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Paper

Mental health disorders of youth in foster care and foster care alumni in the United States

abstract

Aims. This presentation will review the rates of mental health disorders among youth in foster care and foster care alumni in the United States. These data will be contrasted with general population studies, some of which use the CIDI - the Composite International Diagnostic Interview Schedule. Policy and practice implications of these data will be outlined.

Introduction. In 2005 in the U.S.A., nearly 3.3 million U.S. children were reported as abused and neglected, with 899,000 confirmed victims (U.S. Department of Health and Human Services, 2007, p.1). The United States federal government estimated that 513,000 children were placed in foster care in family and non-family settings as of September 30, 2005, with about 799,000 children served during the 2005 federal fiscal year (U.S. Department of Health and Human Services, 2006).

The effects of child abuse and neglect on childhood, adolescent, and adult outcomes are numerous and diverse. Research showed that while many maltreated youth show resilience in the face of such adversity, others struggle with mental health problems, risk taking behavior, social consequences, and physical health problems. The pathways through which the consequences of maltreatment are manifested are complex; sometimes direct but other times mediated by other maltreatment effects (Kendall-Tackett & Giacomoni, 2003).

Prevalence of Mental Health Disorders among Youth Placed in Foster Care

Most youth in foster care have traumatic family histories and life experiences (including the removal from birth-family) that result in an increased risk of mental health disorders. Some of these children develop behavioral, emotional, or developmental problems as a result of prior trauma, or an accumulation of traumatic stress in their lives. These children are faced with the loss of their birth parents and extended family, and familiar environments. They also have to adjust to life in the foster care system, which can contribute to or exacerbate behavior and emotional problems because of placement changes, rejection by foster parents or siblings, stigma of being in care, and other factors.

Many foster care agencies place youth in mental health treatment because it is assumed that they have a mental health disorder, given their history. However, not all youth in care have a mental health disorder and therefore not all youth in care need treatment. This point underscores the need to utilize careful screening and assessment methods for youth entering and remaining in foster care. In comparison to general population mental health disorder prevalence rates, data on the mental health functioning of youth in foster care and alumni of care are less available.

Despite the methodological complexities of measuring these conditions, there is growing support for careful assessment and treatment of children entering the child welfare system.

Although there is limited research examining the developmental and behavioral status of children in the child welfare population, reports suggest that this population of young children, specifically those in out-of-home care, is particularly at-risk for developmental and behavioral problems in comparison to children who have not interacted with the child welfare system. Research on children active to the child welfare system and placed in out-of-home care suggests that between 23 and 61% of children under age five are significantly delayed when screened for developmental problems.

This elevated rate, compared to a rate of 10-12% of children with developmental delays in the general population, may be due to increased risk of pre-natal exposure to maternal alcohol and drug abuse, abuse and neglect in their birth homes, or increased medical conditions such as complications from low birth weight or prematurity. Studies examining behavior problems report as many as 25-40% of children under age six entering out-of-home care have significant behavior problems. This is much higher than the overall prevalence rate of behavioral issues in the general population of preschoolers, which has been estimated at between 3% and 6% (Stahmer et al., 2005, pp. 891).

A recent study of the National Survey of Child and Adolescent Well-Being (NSCAW) by Stahmer and colleagues (2005) involved a sample of children being served by child welfare who were under the age of six (mean age 2.6 years). They found that scores for cognitive, behavioral, and social skills for nearly half of these children (45.7%) would likely qualify them for early intervention services:

  • Significantly more children in the 0-2 age range failed the cognitive screening (30.6%) than children in the 3-5 year age range (15.2%, X2=11.5, p<0.001).
  • Fewer children had difficulty with adaptive behaviors, however, preschoolers (14.9%) were significantly more likely to have adaptive behavior risk than infants and toddlers (6.2%, X2=15.7, p<0.001).
  • Behaviorally, approximately 25-30% of the children in both age groups scored in the at-risk range, making this the most likely area of difficulty.
  • About 10% of the very young children (0-2) had scores two or more standard deviations below the mean on communication assessments compared with 16% of children ages 3-5, however this difference was not significant.
  • Eight percent of the children (ages 3-5) who were assessed in the area of social skills showed significant risk (Stahmer, Leslie, Hurlburt, Barth, Webb, Landsverk, & Zhang, in press, p. 16).

