Youth in Foster Care

Heather Taussig

Scott B. Harpin

William R. Betts

Lora Melnicoe

Gretchen J. Russo

Adolescents in foster care, the vast majority of whom have been abused and/or neglected, are at increased risk for physical and mental health problems throughout the developmental spectrum as evidenced by their involvement in multiple service systems, including juvenile justice, mental health, and special education. For young adults who have emancipated from foster care, the transition to independence may be especially challenging, as these young adults demonstrate high rates of substance use, early and multiple pregnancies, significant physical and mental health problems, criminal justice involvement, victimization, economic hardship, and homelessness. The consequences of maltreatment, early life instability, and trauma are far-reaching, leading to a cycle of both maltreatment and placement in foster care. Despite the many obstacles facing young people in foster care, there are opportunities to promote resilience through positive youth development.

EPIDEMIOLOGY

General Foster Care Statistics

Each year, approximately 6 million youth are referred to social services for maltreatment, and three-quarters of a million have documented (e.g., substantiated report) evidence of abuse. This represents almost 1% of the population of youth aged 0 to 18.¹
Several hundreds of thousands of youth are in foster care each year; of those, 47% are in nonrelative foster homes, 28% are in kinship/relative care, 15% are in residential (congregate) care, and 10% are in other living arrangements.¹
Over a third of those in foster care are 12 years or older.¹
There is a fairly equal gender distribution among youth in foster care, but African American and multiracial youth are overrepresented relative to the population in the US.¹
Neglect is the most common type of maltreatment precipitating foster care placement, followed by physical abuse and sexual abuse. Many youth have experienced multiple forms of maltreatment, including emotional abuse.²

Health and Associated Problems

Eye and dental problems are overrepresented among adolescents in foster care according to Medicaid claims.³
The most frequent diagnoses for adolescents in foster care are attention deficit and conduct disorder. In addition, mood, anxiety, and adjustment disorders are two to three times higher than among nonfoster youth who receive Medicaid.³
Outpatient and inpatient mental health service utilization is higher among adolescents in foster care, and they are more likely to be prescribed psychotropic drugs.³
Approximately 20% to 40% of youth in foster care are in special education classes.⁴
Despite high rates of service use, many youth in foster care do not receive needed physical health, mental health, or educational services.⁵

Emancipating Youth

Approximately 23,000 adolescents “age out” of foster care each year.¹
These young adults are at high risk for unemployment, receipt of public assistance, incarceration, substance dependence, early childbearing, and significant mental health problems.⁶
While some states allow young people to remain in foster care until age 21, many emancipating youth do not take advantage of this opportunity.
Beginning in 2014, the Affordable Care Act (ACA) requires all states to provide Medicaid coverage for youth who emancipate from foster care at age 18 or older. This coverage lasts until the age of 26, but experts have concerns about these young adults navigating the enrollment procedures (http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2014/04/30/states-enroll-former-foster-youth-in-medicaid).⁷
Although many “independent living” programs exist to help with the transition to young adulthood for emancipating youth, none have demonstrated efficacy through rigorous research.⁸

ASSESSMENT AND TREATMENT

Current guidelines⁹,¹⁰ suggest that the general physical examination and primary prevention efforts for adolescents entering foster care have the same components as a thorough well-adolescent examination.

Initial Assessment

An initial assessment should be conducted immediately after entry into foster care to screen for evidence of abuse or neglect, contagious diseases, chronic illnesses, substance use, and mental health issues, including suicidality, all of which may require immediate treatment. The health care provider should be especially cognizant of evidence of recent or past injuries, dental caries and pain, hygiene and nutritional problems, untreated congenital and
chronic conditions, missing immunizations, and developmental delays.

Comprehensive Assessment

A comprehensive assessment is recommended within 30 days of placement, which must include obtaining a complete health history and evaluation of the youth’s adjustment to care. Standardized screening tools for mental health and behavioral concerns, substance use, and psychological trauma should be administered. A confidential questionnaire which includes sexual history, risks for sexually transmitted infections (STIs), and need for contraception is essential.

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