Mental Health Care for Children and Youth in Foster Care

Mental Health Care for Children and Youth in Foster Care

Karen Pridgen


Each year, approximately 250,000 children in the U.S. enter foster care, and these children disproportionately come from low-income families, are ethnic and racial minorities, and have higher rates of physical, psychological, and social problems. Up to 80% of foster children require intervention for serious behavioral or mental health problems. This article explores the current state of mental health care for children in foster care as well as major trends in providing mental health services. It also examines the effects of these trends on key stakeholders.

In 2010, there were 408,425 children and youth in foster care in the United States (Greeson et al., 2011). Each year, approximately 250,000 children enter foster care and these children disproportionately come from low-income families, are ethnic and racial minorities, and have higher rates of physical, psychological, and social problems (Zlotnick, Tam, & Soman, 2012). Prior to entering care, most foster children, close to 90%, have experienced one or more trauma exposures including physical or sexual abuse, neglect, exposure to domestic violence, community violence, or the violent death of a loved one (Dorsey et al., 2012). According to Overstreet and Mathews (2011), “Chronic trauma exposure during childhood significantly increases the risk for a variety of short- and long-term negative developmental outcomes” (p. 740).

Pecora et al. (2009) found that up to 80% of the children in foster care require intervention for serious behavioral or mental health problems. They also found that about three out of five children in foster care had a lifetime mental health diagnosis and close to one in five children had three or more lifetime diagnoses. In one study of the prevalence of lifetime mental health disorders among children in foster care, oppositional defiant disorder was diagnosed in 29.3% of the children, conduct disorder was found in 20.7%, major depressive disorder was found in 19.0%, major depressive episode in 19.0%, panic attacks in 18.9%, and attention deficit hyperactivity disorder in 15.1% (Pecora et al., 2009). Research has found that adults with histories of being in foster care as children had a much higher prevalence of chronic health problems, acute health problems, mental health problems, receiving SSDI benefits, missing up to a year of work, and a lower socioeconomic status (Zlotnick et al., 2012). Zlotnick et al. (2012) explains that the lack of critical physical, mental health and social services during and after foster care may influence adulthood outcomes for graduates of foster care.

Dorsey et al., (2012) concluded that routine trauma exposure screenings should be utilized for all children entering foster care, treatment should include trauma-focused, evidence-based treatment such as Cognitive Behavioral Therapy, and information sharing needs to be increased among care-givers, child welfare workers, and all professionals providing care to foster children. Improved quality, cost, and accessibility of mental health treatment is not only imperative to the welfare of these children, but it is also in the best interest of communities to improve the lifelong physical, mental, and emotional outcomes for foster children.

Current State

Pecora et al., (2012) found from the National Study of Child and Adolescent Well-Being that, even though utilization of mental health services is higher among foster children than is typical in the communities studied, three out of four children involved in an investigation by child welfare systems due to child abuse or neglect had not received any mental health care within twelve months after the investigation. They also found both clinical factors and nonclinical factors, such as the type of maltreatment, racial and ethnic backgrounds, age, and type of placement, affected mental health referrals and utilization. Children and youth in foster care are generally covered by state government insurance plans, such as Medicaid. Zlotnick et al. (2012) found that a 2005 US Department of Health and Human Services review indicated that 71% of states lacked adequate mental health services for children and 69% of state agencies were not consistent in ensuring mental health assessments. In their review of the 50 states’ mental health plans, Gould, Beals-Erickson, and Roberts (2012), found that 90% of state plans reported service barriers and 84% discussed service gaps. They found that a lack of providers was the most common service gap at 74% and a lack of funding was the most common service barrier at 52%. A summary of their review findings of the most common and widespread gaps and barriers that states report is below (p. 771).

Service gapFrequencyPercent
Any type of gap4284
Lack of service providers3774
Specialty population services2550
Transition services from child to adult services2040
Inpatient services1224
Crisis services1122
Community services1122
Services in the juvenile justice system1122
Early intervention918
Residential services714
School services612
Substance abuse services510
Prevention and screening services510
Transition services between inpatient and community services510
Other gaps1428
Any barrier4590
Lack of funding2652
Uncoordinated system of care2346
Strict eligibility criteria1326
Lack of provider cultural competence1326
Uninsured status918
Lack of information regarding available services816
Lack of insurance coverage for mental health services816
Cost of services714
Poor reimbursement612
Funding streams612
Symptoms going unidentified510
Other barriers2244


