Substance abuse, behavioral and mental health issues among children and youth in foster care

When risk factors accumulate and go unaddressed, a youth in foster care is more likely to suffer from mental illness or substance abuse disorders.

Prevalence of mental and substance use disorders is increasing in the United States. In 2016, there were over 45,000 deaths due to mental and substance use disorders, compared to only 13,000 in 1990.1 This growing national concern and, specifically, the opioid crisis, are often cited as one of the largest driving factors in the recent increase in foster care numbers; however, parental mental health and drug abuse are not the only concerns for children and youth in the welfare system. Children in the system are at heightened risk of experiencing such issues themselves. Health issues such as disruptive behavior disorder, bipolar disorder, depression, anxiety, and substance abuse disorders share many risk factors, including history of adverse childhood experiences or trauma, experiences of poverty or a lack of economic opportunity, and childhood exposure to adults who abuse substances and/or suffer from mental health issues.2 Children and families in the welfare system have experienced an undue burden of these risk factors, and thus require additional protective and treatment services. Moreover, research shows that risk of substance abuse is highest during transition periods and periods of emotional or physical turmoil.3 As risk factors accumulate and go unaddressed, a youth in foster care is more likely to suffer from mental illness or substance abuse disorders.

Up to 80% of youth in the foster care system have been diagnosed with significant mental health issues, compared to only around 20% of their general population peers.4 Youth in foster care who experience mental health issues are less likely to be placed in permanent homes, and those that age out of the system are significantly more likely to experience drug or alcohol dependence and major mental health problems compared to the general adult population.5,6 One study found that although levels of substance use in a group of 17 year-old youth in foster care were not significantly different than levels in their general-population peers, youth in care who used alcohol or illicit substances were more likely to experience dependency and abuse issues with those substances, while their peers were more likely to experiment or use recreationally.7

While youth in foster care have likely experienced life events that make them increasingly vulnerable to mental and behavioral health problems, there are protective factors that can alleviate traumatic events, promote wellness, and help youth become resilient during periods of unrest and change. Children and young adults with strong social networks, support groups, and reliable mentors are more likely to remain healthy in spite of accumulating risk factors. Moreover, receiving timely and evidence-based treatment can reduce the harmful outcomes associated with mental and behavioral problems. Recent research and program evaluation has formed a groundwork for successful navigation of such issues—utilizing clinical services, community resources, and programs that follow best practices for child-welfare professionals can change the course of a youth’s life.

The Health Foster Care American Initiative by the American Academy of Pediatrics has stated that mental and behavioral health is the “greatest unmet health need for children and teens in foster care.”8

  • Educate youth and families about risk factors and preventative factors for mental, behavioral, and substance use disorders. Youth in foster care are less likely to report having talked with a guardian about the dangers of drug and alcohol abuse, and they are less likely to report having received consistent messaging in schools.
    Thus, it is particularly critical that youth in foster care be made aware of life experiences that may make them more vulnerable to mental health and drug abuse issues and taught how to access services and understand the evidence behind prevention and recovery programs.
  • Compile resources about accessible, evidence-based, culturally appropriate trauma treatment programs in your area. Access to proper treatment can have monumental impacts on ensuring speedy recovery and reducing the impact of substance use disorders, but knowing where and how to access those services is a critical first step. Ensure that your list contains gender- and addiction-specific programs, as well as programs that integrate a trauma treatment component.
  • Develop written strategies for how to assess and monitor youth’s issues in this area so that mental health problems and substance use disorders are detected early. Early intervention strategies are key to ensuring the best possible outcomes.
  • Encourage youth to participate in age appropriate support groups and community activities. Research shows that social networks are key in developing resiliency and early recognition of warning signs. Provide them with a list of these groups and help them identify someone from the group who can guide and welcome them.

While young adulthood is typically a time of immense physical and mental change, certain changes should be carefully monitored in order to determine whether they are early warning signs of mental health or substance use issues.

