Adapting a Mental Health Engagement Intervention for Older Youth in Foster Care

Background and Purpose:  Nearly 60% of older youth in foster care have a mental health diagnosis and 80% have received psychiatric treatment while in state custody (McMillen et al, 2004; 2005). Yet, many choose to abruptly discontinue treatment immediately after exiting (McMillen & Raghavan, 2009).  Prior negative experiences with treatment, stigma, and a lack of hope contribute to service discontinuation and are targets of the evidence supported intervention, Just Do You (JDY). JDY has demonstrated success in increasing engagement into mental health services among young adults in mental health treatment settings, but was not designed for use specifically with the foster youth population or for delivery in foster care settings. This study describes the process of adaptation and feasibility testing to modify JDY  for young people preparing to exit the foster care system.

Methods:  Our adaption focused on 2 main targets, 1) adapting materials to represent the specific experiences of older youth in foster care and 2) adjusting materials to be delivered in a foster care or group care setting rather than a mental health clinic.  We had 3 focus groups with former foster youth (n=38), 1 focus group with providers (n=3), and individual interviews with a foster care administrator and a supportive adult nominated by youth.  Detailed notes were reviewed and themes identified to revise manuals and create an adapted intervention called JDY-OYFC.  The revised manuals were given to an advisory group who reviewed them, then met together to provide additional feedback.  Manuals were revised again then tested in a feasibility pilot delivered as part of a Medicaid waiver program for older foster youth with serious mental health conditions. 

Results: Modification of the 4 session intervention involved adding 2 new modules – one focused on learning skills to participate in shared decision making in mental health settings and a second on planning for the future and building supports.  Language was adapted based on youth feedback to change the use of the word “recovery” and to simplify wording.  Significant challenges were encountered in feasibility testing in coordinating schedules and transportation for a 6 session group and in delivering the groups as part of an existing program.  An adapted version was created to combine sessions into a 3 session version. Facilitators noted challenges in the diversity of functioning levels youth presented and successes in using media, creative arts and incorporating technology.

Conclusions and Implications: The modification process supported the need to adapt the intervention for use in the foster care setting and to enhance the intervention for the specific experiences of older youth in foster care but logistical challenges were encountered in delivering an extended group based intervention.  In addition, testing the intervention within an existing program added additional feasibility challenges.  Our data support the need to develop an intervention in conjunction with feasibility testing, particularly in settings such as foster care where there are multiple logistical challenges, but our work also highlights the additional challenges of such an approach in testing intervention effectiveness.