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. Author manuscript; available in PMC: 2020 Apr 19.
Published in final edited form as: Child Welfare. 2019;97(5-6):199–215.

A Longitudinal Examination of Service Utilization and Trauma Symptoms among Young Women with Prior Foster Care and Juvenile Justice System Involvement

Daschel J Franz 1, Amanda M Griffin 2, Lisa Saldana 3, Leslie D Leve 4
PMCID: PMC7167304  NIHMSID: NIHMS1578521  PMID: 32308211

Abstract

We investigated the prediction of young adult service utilization and trauma symptoms from adverse childhood experiences (ACEs) and adolescent mental health symptoms in young women with dual child welfare and juvenile justice system involvement. A sample of 166 females (ages 13 to 17) was followed to examine the transition to young adulthood. Path models indicated that more ACEs were associated with poorer adolescent mental health. Adolescent mental health symptoms were associated with more young adult trauma symptoms and service utilization. Implications for service providers and policy-makers are discussed.

Approximately 30% of youth with a history of maltreatment and child welfare system (CWS) involvement have also been involved in the juvenile justice system ( JJS; Smith, Ireland, & Thornberry, 2005). Youth with dual-system involvement are those who have, at some point, received services from both the CWS and the JJS (Herz, Ryan, & Bilchik, 2010). Compared to youth involved in only one (i.e., CWS or JJS involvement only) or neither system, youth with dual-system involvement are a population that is vulnerable and in need of additional mental health services (Dierkhising, Herz, Hirsch, & Abbott, 2019; Herz et al., 2010; Ryan, Marshall, Herz, & Hernandez, 2008). Most studies of youth with dual-system involvement focus on the population as a whole and are cross-sectional or of short duration. Therefore, little research has identified processes across the transition from adolescence to young adulthood in females in this population (Flores, Howes, Westbrooks, & Henderson, 2018). Consequently, the risk and protective factors for females with dual-system involvement are less explicated, despite the fact that the proportion of females with dual-system involvement (33%) is higher than would be anticipated given that they account for 28% of juvenile arrests (Hockenberry, 2019). In this population, childhood adversities may play a critical role in adolescent mental health challenges and influence young adult trauma symptoms and mental health service utilization, defined as the use of any public health service or emergency screening unit for a mental health crisis or an overdose. Investigating the pathways that lead to trauma symptoms and mental health service utilization in young adulthood may help inform how communities support this population’s mental health and service needs as they transition from adolescence into adulthood.

A predominant approach to assessing early life adversity is the adverse childhood experiences (ACEs) framework. The ACEs frame-work indexes a set of risks that occur early in life, such as physical, emotional, and sexual abuse (Felitti et al., 1998). ACEs are a robust risk factor for adverse health behaviors across a wide variety of populations and contexts (Hughes et al., 2017; Oh et al., 2018). For example, ACEs have been associated with later depression and anxiety symptoms (Baglivio et al., 2014; Oh et al., 2018). Given that females with dual-system involvement often experience numerous adversities, it is not surprising that they also experience high rates of ACEs as compared to youth involved with only one system (i.e., CWS or JJS) or no system involvement (Baglivio et al., 2016; Grevstad, 2010). Similar to the general population, youth with dual-system involvement who experience ACEs have more difficulty with emotional functioning, which can lead to ineffective coping strategies (Cloitre, Miranda, Stovall-McClough, & Han, 2005) and may result in the development of mental health symptoms (Herz et al., 2010). Because youth with dual-system involvement often experience ACEs and adolescent mental health symptoms at higher rates, it is important to better understand the pathways in which ACEs may be associated with young adult trauma symptoms and mental health service utilization.

Both childhood ACEs and trauma symptoms in adulthood have been linked to long-term health consequences (e.g., cardiovascular disease, suppressed immune functioning; Hughes et al., 2017). However, to our knowledge, there is a lack of evidence on the association between adolescent mental health symptoms and young adult trauma symptoms in this population. Further investigation of this pathway is warranted as it may be an integral part of how trauma symptoms develop and are sustained into adulthood. Conversely, adolescent mental health symptoms may lead to increased mental health service utilization, reducing the risk of these long-term health consequences.