The National Survey of Child and Adolescent Well Being found that nearly half (47.9%) of the youths aged 2 to 14 years (N = 3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems. Additionally, Brandford & English (2004), in a study of 19-20 year olds, found that although most youth partici­pated in counseling services, 42% had indicators for depression. Meanwhile, self-reports of mental health functioning made by older adolescents in foster care have indicated rates of approximately 25% for borderline clinically significant internalizing behavioral problems and 28% for externalizing behavioral problems (Auslander et al., 2002). This is significantly higher than children in the general population. (See Table 2.)

A study of 267 children in California found consistently high rates of mental health problems among children in foster care using the Child Behavior Checklist, with rates of children in the borderline or clinical range at 2.5 times that found in a general population (Clausen et al., 1998). A large study of 15,507 children receiving medical assistance aid found that the rate of mental health disorders among children in foster care was twice that of youth who were receiving Supplemental Security Income (SSI) and close to 15 times that of children who were receiving other forms of medical assistance aid (dosReis, Zito, Safer, & Soeken, 2001).

In a study of 406 17 year old youths in foster care in Missouri that used the Diagnostic Interview Schedule for DSM-IV, McMillen, Scott, Zima, Ollie, Munson & Spitznagel (2004) reported that 37% met DSM-IV criteria for a psychiatric diagnosis in the past year and 61% met similar criteria for a lifetime disorder, with the highest rates for disruptive disorders (CD and ODD), major depression, and ADHD. Using a slightly smaller sample from that study (N=373) they found that three in five youth (62%) had at least one lifetime mental health disorder and just over one-third (37%) had at least one past year disorder (McMillen et al., 2005).

The Casey Field Office Mental Health Study (CFOMH) included a sample of 188 14-17 year old adolescents in Casey foster care (White, Havalchak, O'Brien, & Pecora, 2007). The rates of lifetime disorders and symptoms of past year mental health disorders among Casey youth are compared to a sample of youth in the general population matched by age, race and gender. About three in five youth being served by Casey (63.3%) had a lifetime CIDI diagnosis, and about one in five (22.8%) had three or more lifetime diagnoses. Of the 22 lifetime diagnoses assessed, six were diagnosed for 15% or more of the sample. The most common lifetime diagnoses were Oppositional Defiant Disorder (29.3%), Conduct Disorder (20.7%), Major Depressive Disorder (19.0%), Major Depressive Episode (19.0%), Panic Attack (18.9%), and Attention Deficit Hyperactivity Disorder (15.1%).

Over one third of youth served by Casey (35.8%) reported symptoms indicative of a mental health disorder in the past year, and a much smaller percentage (7.7%) had symptoms indicative of three or more past year mental health problems. Of the 20 past year mental health conditions assessed, none were diagnosed for 15% or more of the sample. The most common past year conditions were Major Depressive Disorder (10.9%), Major Depressive Episode (10.9%), Post-Traumatic Stress Disorder (PTSD; 9.3%), Intermittent Explosive Disorder (8.6%), and Conduct Disorder (8.3%).

Rates of Mental Health Disorders among Foster Care Alumni

Data are even more scarce for alumni of foster care based on well-recognized standardized measures of mental health functioning. (See Table 1.) The Midwest Study is one excellent example, as well as the Northwest Alumni Study, which examined outcomes for 479 alumni of foster care ages 20 to 33.

Northwest Alumni Study. The Northwest Alumni Study compared the mental health functioning of alumni age 20 to 33 with individuals of a similar age, gender, and ethnicity in the general population (from the NCS-R). Based on questions from the CIDI, both the Northwest Alumni Study and the NCS-R assessed lifetime and 12-month mental health prevalence rates. For lifetime prevalence, highlights include the following (see also Table 6):

  • Alumni prevalence of mental health disorders exceeded the general population on all nine mental health disorders that were assessed.
  • The prevalence of lifetime PTSD was significantly higher among alumni (30.0%) than among the general population (7.6%). This lifetime PTSD rate was comparable to Vietnam War veterans (30.9% for men and 26.9% for women veterans) (Kulka, Fairbank, Jordan, & Weiss, 1990).
  • The prevalence of lifetime major depression was significantly higher among alumni (41.1%) than among the general population (21.0%).
  • In addition to PTSD and major depression, over one in five alumni had one of the following during his or her lifetime: panic syndrome, modified social phobia, or drug dependence.