  • Learn to recognize early warning signs of mental health issues. While young adulthood is typically a time of immense physical and mental change, certain changes should be carefully monitored in order to determine whether they are early warning signs of mental health or substance use issues. In particular, be aware of problems focusing, withdrawal from communities, irritability, paranoia, significant weight loss or gain, and/or a loss of interest in previously enjoyed hobbies.9
  • Research commonly abused drugs, the signs of substance abuse, and the drug-specific short- and long-term impacts of use. The type of drug used and the duration of abuse will ultimately impact the type of treatment required and the impacts on an individual’s well-being.
  • Routinely inquire about a child’s mental and behavioral health. Advocate for mental health care or substance abuse treatment programs when symptoms first arise. Understand that the child welfare system can be utilized as a gateway for getting youth the mental health care and services they need, and take every opportunity to advocate for the right care for children and youth.
  • Remember that recovery is possible. It is much too easy to feel defeated, but youths equipped with the proper tool set, access to treatment and/or rehabilitation, and long-term, supportive mentors can pull through mental and substance use disorders. A CASA/GAL may be a child’s best advocate in this fight.

Therapeutic Foster Care Multiple sites, United States

Therapeutic or treatment foster care (TFC) is a clinical intervention, which includes placement in trained foster parent homes for youth in foster care who experience severe mental, emotional, or behavioral health needs. Since TFC is considered a medically necessary treatment, it must be authorized by public state agencies such as child welfare and/or Medicaid in order for treatment services to be available and reimbursable.

TFC serves youth ages infant to 18, or older if the state Medicaid plan allows. In states using TFC, child welfare agencies recruit, train and support foster parents. A licensed clinical staff person oversees a youth’s individualized treatment plan and provides therapeutic services such as individual and family therapy, crisis intervention, case coordination and medication support.

The difference in TFC placements and residential treatment sites is that TFC services are provided in the specially trained and supervised foster homes in local communities. Youth are generally able to attend the local public school. Based on a number of assessments, youth are matched with a specific TFC home and TFC parents whose training, experience, and professional skills create the best
for the youth’s success.

TFC foster parents in most states are required to complete training that is at least double of that required for non-TFC foster parents. TFC foster parents are to be available to the youth at all times for support, treatment intervention, crisis stabilization and connection to the community and school. The TFC therapist supports the youth and the foster family. This person meets with the TFC family weekly and can be called upon at any time. The treatment plan that is specific to the individual needs of the youth is created by staff the TFC agency and is monitored regularly. The plan itself is to be reviewed no longer than every 90 days.

TFC relies on partnerships with other agencies and providers including the state child welfare agency, the state mental health agency, Medicaid administrators, the courts, and sometimes juvenile justice systems. Many states have unique relationships and programs with the partners involved. For example, in Nebraska, behavioral health services for youth in foster care are administered through managed care as part of a major reform effort in child welfare and Medicaid. TFC, when done correctly assess children and youth for trauma and mental health issues and develops a plan accordingly that addresses safety, permanency and well-being goals. Specialized populations of youth receive specialized intervention and support.

To learn more:

Below are tools, resources, and examples of programs that support prevention, treatment, and knowledge about mental and behavioral health and substance abuse disorders.

Child Welfare Information Gateway: Adoption Assistance by State Database – Mental Health Services

The Child Welfare Information Gateway provides state-specific resources about statutes and services. In particular, the list of state-administered mental health services is useful in determining how to make mental health care affordable and accessible for foster care youth in your state.

Drug and Alcohol Treatment Prevention Network

The Drug and Alcohol Treatment Prevention Network provides drug-specific resources and guides to treatment programs.

Indian Health Service: Find Health Care

The Federal Health Program for American Indians and Alaska Natives (The Indian Health Service) provides a map for locating Indian Health Service, Tribal or Urban Indian Health Program facilities.

National Center on Substance Abuse and Child Welfare

The National Center on Substance Abuse and Child Welfare is a resource for child welfare and substance abuse treatment professionals. Their resources provide insight into relevant topics such as trauma-informed care, drug testing in child welfare, and statistics about child welfare and treatment.

Substance Abuse and Mental Health Services Administration (SAMHSA)

SAMHSA is an online resource that hosts a knowledge network with useful resources about behavioral health training and care. It includes a list of programs, initiatives, and campaigns for the delivery of adequate health services, as well as a treatment services locator, and information on topics and treatment. The SAMHSA hotline, 1-800-662-HELP, provides confidential, free, 24-hour-a-day information in English and Spanish. The hotline can locate nearby support groups, facilities, and local organizations, or you can order additional information to be sent to you directly. The group received an average of 65,000 calls a month in 2016.