Mental health and substance use disorders among foster youth transitioning to adulthood: Past research and future directions

Abstract

At a time when there is increasing attention being given to systematically integrating the well-being of children with the goals of safety and permanence in child welfare, little is known about the psychosocial functioning of foster youth transitioning to adulthood from substitute care. This article systematically reviews 16 peer-reviewed articles and/or research reports to identify lifetime and past year prevalence rates of mental health disorders and service utilization. At ages 17 or 18, foster youth are 2 to 4 times more likely to suffer from lifetime and/or past year mental health disorders compared to transition aged youth in the general population. Findings show that mental health service use declines at ages when the prevalence rate of mental health disorders is peaking. The findings of this review suggest the need to focus future efforts in three main areas: 1) setting a common research agenda for the study of mental health and service use; 2) routine screening and empirically supported treatments; and 3) integration and planning between child and adult mental health service systems.

Introduction

Children and adolescents placed into substitute care experience numerous challenges in psychosocial functioning. They score higher on standardized measures of emotional and behavioral problems than same aged peers in the general population (Clausen et al., 1998, Halfon et al., 1995, Horowitz et al., 1994, Landsverk and Garland, 1999, Leslie et al., 2000, Trupin et al., 1993); they have mental health conditions at twice the rate as same aged children receiving aid from Supplemental Security Income (SSI) (dosReis, Zito, Safer, & Soeken, 2001); and they represent a large percentage of users of mental health services even though they make up a small proportion of the overall population that is eligible (Halfon et al., 1992, Harman et al., 2000, Takayama et al., 1994).

Less is known about the psychosocial functioning of foster youth transitioning to adulthood. Information about foster youth and the prevalence of health, mental health, and developmental conditions in adulthood has only accumulated in the past several years (Courtney and Dworsky, 2006, Courtney et al., 2004, Hill et al., 2010, Kushel et al., 2007, Narendorf and McMillen, 2010, Needell et al., 2002, Raghavan and McMillen, 2008). Several areas, which are arguably central to well-being, such as physical health and substance use, remain poorly understood (Courtney & Heuring, 2005). Although several studies shed light on mental health and service use (Barth, 1990, Courtney et al., 2001), few have used a diagnostic assessment that is capable of making precise clinical diagnoses which are necessary to determine need. Limited information concerning common dimensions of mental health, such as the age of onset, severity, and co-occurrence with other conditions, further obscures understanding of the ways in which mental health contributes to risks in adulthood.

A lack of current and comprehensive information about the psychosocial functioning of foster youth transitioning to adulthood presents a significant gap in the existing knowledge base with relevance to prevention and intervention. The transition to adulthood is increasingly being considered as a unique “window of opportunity” for altering developmental trajectories (Masten, 2006, Masten et al., 2006, Schulenberg et al., 2004). Advances in developmental neuroscience and developmental psychology are building a persuasive case for new ways of thinking about catalysts for change in adolescence and adulthood (Tough, 2012). Findings suggest that parts of the brain develop well into the twenties, and lead to improved competence in executive functioning, including attention, memory, self-regulation, and future planning (Blakemore and Choudhury, 2006, Dahl, 2004, Steinberg et al., 2009). It may then follow that well-specified programs in adolescence and early adulthood hold promise for optimizing health and development when they are integrated within the larger goals of child welfare and other systems of care. Active responses to these developments require a new paradigm for conceptualizing the meaning of safety, permanence and well-being for adolescents and transition aged youth. In the interest of providing guidance for future research, intervention development, and programming, we review the research on foster youth transitioning to adulthood and mental health in the context of evolving developments in independent living policy in the United States and the growing importance of developmental transitions in directing the life course.