Mental Health, Behavioral and Developmental Issues for Youth in Foster Care

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Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.

Introduction

Youth in the foster care system experience a disproportionate risk of mental and behavioral health problems and developmental disorders compared to peers.1 Nearly two-thirds of children in foster placement have mental and behavioral health problems,2 and estimates of developmental disorders range from 20% to 60%.3, 4, 5, 6 While this article focuses specifically on children in foster care, emerging research demonstrates that mental, behavioral, and developmental issues faced by these children look similar to all children served by the child welfare system.7

These profound health care needs are best understood within a framework of the neurobiologic stress response. Both nature, genetic loading associated with parental impairment, and nurture (abandonment, parental rejection, early adversity, and resultant trauma) contribute to the high prevalence of mental health and developmental diagnoses in this population.8 Issues that exist pre-placement, before entry into foster care, directly affect child development, particularly during formative infancy, toddler, and preschool years.9 The effects of chronic neurobiologic stress predispose children entering foster care to serious behavioral and developmental issues, rendering early intervention imperative.9, 10 Evidence-based behavioral and developmental interventions, along with coordinated healthcare service delivery, have the potential to more effectively ameliorate early adversity and improve long-term outcomes, particularly for younger children.11

This article examines the unique mental health, behavioral, and developmental needs of children in placement, reviews challenges associated with service delivery, and illustrates opportunities for intervention by the general pediatrician to improve downstream outcomes for children and adolescents in foster care.

Section snippets

Mental and Behavioral Health Issues Affecting Children in Foster Placement

Mental and behavioral health challenges are a significant health concern for most children in foster care,2 and understanding the true prevalence of psychological and emotional issues is challenging. Current challenges for care therefore surround accurate diagnosis, labeling of clinical symptoms, and use of appropriate treatment plans and approaches.

The most common mental health diagnoses for the foster care population include attention deficit/hyperactivity disorder, oppositional defiant

Developmental Issues Among Children in Foster Care

Developmental and cognitive differences exist among children who have experienced early adversity. For the foster care population in general, language disorders, poor social-adaptive skills, and delayed fine motor skills predominate among younger children, whereas older children have higher rates of educational disorders, learning disabilities, behavioral disorders, and limited cognitive ability.6 Recognition and prompt identification is important, as these issues can significantly impact a

Barriers to Mental and Behavioral Health and Developmental Healthcare Delivery

Despite the significant prevalence and overwhelming evidence of need for services, studies consistently demonstrate that many health care needs go unmet for children in foster care, or that required services may not be provided in a timely fashion.2, 6, 32, 33 While the concept of unmet health needs may seem paradoxical, as most youth in foster and adoptive care have categorical eligibility for the Medicaid program, patterns of healthcare resource utilization demonstrate high medical service

Use of Psychotropic Medications Among Youth in Foster Care

Psychotropic prescription medication use for treatment of mental and behavioral health disorders among the nation׳s youth has increased,43, 44, 45, 46 gaining acceptance as a mainstay of care.76 Widespread use among youth in foster care is no exception, despite increased concern that this population is being excessively medicated.47, 48, 49

Persistent challenges with psychotropic medication prescribing among youth in foster care include polypharmacy and antipsychotic use. Rates of psychotropic

Summary

Children in foster care have diverse mental, behavioral health, and developmental needs, all of which, if untreated or ineffectively treated, may impact long-term health, social, educational, and occupational trajectories. Multiple barriers within the medical and child welfare systems must be overcome to improve service delivery and optimize outcomes. Pediatricians can play a critical role, helping children access needed services, supporting foster parents in recognizing and managing mental,

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