a greater number of primary care visits and the odds of having >3 visits were significantly lower for children in foster care with a mental health disorder diagnosis. Additionally, more than a quarter of children in foster care had a diagnosis of a mental health disorder, compared with 15% of children not in foster care.

Toward a Defined Role for Occupational Therapy in Foster Care Transition Programming

Youth who age out of the foster care system and transition to adulthood face challenges that are exacerbated by a history of trauma, severed relationships, and instability of living and educational placements. A review of the literature demonstrates poor outcomes overall for this population. Occupational therapists are positioned to meet the needs that arise during this time; however, a review of emerging roles for occupational therapists is necessary to describe how occupational therapists can best fulfill gaps in current programming. Through a review of the literature and a preliminary mixed-methods study, this paper establishes a direction for the inclusion of occupational therapy for youth aging out of foster care using the Person Environment Occupation Performance (PEOP) model as a structure. Federal, state, and local organizations provide resources to assist transitioning foster youth. However, there is a lack of collaborative, individualized, and evidence-based approaches reporting good outcomes. Specific occupational therapy interventions are suggested to delineate our role with this high-risk population during transition to independent living: both novel interventions and additions to current evidence-based programming.

A Descriptive Analysis of Long-Term Treatment with Adolescent-Aged Foster Youth

Foster youth experience a complex combination of psychological symptoms associated with the experience of abuse and/or neglect. Among adolescents, psychological challenges can be magnified by an increased likelihood of placement disruption once in foster care, longer stays in the system, and numerous barriers that impede access and use of mainstream psychological intervention. This manuscript relies on two studies to learn more about the experience of adolescent-aged foster youth who utilize long-term mental health services coordinated through A Home Within, a national nonprofit committed to reducing treatment barriers by asking licensed therapists to provide pro bono therapy "for as long as it takes." Study 1 evaluates 84 therapist interviews about client demographics, trauma history, and mental health symptoms in an effort to learn more about the concerns and experiences of adolescent-aged youth participating in treatment. Study 2 examines 30 pre/post interviews with therapists to understand outcomes associated with treatment completion, as well as to describe treatment practices. Findings support a need for continued investigation of long-term psychotherapeutic services with foster youth focused on the needs of youth accessing care and best treatment practices with this population of vulnerable youth.

Childhood Adversity and Associated Psychosocial Function in Adolescents with Complex Trauma

Background

Childhood adversity is linked to a number of adult health and psychosocial outcomes; however, it is not clear how to best assess and model childhood adversity reported by adolescents with known maltreatment exposure.

Objective

This study sought to identify an empirically-supported measurement model of childhood adversity for adolescents in child protective custody and associations among childhood adversity and adolescent outcomes.

Methods

Self-report survey data assessed childhood adversity and adolescent outcomes, including psychological wellbeing, quality of life, and substance use, in 151 adolescents ages 16 to 22 in protective custody with a documented maltreatment history.

Results

Findings suggest that, among youth with complex trauma histories, it is important to distinguish among risk related to unexpected tragedy (e.g., natural disaster, parental divorce), family instability (e.g., parental substance abuse or mental health concerns), and family violence (e.g., physical or sexual abuse). Family violence was associated with poorer psychological wellbeing and quality of life, while family instability was associated with cigarette and marijuana use.

Conclusions

Among adolescents with complex trauma histories, childhood adversity assessments reflect multiple domains of adversity, each of which are differentially related to adolescent risks. Properly assessing childhood adversity in adolescents with complex trauma histories may help target interventions for specific risks (e.g., substance use) based on which types of childhood adversity youth have been exposed to.

Optimizing the Impact of Public-Academic Partnerships in Fostering Policymakers' Use of Research Evidence: Proposal to Test a Conceptual Framework

Background

Previous research has reported that public-academic partnerships (PAPs) can effectively promote PAP leaders’ use of research evidence in improving youth outcomes. However, the existing literature has not yet clarified whether and how PAP leaders’ use of research evidence evolves along the PAP life cycle and whether PAP partners’ concordant perceptions of usefulness of their PAP has an impact on PAP leaders’ use of research evidence. Developing a conceptual framework that recognizes the PAP life cycle and empirically identifying contexts and mechanisms of PAPs that promote PAP leaders’ use of research evidence from the PAP life cycle perspective are imperative to guide researchers and policymakers to successfully lead PAPs and foster policymakers’ use of research evidence for improving youth outcomes.

Objective

Utilizing an integrated framework of organizational life cycle perspective, a social partnership perspective, and a realist evaluation, this study examines the extent to which PAP development and PAP leaders’ use of research evidence can be characterized into life cycle stages and identifies PAP contexts and mechanisms that explain the progress of PAPs and PAP leaders’ use of research evidence through life cycle stages.

Methods

Recruiting PAPs across the United States that aim to improve mental health and promote well-being of youth aged 12-25 years, the study conducts a document analysis and an online survey of PAPs to inform policymakers and academic researchers on the contexts and mechanisms to increase PAP sustainability and promote policymakers’ use of research evidence in improving youth outcomes.

