Relationship between placement change during foster care and utilization of emergency mental health services

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Abstract

The present study aimed to confirm a relationship between placement change during a foster care episode and use of emergency mental health care, specifically crisis services and psychiatric hospitalization. Additionally, the study sought to differentiate between placement change's impact on emergency mental health care and emergency mental health care's impact on placement change. We examined placement change during the first 90 days in foster care among 19,351 Californian children and youth who started a new foster care episode between October 1998 and March 2001. Sample selection procedures differentiated between use of crisis and inpatient services prior to and following a placement change. Multivariate analysis revealed that while placement change is a significant predictor of subsequent psychiatric hospitalization, use of crisis services and psychiatric hospitalization are predictors of subsequent placement change. This bidirectional relationship suggests that children in foster care could benefit from both interventions that promote placement stability and improved mental health treatment following psychiatric crises.

Highlights

► Placement change is related to use of emergency mental health services. ► The relationship is bidirectional. ► Interventions should target both mental health needs and placement instability.

Introduction

The U.S. foster care system is plagued by a high rate of mental health problems among foster children and by placement instability during foster care. Approximately 40–80% of children in the child welfare system suffer from psychiatric disorders (Burns et al., 2004, Clausen et al., 1998, Garland et al., 2001). The rate of placement instability varies by states and by counties, but in too many instances placement instability rates are quite high (Connell et al., 2006, James, Landsverk, Slymen and Leslie, 2004). One national study of 725 children in foster care found that 18% of the children had four or more placement changes within 3 years (Barth et al., 2007).

Mental health problems and placement instability are linked: children in foster care who have experienced placement instability are more likely than other children in foster care to show symptoms of mental health disorders (Aarons et al., 2010, Barber and Delfabbro, 2003, Newton et al., 2000, Rubin et al., 2004) and to receive outpatient mental health treatment (James, Landsverk and Slymen, 2004, James, Landsverk, Slymen and Leslie, 2004). Not only is placement change associated with mental health problems, it is also a disruptive experience — when children change placements they must break ties with former caregivers, move to a new environment, and establish an attachment to their new families. Thus, one would expect that children who experience frequent placement change would be more likely to utilize emergency mental health care than other foster children. To date, little is known about the relationship between placement instability and use of emergency mental health services.

The purpose of this study is to examine this relationship. It is important to determine if placement instability is related to use of emergency psychiatric care, which will be defined in this paper as use of crisis services and inpatient hospitalization, because they are both negative outcomes. Frequent placement changes prevent children in foster care from forming lasting attachments with families. Meanwhile, crisis and inpatient services are among the most expensive treatments in the mental health continuum of care. Although they may be necessary for children who are a danger to themselves or others, they are not an optimal form of mental health care: because they are brief services designed to stabilize crises rather than to treat ongoing, serious mental health problems (American Academy of Pediatrics, Committee of Pediatric Emergency Medicine, 2006). If placement instability and use of emergency mental health services are linked, service providers can be alerted to this relationship and help children in foster care who have significant mental health problems avoid both of these outcomes.

Section snippets

Literature review

While the connection between placement instability and emergency mental health care utilization has not been extensively studied, there is some evidence to suggest that children in foster care who change placements frequently may be more likely to use crisis and psychiatric inpatient services. For example, one study of 1635 children in foster care in Philadelphia found that children who changed placements frequently had greater odds of using costly mental health services (Rubin et al., 2004).

Data

The data consisted of Medi-Cal paid claims and foster care placement records. The Medi-Cal claims were for mental health services delivered to youth under age 18 between July 1, 1998 and June 30, 2001, and they were provided by the California Department of Mental Health. These data files included variables measuring client age, gender, ethnicity, diagnosis, Medi-Cal eligibility code and a unique client identifier. In addition to client characteristics, the data files reported on type of

Sample description

Descriptive information regarding the entire sample, crisis service users, and children who were hospitalized is shown in Table 1. The racial and ethnic demographics of the sample were as follows: Hispanic (38%), White (34%), Black (23%), Asian (3%), and Other (2%). There were slightly more females (54%) than males (46%), and the mean age was approximately 11-years-old at the start of the episode.

Children who used crisis and inpatient psychiatric services were more likely to be White and less

Discussion

Children who use crisis services and psychiatric hospitalization during their first 3 months in foster care are a unique group. They tend to enter foster care at older ages and are more likely than other youth to have received mental health treatment prior to their foster care episode. This finding suggests that youth who end up using emergency mental health care during their episode are more likely than other children to enter foster care with pre-existing mental health problems.

These problems

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