Mental health service utilization may be an index of an individual’s help-seeking abilities or the accessibility of services. Utilizing mental health services has been associated with the reduction of symptom severity, including reduced depressive and anxiety symptoms (Young, Grusky, Jordan, & Belin, 2000). Among the handful of studies that has investigated mental health service utilization among youth with prior involvement in either the CWS or JJS, results indicate that these youth rarely access mental health services (Culhane et al., 2011; He Len Chung, Schubert, & Mulvey, 2007; Heard-Garris et al., 2019). In contrast, Culhane and colleagues (2011) found that within the first four years of exiting either system, 47% of youth with prior dual-system involvement accessed mental health-related services, compared to 17% and 11% for youth with prior involvement in only CWS or JJS, respectively. This evidence suggests that individuals with prior dual-system involvement access more mental health services.

More research is needed on the mental health service utilization patterns of females with dual-system involvement because of the distinct adversities such women may have experienced. To our knowledge, no study has examined the relationship between adolescent mental health symptoms and young adult mental health service utilization in this population. It is critical to examine the pathways between childhood ACEs, adolescent mental health symptoms, and mental health service utilization and trauma symptoms in adulthood to better understand the risk and protective processes that youth with dual-system involvement may experience.

To further understand the transition into adulthood for women with previous dual-system involvement, we investigated the relationship between ACEs, adolescent mental health symptoms, and young adult trauma symptoms and mental health service utilization. We hypothesized that individuals who experienced more ACEs would have higher levels of adolescent mental health symptoms. We further hypothesized that higher levels of adolescent mental health symptoms would be associated with higher levels of young adult trauma symptoms and engagement in mental health services. We also hypothesized that ACEs would have an indirect influence on young adult trauma symptoms and mental health service utilization through its effects on adolescent mental health symptoms.

Methods

Participants and Recruitment

Participants included 166 females (Mage = 15.31, SDage = 1.17, range = 13 to 17 years old at baseline) who participated in a randomized controlled trial evaluating the efficacy of a family-based intervention, Treatment Foster Care Oregon (TFCO; n = 81), versus services-as-usual group care (SAU; n = 85). The study was conducted with two consecutively cohorts (n = 81 and 85 in Cohorts 1 and 2, respectively) in the Pacific Northwestern region of the United States, with initial recruitment into the study occurring between 1997 and 2006 and a follow-up assessment between 2008 and 2013 to examine young adult outcomes. Participants were recruited if they had been mandated by the JJS to community-based out-of-home care due to chronic delinquency and were enrolled within 12 months of a criminal referral. Youth who were pregnant during the recruitment phase were excluded from study participation. At each assessment, those who were under age 18 provided assent and those over age 18 and legal guardians provided consent to participate. Prior to random assignment to condition placement (i.e., TFCO or SAU), participants completed a baseline assessment.

Participants self-identified as follows: 68.1% Caucasian, 1.8% African American, 11.4% Hispanic, 0.6% Native American, and 0.6% Asian, 16.9% “multiracial,” and 0.6% “other/unknown.” At study intake, 63% reported living with single-parent families, and 54% reported family incomes of less than $10,000. The vast majority of participants (85.5%) had dual-system involvement (i.e., CWS and JJS; Leve, Chamberlain, & Kim, 2015). Prior to entering her out-of-home placement, each youth and parent (or other primary preplacement caregiver) completed an in-person baseline assessment. Youth in both conditions received JJS-mandated treatment services for an average of six months after the baseline assessment. In-person follow-up assessments were conducted at 6, 12, 18, 24, 36 months postbaseline. In addition, six interviews were conducted during young adulthood, at 8.5, 9, 9.5, 10, 10.5, and 11 years postbaseline. Cohorts 1 and 2 completed the first young adult assessment approximately 12 and 7 years, respectively, after baseline (Mage = 27.42, SDage = 2.05 and Mage = 22.38 SDage = 1.57, respectively).

JJS Intervention Services

Youth who were randomly assigned to receive TFCO services were placed in one of 22 homes with state-certified foster parents trained to implement a behavioral reinforcement program (e.g., point-and- level system). For more information about the TFCO intervention, see Chamberlain, Leve, and DeGarmo (2007). Youth who were randomly assigned to receive SAU were placed in one of 35 community-based group care programs that represented community treatment as usual for youth referred to out-of-home care by the JJS. SAU program treatment was primarily behavioral (67%) or multi-perspective (33%), and the majority of programs (80%) reported delivering weekly therapeutic services.

Measures

Childhood Adverse Experiences (ACEs)

A ten-item ACE score was created using three items from youth self-report, six from caseworker report, and one coded from maltreatment records regarding adverse experiences that occurred early in life (Felitti et al., 1998). The presence or absence of each item was summed to create a count score, where higher values indicated more ACEs (range = 0–10). A weighting approach was used for those who did not have data on all 10 items.