 

 

 

 

 

Tab. 1 - Mental Health Functioning: Rates for Lifetime Symptoms, Symptoms in the Past 12 Months, and Lifetime Recoverya

Mental Health Outcomes

Northwest Foster Care Alumni

National Co-Morbidity Study Revised (NCS-R for General Population)

Northwest Alumni Study: % Who Had Symptoms-Lifetime

Northwest Alumni Study: % Who Had Symptoms in Past 12 Months

Northwest Alumni Study:
% Recovered

Gen. Pop. (NCS-R) for Ages 20-33: % Who Had Symptoms-Lifetime

Gen. Pop. (NCS-R) for Ages 20-33: % Who Had Symptoms in Past 12 Months

Gen. Pop. (NCS-R): % Recoveredb

CIDI diagnosisc

--

54.4 (2.7)

--

--

22.1 (1.0)*d

--

3 or more CIDI diagnosesc

--

19.9 (2.3)

--

 

2.9 (0.5)*d

--

Major depression episode

41.1 (2.8)

20.1 (2.3)

51.0 (4.5)

21.0 (1.4)*

11.1 (0.8)*

48.3 (2.2)

Panic syndrome

21.1 (2.2)

14.8 (1.9)

30.1 (5.4)

4.8 (0.5)*

3.5 (0.4)*

30.4 (4.7)

Modified social phobia

23.3 (2.5)

17.1 (2.3)

26.6 (5.2)

15.9 (1.6)*

9.4 (1.0)*

36.7 (3.1)*

Generalized anxiety disorder

19.1 (2.4)

11.5 (2.0)

39.6 (7.3)

7.0 (0.8)*

4.0 (0.6)*

39.8 (3.8)

PTSDe

30.0 (2.5)

25.2 (2.5)

15.7 (2.4)

7.6 (0.7)*

4.6 (0.5)*

41.9 (4.1)*

Alcohol problem

Not measured

11.9 (1.6)

--

Not measured

Not measured

--

Alcohol dependence

11.3 (1.2)

3.6 (0.6)

67.9 (4.5)

7.1 (0.1)*

2.3 (0.6)

63.4 (5.4)

Drug problem

Not measured

12.3 (2.2)

--

Not measured

Not measured

--

Drug dependence

21.0 (2.3)

8.0 (1.8)

61.8 (6.6)

4.5 (0.7)*

0.7 (0.2)*

80.4 (4.8)*

Anorexiaf

1.2 (0.3)

0.0

100.0

0.3 (0.1)*

0.0

--

Bulimia

4.9 (1.4)

3.6 (1.3)

25.8 (1.1)

0.8 (0.2)*

0.5 (0.2)*

48.3 (13.6)*

SF-12® mental health score of 50 or above

--

50.6 (2.8)

--

--

--

--

Sample size

479

1601

* Indicates a significant difference between the Northwest Alumni Study and the National Co-Morbidity Study - Replication (NCS-R), p<.05, two-tailed.

aThis analysis takes the NCS-R data matched to age 20-33 and post-stratifies the NCS-R data to match the Northwest distribution of race x sex x age. The NCS-R prevalence estimates were then run on this post-stratified data set. These numbers are slightly different from the NCS-R mental health comparison statistics published previously in the Northwest Alumni Study report (Pecora et al., 2005) because those original numbers did not take into account the post-stratification.

bAlumni were considered to have recovered if the lifetime occurrence of a mental health symptom was not present in the past 12 months.

cBecause alcohol and drug problems were not assessed during the lifetime, CIDI diagnosis and three or more CIDI diagnoses could not be computed for the lifetime, and consequently, no recovery rate could be computed for either item.

dNot adjusted by race or gender.

eThe NCS-R PTSD section included some additional specific trauma items but the Northwest Alumni Study version of the CIDI PTSD items included some general questions that were designed to identify potentially traumatic events. The focus was to help the respondent identify at least one event so the focus was on measuring whether the reactions to any of these events constituted PTSD, rather than measuring the number or type of items per se. The measures, therefore, should be comparable.

fAnorexia is extremely rare in the general population.

Recent mental health data about older alumni from foster care is scarce. However, while age at the time of the interview was younger, the Midwest Evaluation of the Adult Functioning of Former Foster Youth study used the same mental health assessment instrument as the Northwest Alumni Study (the CIDI). Courtney, Dworsky, Ruth, Keller, Havlicek, et al. (2005) assessed the mental health of the 19-year-olds in their sample using the lifetime version of the CIDI. Table 1 presents the overlapping CIDI diagnoses in the Midwest study for 17 year olds and the Northwest study for 20-33 year olds (average age 24). The most prevalent mental health problems in the Midwest study were PTSD, major depression, and alcohol dependence. Although prevalence rates were lower than the Northwest Alumni Study, this may be largely attributable to the age discrepancy between the two studies (all 19-year-olds for the Midwest study compared to an average age of 24.2 years for the Northwest Alumni Study).