One trend occurring in mental health treatment is an increase in the number of community health centers that provide mental health treatment (Druss et al., 2008). Between 1998 and 2003, a study found that the number of community health centers increased by 22% and the number of those centers providing mental health or substance abuse treatment increased from 60.4% to 73.5% (Druss et al., 2008). Although there was an increase in the number of centers providing services, there was not a significant increase in the number of behavioral health full-time employees employed at each center. However, the study also found the number of patients diagnosed with a mental health or substance abuse disorder almost tripled, and the number of people treated for these disorders at community health centers more than tripled (Druss et al., 2008). This increase in patients led to an increase in the number of patients per clinician, from 178 to 499. Because of the increase in patient case load, the frequency of mental health treatment declined from 6.0 visits a year to only 3.0 visits per year (Druss et al., 2008). This study suggests that more primary care physicians are providing mental health and substance abuse treatment instead of mental health and substance abuse clinicians. It also suggests that the demand for treatment may be out-pacing the capacity of community health centers (Druss et al., 2008). Initiatives such as HRSA/BPHC Mental Health and Substance Abuse Service Expansion Grants and the Depression Health Disparities Collaborative are working to fund the expansion of mental health and substance abuse treatment in community health centers and to increase the skills of primary care physicians in recognizing and treating mental illness. Also, community health centers are working toward developing and strengthening partnerships with other mental health providers in the community, with hopes to ensure access to high quality care across the population spectrum (Druss et al., 2008).

Another trend occurring is the increase in schools providing mental health services. Overstreet and Mathews (2011) explain, “The President’s New Freedom Commission on Mental Health (2003) recommended that the utilization of mental health services be enhanced through delivery in schools, where they would be widely accessible and more likely to be accepted” (p. 743). One study shows that 96% of students referred for school-based counseling actually received those services compared to only 13% of students who were referred for community-based treatment (Overstreet & Matthews, 2011). In many underserved communities, schools are establishing comprehensive school-based health centers that include mental health services (Gampetro, Wojciechowski, & Amer, 2012). The National Census by the National Assembly on School-Based Health Care conducted a survey of 1,909 school-based health clinics, with 1,226 responding, for the 2007-2008 school year. The findings illustrated the following:

  • 82% of the schools had a school-employed mental health provider
  • School-based health clinics improved the children’s and adolescents’ access to care
  • Students were 10 to 21 times more likely to receive mental health services at the school-based clinic than at an off-site clinic
  • Depressed and suicide-prone students were more willing to go to counseling at the school-based clinic
  • Students who received mental health services had an 85% decline in school discipline problems (Gampetro et al., 2012).

Overstreet and Mathews (2011) explain, “Experts argue that a public health model of school-based mental health services can reduce fragmentation in services and create a truly integrated comprehensive system of care” (p. 744). For children with trauma exposure, as many foster children have, it is imperative to have a continuum of mental health services that includes mental health promotion, treatment, universal health promotion, risk prevention programs aimed at preventing youth violence, and teaching coping skills for stressful and traumatic exposure (Overstreet & Mathews, 2011). A survey of student satisfaction of school-based mental health services found that students saw the services as reliable, supportive, and confidential, which all seemed to be imperative to students accessing the services, and overall the students held a high level of satisfaction with the services (Gampetro et al., 2012). However, even with the benefits of school-based mental health services being evident, schools have been slow to implement services because it seems that they do not have the will or the means to implement a public health service delivery model (Overstreet & Mathews, 2011). Overstreet and Mathews (2011) expound, “Of course, long-term access to necessary resources is also critical for the maintenance of school-based mental health services, either through commitment of funds from local community stakeholders or through participation in federal grant initiatives” (p.748).

One negative trend is an increase in the number of children and adolescents being sent to local emergency rooms for mental health concerns (Shaw & Donise, 2010). Studies have shown that schools have become one of the main referral sources for sending children to the emergency room for nonemergency mental health services, even though many of these students had been seen and previously evaluated by a school counselor (Shaw & Donise, 2010). Some contributing factors to this phenomenon are: 1) the difficulty schools have in assessing the students’ psychiatric care needs, 2) difficulty in arranging out-patient services, 3) zero-tolerance policies that schools have developed for violence or poor behavior, and 4) students presenting with more psychological needs during school hours, partially believed to be caused by the stress of school (Shaw & Donise, 2010). A study of the referral patterns to the Psychiatric Emergency Service center in Rhode Island during May 2009 presented the following results:

  • 170 children and adolescents were evaluated and 44, a little over 25%, of those were referrals made by the school
  • Of those 44 school-referrals, 13 students, only 30%, were admitted for inpatient care, with the others being discharged for outpatient follow-up
  • 15 of the referrals were for aggression which resulted in 7 students being admitted for inpatient care
  • 13 of the referrals were for suicidal ideation which resulted in 6 students being admitted for inpatient care
  • 10 of the referrals were for cutting or other self-harm behaviors which resulted in no inpatient care admissions
  • 6 of the referrals were for other behaviors, such as carrying a knife to school, which resulted in no inpatient care admissions (Shaw & Donise, 2010).