Results

Fifty-three PAPs that meet the recruitment criteria have been identified, and document review of PAPs and participant recruitment for the online survey of PAP experience have been conducted.

Conclusions

This paper will help policymakers and researchers gain a deeper knowledge of the contexts and mechanisms for each PAP life cycle stage in order to optimize PAP leaders’ use of research evidence in achieving positive youth outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14382

Understanding support network capacity during the transition from foster care: Youth-identified barriers, facilitators, and enhancement strategies

This study explores how foster care experiences can impact support network functionality as young people exit the foster care system. This can be conceptualized as a function of both network member capacity to provide adequate support to address young adult needs, and network stability, which reflects cohesion within and across relationships to facilitate consistent support over time. We conducted support network mapping and semi-structured interviews with youth in foster care aged 16-20 (N=22) and used theoretical thematic analysis to explore support barriers and facilitators in relation to the organizing concepts of support capacity and network stability. Overall, support capacity was limited by interpersonal difficulties inhibiting the presence and supportiveness of some network members (including family members, informal peer and community-based connections, and caseworkers), whereas network stability facilitated multidimensional support through strong and interconnected relationships with caregivers and service providers. Emergent network patterns reflected distinct subgroups of more and less functional support networks, and strategies for network enhancement focus on promoting youth-directed services and support, developing youth skills and opportunities to invest in informal relationships, and using network assessment to identify unmet support needs. Findings advance a framework for understanding how foster care impacts support network characteristics, and inform ongoing efforts to address resulting limitations through services and programming.

Risk and Protective Factors for Alcohol, Marijuana, and Cocaine Use Among Child Welfare-Involved Youth

Youth involved in child welfare services (CWS) are at elevated risk for substance use. CWS involvement may provide an opportunity for intervention to prevent subsequent use; however, little is known about mitigating substance use risk in this population. Using data from the second National Survey of Child and Adolescent Well-Being (NSCAW II), the present study examined individual, psychological, and contextual risk factors (e.g., prior substance use, depression, posttraumatic stress, maltreatment experiences) and protective factors (e.g., caregiver monitoring, peer relationships) following CWS involvement (Wave 1) in relation to alcohol, marijuana, and cocaine use 36 months later (Wave 3). The nationally-representative sample of CWS-involved youth was restricted to individuals who were aged 11 years or older at Wave 1 and had at least a partial interview at Wave 3 (N = 763). Three logistic regression models showed that Wave 1 substance use increased the likelihood of marijuana and cocaine use at Wave 3 [marijuana OR = 1.41 (1.19-1.68); cocaine OR = 1.26 (1.07-1.50)] but not binge alcohol use [OR = 1.44 (0.95-2.19)]. Other risk and protective factors had limited predictive value for Wave 3 substance use. The present findings suggest that initiating substance use prior to or at the time of CWS involvement is a critical risk factor for later substance use. Substance use screening and referral to treatment is imperative for CWS-involved youth.

Psychosocial profile of institutionalised street children in Alexandria, Egypt: a comparative study with school children

OBJECTIVE

The phenomenon of street children in Egypt constitutes a public health concern. This study aimed to investigate the characteristics of institutionalised street children in Alexandria, to compare the prevalence of substance abuse and conduct disorder between street children and school children, and to identify predictors of these mental health outcomes among street children.

METHODS

Institutionalised street children (n = 102) participated in a cross-sectional comparative study with a matched group of school children (n = 156). An interviewing questionnaire was used to assess demographic characteristics and substance use. Conduct disorder was measured using the Revised Ontario Child Health study scale.

RESULTS

Poverty, family breakdown, and domestic violence were the main reasons for street children having left home. Street children recorded significantly higher rates of substance use (9.8%) and conduct disorder (35.3%) compared to school children. In street children, smoking was a significant predictor of substance use and conduct disorder. Other predictors of conduct disorder included physical illness and having 5 to 7 siblings.

CONCLUSION

Substance abuse and conduct disorder were present among institutionalised street children at higher rates than school children. Absence of basic life needs and disrupted families constituted the main reasons for leaving home. Interventions at the governmental and non-governmental levels are needed.

Childhood adversity, social support networks and well-being among youth aging out of care: An exploratory study of mediation

The goals of the present study are to examine the relationship between childhood adversity and adult well-being among vulnerable young adults formerly placed in substitute care, and to investigate how characteristics of their social support networks mediate this association. A sample of 345 Israeli young adults (ages 18-25), who had aged out of foster or residential care, responded to standardized self-report questionnaires tapping their social support network characteristics (e.g., network size or adequacy) vis-à-vis several types of social support (emotional, practical, information and guidance), experiences of childhood adversity, and measures of well-being (psychological distress, loneliness, and life satisfaction). Structural equation modelling (SEM) provided support for the mediating role of social support in the relationship between early adversity and adult well-being. Although network size, frequency of contact with its members, satisfaction with support, and network adequacy, were all negatively related to early adversity, only network adequacy showed a major and consistent contribution to the various measures of well-being. While patterns were similar across the types of support, the effects of practical and guidance support were most substantial. The findings suggest that the detrimental long-term consequences of early adversity on adult well-being are related not only to impaired structural aspects of support (e.g., network size), but also to a decreased ability to recognize available support and mobilize it. Practical and guidance support, more than emotional support, seem to be of critical importance.

