What Are We Treating? the Complexity of Addressing Trauma in Mental Health Treatment for Youth in Foster Care

Background

Youth in the US foster care system are prescribed psychotropic medications at alarmingly high rates, higher than other children insured by Medicaid than same-age counterparts in the general population. At the same time, research has documented the extent of trauma present in this population, associated with histories of abuse and neglect as well as the disruption and upheaval that frequently accompanies involvement in the child welfare system. Addressing the effects of trauma in children has become a central imperative for mental health practitioners. However, for youth in foster care, who frequently straddle both mental health and child welfare systems, securing safe, appropriate, and trauma-informed therapeutic approaches is elusive. Locating and accessing resources that address trauma in the context of a fragmented and bureaucratic child welfare system is often extremely difficult. This project explores stakeholder perspectives about mental health treatment for youth in foster care and the extent to which trauma is acknowledged and understood in the context of psychotropic medication prescriptions and treatment planning.  

 Methods:

Qualitative data were collected from four stakeholder groups involved in the child welfare system with lived experience in prescribing, being prescribed, or overseeing prescriptions for psychotropic medication. Semi-structured interviews and Deliberative Discussion focus groups were conducted with: clinicians (n= 32), foster caregivers (n = 20), child welfare caseworkers (n = 24) and foster youth alumni (n= 10 focus groups). Participants were recruited from four states through snowball sampling methods through state agencies and advocacy organizations. Data analysis included descriptive and bivariate summaries of stakeholders’ demographic and background information. Four trained qualitative analysts conducted the analysis using Dedoose software. Emergent and a priori coding structure was employed.

 Results & Implications:

Related to addressing trauma in this population, multiple themes emerged across stakeholder groups. All stakeholders acknowledged both the trauma inherent to maltreatment victimization, as well as the trauma associated with removal from biological caregivers and placement in foster care. All stakeholder groups also believed that better mental health training and education should be available for everyone on a child’s team. Participants noted the need for improved psychosocial resources for foster youth, specifically resources designed for addressing the trauma unique to child welfare system involvement. There was a sense that foster youth need an additional adult to help them navigate treatment planning, resources and to provide emotional support, but there was not a consensus on who could most appropriately play that role. Views differed considerably about the role of psychotropic medication for youth in foster care. Some participants asserted that medication may be beneficial, but perceptions of treatment intentions varied. While some stakeholders believed it was appropriate to treat trauma or “normal child behaviors,” with psychotropic medication, others thought medication should only be used for valid mental health challenges.

 Results convey the high level of need for improved access to high-quality trauma-informed mental health services for youth in foster care, and the importance of treatment decision-making that takes into account  the wide variation in needs, circumstances, and support systems available to these vulnerable children and youth.