System Decisions and Dynamics Contributing to Mental Health Services Access for Youth in Foster Care

Background and Purpose: Rates of child mental health need have steadily increased in the past decade, and the COVID-19 pandemic has contributed to an even greater surge in the prevalence of child depressive and anxiety symptoms, behavioral health challenges, eating disorders, and suicidality. Youth in foster care have likely been more vulnerable to these shifts due to prior elevated levels of risk and the isolation that characterizes stays in non-family settings during pandemic conditions. Indeed, a host of complex and interrelated factors arising during this period have impacted processes of assessment, referral, and service provision for foster youth in unprecedented ways. These changes have produced a shortage in the supply of available community-based providers, a lack of available beds in emergency and mental health settings, and staggering delays in the provision of supportive services. Such problems are likely to be dynamic and multifaceted, and change efforts that do not factor in such complexity are likely to have minimal or unintended effects. Accordingly, this study employed community-based system dynamics methods to understand (1) the most salient service access problems experienced in a Southeastern state’s child welfare and mental health systems and (2) the interrelated factors, dynamics, and decision points that shape these issues for youth in the state’s foster care system.

Methods: A group model-building session and two semi-structured follow-up interviews were conducted to solicit administrators’, practitioners’, advocates’, and affected populations’ perspectives on system behaviors and structures. All group discussion and interview content was recorded, transcribed, and double-coded to synthesize participants’ descriptions of mental health service access dynamics. These findings were then summarized thematically and documented in a series of causal loop diagrams that depicted the links and feedback structures that shape service access problems.

Results: Participants readily identified the limited supply of placements and diminished workforce capacity as key contributors to delayed service access. However, group model-building activities prompted system actors to uncover complex feedback structures that considerably increased demand for intensive services for youth with significant behavioral challenges. Notably, families were described as experiencing a “double access problem” in which (1) difficulty navigating preventive service arrays denied children access to supports that could maintain them in family settings and (2) limited residential bed capacity denied them access to more intensive supports when their challenges worsened in severity over time. Further, emergency solutions in which children were placed in inappropriate settings to prevent delays were described as only contributing to further placement disruptions and crises.

Conclusions and Implications: The results of this study suggest that complex features of child welfare and mental health systems contribute to increased need, limited treatment capacity, delayed service access, and unnecessary disruption. While efforts to build the systems’ capacity to serve high-needs children are worthwhile, these strategies may fail to address the demand-related influences of poor preventive services access. Accordingly, practitioners, policymakers, and researchers should explore multipronged approaches that improve assessment, referral, and navigation issues that undermine systems’ abilities to support children proactively before symptoms worsen and family separation becomes necessary.