 

Tab. 2 - Lifetime CIDI Diagnoses from the Midwest and Northwest Foster Care Studies

Mental Health Outcomes

Lifetime CIDI Prevalence Rate

Midwest Study

Northwest Study

Major depression

10.3

41.1

Modified social phobia

0.0

23.3

Generalized anxiety

0.0

19.1

PTSD

12.5

30.0

Alcohol dependence

6.2

11.3

Drug dependence

5.3 (substance)

21.0

Sample size

321
(age=19)

479
(mean age=24.2)

Source: Courtney, Dworsky, Ruth, Keller, Havlicek, et al., 2005, p.42; Pecora et al. 2005, p. 34.

 

Data in Table 2 indicate reasonably high rates of recovery for alumni for certain mental health disorders, including alcohol dependence (67.9%), drug dependence (61.8%), and major depression (51.0%). In contrast, some mental health problems have endured, with lower recovery rates for generalized anxiety disorder (39.6%), social phobia (26.6%), bulimia (25.8%), and PTSD (15.7%). In comparison, recovery rates were significantly higher for the general population on five of the eight mental health outcomes that were tested. There were no significant differences on the other three.

Rates of mental health diagnoses were significantly higher in the Northwest Alumni Study for seven of nine lifetime diagnoses and seven of 11 past year diagnoses. For many diagnoses, rates among alumni in the Northwest Study were three to five times those of youth in the Casey study of adolescents in foster care study (CFOMH). For example, the rate of past year PTSD in the Northwest Study was 25.2%, compared with 9.3% in the Casey CFOMH study. This pattern of results suggests that alumni of foster care may be more at risk for mental health problems than youth still in care. This may be because unresolved issues surface in the difficult years after emancipation, when young adults may not have the means or supports to address them properly.

Midwest Alumni Study. The Midwest Study also measured short-term recovery rates but on a much shorter time basis. There these short-term recovery rates may in fact reflect more of the stresses of emancipation, the fact that a slightly higher functioning group of youth may still be in care, and a lack of opportunity to recover. For example, compared to young adults still in care, respondents no longer in care had notably higher lifetime prevalence rates of alcohol dependence (t = 2.5, p < .01), alcohol abuse (t = 3.4, p <.001), substance dependence (t = 2.0, p = .04), and substance abuse (t = 3.4, p<.001) (Courtney et al., 2005). So in contrast to the lifetime recovery rates of the Northwest Alumni Study, the short-term trajectory of the Midwest alumni is negative, no doubt exacerbated by the stresses of trying to live in the community with insufficient supports so soon after leaving foster care.

 

Tab. 3 - CIDI-Based Diagnoses of Foster Care Alumni

Mental Health Diagnoses

Northwest Alumni Study (ages 20-33- Males and Females)

Midwest Study (age 21) Past year (%)a

 

Lifetime (%)

Past year (%)

Females

Males

At least one CIDI DSM diagnosis

54.4b

22.1b

14.2b

11.6b

Alcohol Dependence

11.3

3.6

3.5

11.6

Anorexia

1.2

0.0

4.8

9.4

Drug Abuse

--

12.3c

1.9

5.8

Drug Dependence

21.0

8.0

1.0

5.1

Generalized Anxiety Disorder

19.1

11.5

0

0

Post-Traumatic Stress Disorder (PTSD)

30.0

25.2

7.9d

3.8d

Sample size

479

 

 

Notes: "--" indicates that the diagnosis was not assessed.

a Midwest alumni data and have not been weighted for age, gender, race or other variables to be equivalent to the Northwest Alumni study so comparisons should be viewed with caution. Midwest data abstracted form Courtney et al 2007, p. 46.

b Comparisons of the Midwest Study data with the Northwest Alumni Study in terms of number of diagnoses must be made with caution, given that the Northwest Alumni study measured more diagnoses. Lifetime diagnoses in the Northwest Study included: Alcohol Dependence, Anorexia, Bulimia, Drug Dependence, Generalized Anxiety Disorder, Major Depressive Episode, Modified Social Phobia, Panic Syndrome, and PTSD. Past year diagnoses included all lifetime diagnoses, with the addition of Alcohol Problem and Drug Problem.

c The Northwest Alumni Study measured Drug Problem.

dPTSD diagnosis was indeterminate for eleven females and ten males because of missing data.

 

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Contacts: Peter J. Pecora, Ph.D., Senior Director of Research Services, Casey Family Programs (Seattle, WA), Professor, School of Social Work, University of Washington. E-mail: PPecora@casey.org

 

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