In Rhode Island, the estimated cost for a psychiatric evaluation in an emergency department is over $2000, whereas the cost of an outpatient evaluation is under $300 (Shaw & Donise, 2010).

Emergency departments, schools, and communities are attempting to find and implement plausible alternatives, which include more school-based mental health programs; however Shaw and Donise (2010) explain, “The majority of school districts reported that despite an increasing need for mental health services, funding had not kept up with demand” (p.6).

One final trend is a shift from traditional psychotherapy to more evidence based practices, which “have clear goals and objectives, manuals or specific treatment guidelines, and explicit assessments that have been scientifically tested” (Love, Koob, & Hill, 2008, p.38). Gampetro et al., (2012) explains, “Interventions with the best evidence for support included cognitive behavior therapy, cognitive behavior therapy and medication, assertive training, family therapy, group therapy, and social skills training” (p.24). Research has shown that cognitive behavior therapy interventions are the most effective for youth experiencing emotional distress caused by trauma exposure, because they “reduced psychological harm (including PTSD symptoms, anxiety, depression, and externalizing problems) associated with trauma exposure” (Overstreet & Mathews, 2011, p.746). Barriers to implementation of evidence based practices are the need for the development of more culturally appropriate and sensitive services while maintaining the fidelity of the practices, more culturally trained clinicians and school psychologists, and more specific training for clinicians on trauma-focused interventions (Overstreet & Mathews, 2011).

Effects of Trends on Key Stakeholders

Druss et al., (2008) explains, “As of 2003, community health centers provided health care to more than 12 million individuals, a majority of whom were uninsured or on Medicaid” (p. 126). Increasing the number of community health centers that provide mental health services greatly benefits the consumers or patients by increasing the accessibility of services. However, due to the volume of people that are seen at community health centers, the treatment does not always provide the intensity of care that is needed. The effect this trend has had on providers is profound. The number of patients per mental health and substance abuse clinician rose from 178 in 1998 to 499 in 2003 (Druss et al., 2008). The increase in the number of patients being seen daily has created a large burden for services on clinicians. The increase in volume of patients is creating an environment where patients are not able to get the level of intense treatment they may need. The annual number of visits per mental health patient declined from 6.0 visits per patient in 1998 to only 3.0 visits in 2003 (Druss et al., 2008). Because community health centers are funded through taxpayer dollars, increasing the number of centers and increasing the available services effects the communities they are in by using tax revenue. However, because a large portion of the population that receives care at these centers is uninsured or on state funded insurance, the cost of these out-patient services is much less than a visit to the local emergency room would be, so it actually provides a savings in some instances. This trend affects third party payers by providing a low cost option for mental health services. But because the treatment is provided at such a low intensity, the patients might not be receiving the appropriate level of care and this could lengthen the amount of time that patients must utilize the services. This could impact the overall health and well-being of the patients, and could ultimately eliminate any upfront savings that were achieved.

The trend of schools providing mental health services has had beneficial effects on patients and students. “One of the most commonly cited barriers to mental health care among youth is access,” explains Overstreet and Mathews (2011, p. 743). One study shows that the accessibility of mental health services, combined with the availability of healthcare, has led to an 85% decline in school discipline problems (Gampetro et al., 2012). The effect this trend has had on providers is an increased responsibility to become culturally competent so that their interventions are useful and beneficial (Overstreet & Mathews, 2011). This has also required school mental health providers to become better informed and trained in the core components of trauma-focused, evidence based practices and cognitive behavior therapies (Overstreet & Mathews, 2011). The effect this trend has had on communities is an increase in the number of children and youth who are able to receive mental health services, which improves individual outcomes, family outcomes, and community outcomes. Although the funding of school-based programs can be difficult, it can be accomplished through partnerships with local universities and with regional and national organizations, commitment of funds from community stakeholders, and through federal grant initiatives (Overstreet & Mathews, 2011). Third party payers are affected by this trend because the needed services are becoming more readily available, but at a lower cost, and sometimes not paid for by insurance at all. The benefits of youth receiving services, especially foster children and youth, who have been exposed to trauma, even if the insurer does have to pay, far exceed the potential costs of them not receiving timely and effective treatment. Gampetro et al., (2012) explain, “If left untreated, childhood mental disorders may continue into adulthood” (p. 24). This can lead not only to potential increased costs of more intense mental health treatment at a more expensive, out-patient facility, but also can contribute to many other decreased health outcomes which can prove to be quite costly. Many individuals with mental health disorders also experience other medical conditions such as heart disease, high blood pressure, diabetes, or cancer (Pecora et al., 2009).

