Predisposing, Enabling, and Need Factors Associated with Using Mental Health Services and Psychotropic Medications Among Children in out-of-Home Care: A Scoping Review

Background and Purpose:

Children in out-of-home care (OOHC) may have severe mental health problems due to child maltreatment and other adverse childhood experiences (Engler et al., 2022). Furthermore, it is noted that children in OOHC can have limited access to appropriate mental health services and may overly rely on psychotropic medication (Larsen et al., 2018; Narendorf et al., 2011). To systematically unpack this issue, this scoping review is guided by Andersen’s Behavioral Model of Health Services Use (Andersen & Newman, 1997) to identify predisposing, enabling, and need factors associated with the use of mental health services and psychotropic medications among children in OOHC.

Method:

This review followed the scoping review methodology framework as outlined by Arksey and O’Malley (2005). The literature search was conducted using two key concepts “mental health service utilization” and “OOHC” in PsycInfo, SocIndex, Medline, and Scopus in November 2021. Inclusion criteria were articles published in peer-reviewed journals since 2000 and those that quantitatively examined factors associated with using mental health services and psychotropic medications among children in OOHC in the United States. Database searches yielded 13,440 articles. Facilitated through COVIDENCE, the research team screened study titles, abstracts, and full-text articles independently and conflicts were resolved by the first author with input from other research team members. The final synthesis included 22 studies that addressed mental health service utilization and psychotropic medication use among youth in OOHC.

Results:

Among the included studies, seven examined predictors associated with taking psychotropic medications, while 16 examined factors associated with the use of mental health services. Of note, one study examined both outcomes in the same article.

Regarding the use of psychotropic medications, we identified significant predisposing factors, including child race/ethnicity (mixed findings), child age (older +), and child gender (male+). Enabling factors included different types of OOHC (e.g., group home, therapeutic foster care, congregate care, non-relative foster homes), length in care, and perception of medication use. Need factors were internalizing and externalizing behaviors, mood disorders, ADHD, and disruptive behavior disorders.

Regarding their use of mental health services, an array of services were highlighted including outpatient mental health services, in-home counseling/crisis services, residential mental health services, inpatient psychiatry, and outpatient therapy. Significant predisposing (e.g., child age, race, gender, emotional abuse, neglect, physical abuse, sexual abuse, history of juvenile detention), enabling (e.g., placement instability, caretaker absence, foster parent education, time in care, receiving recommended new services, having close contact with a court social worker), and need factors (e.g., emotional and behavioral problems, PTSD, anxiety, psychological well-being, ADD, conduct disorder, chronicity and comorbidity of mental health problems) were identified.

Conclusions and Implications:

Results provide insight into factors associated with using mental health services and taking psychotropic medications among children in OHHC. The identified need factors can be informative to the child welfare agencies and stakeholders on ways to improve access to mental health services and decrease the overuse of psychotropic medications among youth in OOHC. Additional research is needed on the quality of mental health services s received by children in OOHC.