Assessing the Impacts of the Covid-19 Pandemic on Foster Youth Mental Health Services Utilization

Background and Purpose: Unmet mental health needs are prevalent among children in the United States, and the societal changes occurring during the COVID-19 pandemic have likely exacerbated existing barriers to service access. These issues are particularly pronounced for youth in foster care, whose access is dependent upon systems of professional decision-making. However, little is known about the changes in utilization that such youth have experienced during this time. This study used Medicaid claims data to examine (1) how the COVID-19 pandemic and the resulting public health response in March 2020 impacted rates and trends of child mental health utilization and (2) how the unique experiences of youth in foster care produced differential patterns in access to community-based treatment, residential placement, and psychotropic medication prescriptions.

Methods: This study used Medicaid claims data from a Southeastern state to identify population-level estimates of child mental health service utilization rates between 2018 and 2022. Descriptive analyses of the state’s publicly-insured child population (n = 1,717,640) were conducted to examine trends. Further, using propensity score matching, a subsample of youth continuously in foster care in the year before and after COVID-era lockdowns (n=3397) was compared to a matched subsample of non-foster care youth with similar needs and contexts (n=3397). Comparative interrupted time series models were estimated to determine whether pre-COVID trends, post-COVID trends, and rates of each type of service use at the time of lockdown changed for the foster care group above and beyond their publicly-insured counterparts.

Results: Descriptive rates of service use were considerably higher for foster youth compared to their publicly-insured peers. Each year, foster youth were nearly seven times more likely to use community-based services (48 vs. 7 percent), two-and-a-half times more likely to be prescribed psychotropic medications (34 vs. 13 percent), and forty-six times more likely to be placed in a residential facility (2.8 vs. 0.06 percent). However, both groups experienced stagnation in rates of all types of service use after the emergence of COVID-19. Comparative interrupted time series models indicated significant but temporary decreases in community-based service use for each group, although greater gains in telehealth service use led to a more rapid return to pre-COVID use rates for youth in foster care by the end of lockdown. Psychotropic medication prescriptions decreased temporarily and remained at pre-COVID rates thereafter, and residential facility placement remained stable throughout the study period.

Conclusions and Implications: These results suggest that, while the foster care system appears to have served as a gateway to greater and more stable mental health service use rates for children in custody, all children within the state have experienced a flattening of use rate trends after the emergence of COVID-19. This trend is particularly concerning given widespread accounts of surging mental health need among overall child and foster care populations. Accordingly, researchers and policymakers should investigate strategies to enhance the detection of child mental health need, improve referral procedures to facilitate access, and expand the system’s capacity of high-quality providers and placements.