Mental Health among Foster Youth: A Socioecological Approach to Understanding Healthcare Access and Psychotropic Medication Use

Abstract

Mental health among foster youth is a significant public health problem. In the United States, one in every hundred youth finds themselves in the foster care system, (Children’s Defense Fund, 2012; The Children’s Bureau, 2021). The statistics are staggering, with a child entering the foster care system every two minutes, culminating in approximately 437,283 young individuals in care nationwide, including 17,000 in North Carolina alone (Foster Care Statistics, 2021). The mental health challenges faced by foster youth are profound and significantly more severe than those not in foster care. Foster youth are four times more likely than non-foster youth to suffer from a mental health disorder, with minoritized foster youth facing even greater challenges. The risk of attempting suicide is three to four times higher for individuals who have been in foster care compared to their peers not in the system (Brown, 2020). Despite the need for mental healthcare, access to providers for foster youth can be limited and healthcare can be fragmented (Simms et al., 2018). This may lead to high rates of psychotropic medication use, which can further exacerbate health inequities experienced by this population and lead to deleterious long-term health consequences (Mackie et al., 2017).This dissertation aims to address knowledge gaps regarding the mental health of foster youth, including their access to healthcare and use of psychotropic medications. Through the integration of a socioecological perspective, qualitative data from foster parents and providers, and quantitative data on the prevalence of medication prescribing patterns in North Carolina, a comprehensive understanding of mental health is generated for this population. In Chapter 2, a socioecological framework to help providers approach difficult conversations with youth with chronic health conditions was proposed. Multilayered influences that affect patients and their parents during provider-led goals of care conversations were delineated to help facilitate holistic and effective communication. This framework can be applied to addressing chronic mental health conditions among foster youth. Chapter 3 dives into the experiences of foster parents accessing healthcare, uncovering facilitators and barriers to mental health care through focus group discussions. The unique insights and lived experiences of foster parents revealed key themes and subthemes, emphasizing the need for interventions to alleviate health inequities experienced by foster youth and inform evidence-based policy in the care of foster youth. Building on the findings from Chapter 3, Chapter 4 examined psychotropic medication prescriptions among North Carolina's foster youth using a mixed-methods approach. Combining qualitative feedback from child welfare professionals (N=12) with quantitative analysis of Medicaid claims data (N=14,915), the study documented the high prevalence of psychotropic medication prescriptions, with rates up to 82% among adolescents. Different patterns in psychotropic medication prescriptions were documented according to demographic characteristics and region. When the prevalence of psychotropic medication prescriptions was coupled with qualitative descriptions of systemic fragmentation, critical gaps in continuity of care and medication management were highlighted within the foster care and healthcare systems. In summary, this dissertation brings forth the pressing issues of mental health care access and psychotropic medication use among foster youth. By integrating a novel theoretical perspective and qualitative and quantitative research methods, it provides a comprehensive examination of the intricacies within foster and healthcare systems that contribute to health inequities in this population. The insights gained underscore the need for systemic reform, better coordination between the healthcare and foster care systems, and coordination of care to enhance mental health outcomes for foster youth. This work lays a foundational platform for policymakers, practitioners, and researchers to develop tailored, evidence-based interventions and policies aimed at supporting this historically marginalized group more effectively.