The effects on key stakeholders from increased use of emergency rooms for non-emergency psychological care are astounding. In a study in Rhode Island, the cost of an emergency room psychological evaluation was more than $2000 compared to less than $300 for an outpatient evaluation (Shah & Donise, 2010). This trend is not beneficial to any of the main stakeholders. The patient is not able to get the needed treatment for any continued amount of time, although he or she can be referred to an out-patient provider for continued services. The providers have to pay an extremely high opportunity cost by tending to patients without a true emergency instead of assisting those patients with true emergencies. The community and tax payers will often be subjected to higher healthcare costs due to the hospital having to recoup unpaid claims. Third party payers are subjected to extremely high costs for services that could have been received at a greatly reduced amount if provided by an outpatient clinician.

The shift of focus from traditional psychotherapy to more evidence based practices has been extremely beneficial to patients. Pecora et al. (2009) asserts, “Given this need and the shared interest of policymakers and advocacy groups to improve existing child welfare practices, guidelines on best practices for overall mental health approaches within child welfare are necessary” (p. 8). According to one study, adults who at some point were in foster care are two to seven times more likely to have PTSD, anxiety disorders, depression, and drug dependence than adults who were not in foster care (Pecora et al., 2009). Another study showed that traditional psychotherapy received for six months by foster children at the time of entry into foster care did not have any better overall outcome in depression, self-esteem, and behavior problems when compared to just standard care (Love et al., 2008). This makes evidence based practices an imperative when working with children and youth, especially those in foster care. The effect this trend has had on providers has been an increase in the demand for them to improve their skills, be culturally competent, and be trained in new areas of cognitive behavior therapies (Overstreet & Mathews, 2011). The effects on the community has been that better outcomes have been achieved, which often thwarts other issues such as more health concerns, lower performance in school, violence and other criminal behavior, and worsening psychological disorders. The effect for third party payers has been better outcomes for the money that was spent for services. Evidence based interventions often improve the long-term psychological outcomes for children, which can improve their overall health and provide a decrease in the amount of money that has to be spent over the lifetime of treating psychological disorders.


With approximately 250,000 children entering foster care annually, it is imperative that their mental health needs become a center of focus (Zlotnick, 2012). Many of these children have experienced trauma-exposure and even multiple trauma-exposures (Dorsey et al., 2012). The long lasting effects of these exposures are numerous, costly, and detrimental. In order to start achieving more positive psychological outcomes, more trauma-exposure screenings need to take place upon entry into foster care, more evidence-based interventions need to be available and practiced, and information among care-givers, schools, child welfare workers, and psychological clinicians needs to improve (Dorsey et al., 2012). Although treatment can be costly at many levels, the life-long implications of not improving the outcomes for these children far outweigh any costs incurred for treatment. Foster children and youth receiving no treatment, less intense treatment, or inappropriate mental health treatment can have multiple, long lasting, costly, and negative effects as they progress into adulthood. These negative effects can include putting a strain on families and communities, creating the possibility for the need of more costly and longer lasting mental health treatment, increasing the probability of needing more physical health treatment, and increasing the likelihood that these children will not be able to become fully functioning and contributing members of society. In order to address the mental health needs of foster children and youth and to begin to see true benefits of addressing these needs, accessibility to appropriate evidence-based practices must improve, providers must become more highly trained and better equipped to address the multiple emotional and psychological needs of this population, third-party payers must address their payment systems in order to attract more providers, and communities must increase their support and funding for nontraditional services.


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Karen PridgenKaren Pridgen is a senior graduating in the Spring of 2014 with a Bachelor’s of Science in Business Management and a minor in Healthcare Management. She has owned and operated her own business, 4theKids Support Services, since July 2011, which provides in home mental health counseling to children. Karen and her husband have been involved with the foster care system since 2010 when they first became foster parents. Currently they have four girls living at home, two adopted and two foster children. Karen plans to continue her work with children and to ultimately pursue a Master’s degree to assist with her endeavors to positively influence the foster care system as well as the many children that are in foster care.