Latent classes of older foster youth: Prospective associations with outcomes and exits from the foster care system during the transition to adulthood

Youth in the foster care system face considerable challenges during the transition to adulthood. However, there is significant variability within this population. This study uses person-oriented methods and a longitudinal dataset of youth aging out of foster care to examine differences in how subgroups of foster youth fare during the transition to adulthood. We identified four distinct latent classes, consistent with prior person-oriented studies of this population, and validated these classes by examining differences on additional relevant factors at age 17. After establishing these classes, we tested their predictive validity by examining differences in outcomes at age 19 in domains relevant to the transition to adulthood, including education and employment, problem behaviors, and mental health problems. Finally, given the importance of extended foster care in promoting better outcomes, we used survival analysis to prospectively examine whether class membership was associated with differences in the rates at which youth left foster care between ages 17 and 19. One large group of youth exhibited moderate behavior problems and left care quickly, while another large group of resilient youth had favorable outcomes and left care relatively slowly. A small group exhibited considerable behavior and mental health problems, but left care more slowly, and a very small group was characterized by a history of pregnancy. Findings suggest considerable variability in service need among older foster youth. Implications for service provision during the transition to adulthood are discussed.

Prevalence, withdrawal symptoms and associated factors of khat chewing among students at Jimma University in Ethiopia

BACKGROUND

Recently, khat chewing has become a common practice among high school, college, and university students. Regular khat chewing is thought to be a predisposing factor for different physical and mental health problems. It can lead to absenteeism from work and classes. In Ethiopia, to our knowledge no published study has investigated khat withdrawal symptoms. Therefore, this study was conducted to determine the prevalence, withdrawal symptoms, and associated factors of khat chewing among regular undergraduate students on the main campus of Jimma University in Ethiopia.

METHODS

The institution-based, cross-sectional study was conducted in January 2016. Data were collected from 651 main campus regular undergraduate students with a structured, self-administered questionnaire, entered into Epidata 3.1 and exported to SPSS version 20 for Windows. Bivariate and multivariate logistic regressions were used to explore associations and identify variables independently associated with khat chewing.

RESULTS

The study found that the lifetime and current prevalence of khat chewing among students were 26.3% (95% CI: 24.3, 28.3) and 23.9% (95% CI: 21.94, 25.86), respectively. About 25.7% of students started chewing after joining university, and 60.5% of these students started during their first year. The main reason given for starting khat chewing was for study purposes (54.6%), followed by socialization purposes (42.3%). Among current khat chewers, 72.9% reported that they had chewed khat for 1 year or more and 68.2% reported that they had experienced various withdrawal symptoms. The most frequently reported withdrawal symptoms were feeling depressed, craving, and feeling fatigued. Being male, attending a place of worship daily/2-3 times per week, cannabis use, smoking cigarettes, and having family members currently chewing khat were independently associated with khat chewing.

CONCLUSIONS

This study found that large numbers of university students were currently chewing khat. In this study withdrawal symptoms and factors that significantly affect khat chewing were identified. Besides it gave new ideas regarding khat withdrawal symptoms in Ethiopia. It serves as a critical role of providing information to form rational foundation for public health policy, prevention and planning to bring change in contributing factors for Khat chewing. The finding will be serving as base line information for further study.

Testing a Dynamic Automated Substance Use Intervention Model for Youths Exiting Foster Care

With an ever increasing gap between need and availability for substance use services, more scalable and efficient interventions are needed. For youth in the foster care system, this gap is dramatic and expands as they leave care. Effective prevention services are strongly needed for this group of vulnerable young people. We propose a novel technology-driven intervention for preventing problematic substance use among youth receiving foster care services. This intervention approach would extend the work in brief computerized interventions by adding a text message-based booster, dynamically tailored to each individual's readiness to change. It also combats many barriers to service receipt. Dynamically tailored interventions delivered through technologies commonly used by adolescents and young adults have the strong potential to reduce the burden of problematic substance use.

Health Care Issues for Children and Adolescents in Foster Care and Kinship Care

Children and adolescents involved with child welfare, especially those who are removed from their family of origin and placed in out-of-home care, often present with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. As such, they are designated as children with special health care needs. There are many barriers to providing high-quality comprehensive health care services to children and adolescents whose lives are characterized by transience and uncertainty. Pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services in the context of a medical home, and health care coordination and advocacy on their behalf. This technical report supports the policy statement of the same title.