Mental Health Needs and Multi-Service Utilization Among Youth in Foster Care: A Longitudinal Analysis

Background and purpose: Cross-sectional and longitudinal research has demonstrated a strong relationship between foster youth mental health symptomatology and mental health service receipt, particularly through mid-adolescence (Burns et al., 2004; Horwitz et al., 2012; Villodas et al., 2014). Yet little research to date has examined the influence of foster youth mental health needs on service utilization across adjacent mental health service domains, notably emergency department (ED) visits and substance use treatment (for exceptions, see McMillen et al., 2004; Thackeray et al., 2016). And no study has sought to examine the longitudinal nature of the relationship between mental health needs and trajectories of service use in these adjacent domains. The current study sought to examine the influence of foster youth mental health symptoms on multi-service utilization trajectories is a sample of 328 early to mid-adolescent foster youth living in a metropolitan Pacific Northwestern city.

 Methods: Quantitative data were drawn from the Supporting Siblings in Foster Care study, a longitudinal experimental test of a sibling relational enhancement intervention (McBeath et al., 2014). Youth ranged from 7-15 years old at study enrollment; about 60% of participants were youth of color. At baseline, participants completed the Child Behavioral Checklist (CBCL) internalizing and externalizing subscales, and reported their gender, race/ethnicity, age, and where they currently lived (in foster care, with family, or other location). At each of 4 data collection waves (months 0, 6, 12, and 18), participants reported on their number of received (a) outpatient mental health services, (b) ED visits, (c) alcohol or drug outpatient services, and (d) any other services associated with a crisis episode. Service utilization count variables were used as dependent variables in separate multilevel mixed-effects regression models to examine whether baseline CBCL scores were associated with service utilization patterns over time, controlling for sociodemographic characteristics.

 Results: At baseline, the average total score on the combined CBCL was 60.4 (range 25-86). Over the 18-month study period, 73% of youth reported mental health service utilization, 29% reported an ED visit, 5% reported alcohol or drug outpatient service utilization and 30% reported using other services associated with a crisis episode. Mixed-effects regression models showed that over time higher CBCL scores were associated with significantly higher mental health service utilization and alcohol or drug outpatient service utilization. However, over time higher CBCL scores were associated with fewer ED visits and lower rates of other services associated with a crisis episode.

 Conclusions and implications: Findings suggest that the relationship between mental health needs and service receipt may be time-sensitive and may differ by service type. Specifically, for study foster youth with strong mental health needs, use of ED services and services for specific crisis episodes tended to occur quickly then taper off, while there was more consistent use of outpatient mental health and AOD services. Future research should examine how caseworkers and mental health professionals adjust treatment programming in response to foster youths’ service needs, and if distinct constellations of multi-service use can be identified in relation to youth mental health needs.