Mental Health Services Use By Kinship Children: An Application of Andersen's Model of Health Care Utilization

Background: More than 30% of children in out-of-home care are placed in kinship care (U.S. Department of Health and Human Services, 2019). Although the majority of prior studies suggest that kinship children fare better in mental health (MH) than non-kin foster children, much less is known about MH needs and use of MH services among children in kinship care. Guided by Andersen’s model of health care utilization (Andersen & Davidson, 2001), this study aims to examine (1) MH services use rates and (2) factors associated with use of outpatient, school-based, medical-based MH services among kinship children.

Methods: This study selected kinship children (N = 566) who aged between two and 18 years old from wave II data of the second National Survey of Child and Adolescent Well-being study. Informed by Andersen’s model, we selected predisposing factors that are related to use of MH services, such as the child’s age, gender, race/ethnicity, maltreatment types, dysfunctional household indicators, caregiver’s age, gender, education, and family poverty status. We also included enabling factors such as child’s health insurance, and need factors such as child internalizing and externalizing problems, and physical health conditions. The use of MH services was measured by asking whether children had received various types of MH services in the past year. We grouped MH services into three classes: Outpatient, school-based, and medical-based MH services (Horwitz et al., 2012). Descriptive analyses, binomial logistic regression, and multinomial logistic regression models were conducted using Stata 15.0.

Results: Despite 24% of kinship children had clinically significant internalizing and externalizing problems, 18% used outpatient, 18% used school-based, and 6% used medical-based MH services. Logistic regression indicated that the child’s older age (Odds Ratio (OR) = 1.11), more externalizing problems (OR = 1.05), and caregiver’s higher educational levels (OR = 3.94) were significantly associated with the use of outpatient MH services, while being female (OR= 0.22) was less likely to use it. Regarding the use of school-based and medical-based MH services, a child’s older age and female gender both were significant predictors. With regards to the relative likelihood of the use of different facilities, multinomial regression indicated that children who experienced any abuse (Relative Risk Ratio (RRR) = 0.026) and any neglect (RRR = 0.013) and who were at an older age (RRR = 0.74) predicted a lower likelihood of outpatient MH services use than school-based MH services use. However, children with more internalizing problems (RRR = 1.16) were more likely to use outpatient or medical-based than school-based MH services, and who lived with a caregiver with a higher educational level (RRR = 7.91) were more likely to use outpatient than school-based MH services.

Conclusions: Kinship children underuse MH services, and children who had more severe MH symptoms are more likely to use outpatient and medical-based than school-based MH services. Children’s clinical and non-clinical characteristics influence the use of MH services. These findings suggest that more accessible MH services at various facilities should be available to kinship children.