Mental Health Symptoms

Mental health symptoms, including anxiety and depressive symptoms, were assessed during adolescence over five waves (i.e., 6, 12, 18, 24, and 36 months postbaseline) using the Brief Symptom Inventory (BSI; Derogatis & Spencer, 1993). Anxiety and depression symptoms were both assessed with six separate self-report items that participants rated on a five-point Likert scale (symptom not present to extremely severe). The anxiety and depression scales demonstrated strong internal consistency at each wave (Cronbach’s α = .73–.86 and .82–.90, respectively). In each of the five waves, anxiety and depression scores were highly correlated with one another (ranged from .15 to .78). Given the high correlations, a composite variable was computed that combined anxiety and depression symptom scores at each wave, and then an average score was computed across the five waves (r = .20, p < .01); higher values indicated more mental health symptoms.

Trauma Symptoms

Trauma symptoms were measured during young adulthood using the Trauma Symptom Checklist (Elliot & Briere, 1992), assessed every six months over six waves (i.e., 8.5 to 11 years post-baseline). The checklist consisted of 40 self-report items that measured trauma-related symptomatology in adults for events that occurred earlier in life. Participants reported on the frequency of each symptom over the past two months on a four-point Likert scale (never to often), (range = 0–120). The trauma symptom scores demonstrated strong internal consistency at each wave (Cronbach’s α = .91–.94) and were significantly correlated across waves (ranged from .40 to .72). Thus, a composite was created that averaged trauma symptom scores all waves.

Mental Health Service Utilization

Mental health service utilization was measured during young adulthood every six months (i.e., 8.5, 9, 9.5, 10, 10.5, and 11 years post-baseline). At each wave, the use of public health services or emergency screening unit for a mental health crisis or an overdose was assessed (yes or no). The mental health service utilization items were highly correlated across waves (ranged from .24 to .54), thus a cumulative score was computed across waves, where higher values indicated more mental health service utilization (range = 0–6).

Covariates

All measures were residualized to account for the effect of intervention condition and for the length of time between the intervention and the first young adult assessment.

Analytic Approach

Structural equation path analyses were conducted using Mplus 7 soft-ware (Muthén & Muthén, 2012) to examine pathways from ACEs to young adult trauma symptoms and mental health service utilization. Indirect effects were tested using the bootstrapping standard errors (n = 1,000 draws). Because the chi-square is highly sensitive to sample size and distributional assumptions (Hu & Bentler, 1995), three other measures of the overall goodness-of-fit were used. Fit was assessed using comparative fit index (CFI), Tucker-Lewis Index (TLI), root mean square error of approximation (RMSEA), and maximum likelihood chi-square values. The CFI and TLI indicate the proportion of improvement in the overall fit of the hypothesized model relative to a null model in which all covariances between variables are zero. Values of 0.95 or greater are desirable for the CFI and TLI (Bentler, 1990; Hu & Bentler, 1999). The RMSEA is a measure of lack of fit per degrees of freedom; values that range upwards from 0 through to 0.05 indicate a good fit, and up to 0.08, a fair fit (Browne & Cudeck, 1993).

Results

Descriptive Analyses

Approximately 86% of TFCO and 92% SAU participants endorsed four or more ACEs. Participants who were assigned to the TFCO condition during adolescence reported significantly lower mental health service utilization in adulthood (M = 0.65, SD = 0.43) than those assigned to SAU (M = 0.69, SD = 0.60, t[144] = 0.54, p < .05). Other than mental health service utilization, there were no differences in study variables by intervention condition. Correlations between study variables after accounting for covariates are reported in Table 1. ACEs were associated with more adolescent mental health symptoms (r = .21, p < .01), but were not associated with young adult mental health service utilization (r = .07, ns) or trauma symptoms (r = .11, ns). Adolescent mental health symptoms were not associated with young adult mental health service utilization (r = .06, ns), but were associated with more young adult trauma symptoms (r = .36, p < .01). In addition, young adult mental health service utilization was modestly correlated with young adult trauma symptoms (r = .23, p < .01), indicating that these measures capture distinct, but modestly correlated, behaviors.

Table 1.

Descriptive Statistics for Study Variables

Total (N = 166) Correlations
M (SD) 1 2 3
Baseline
1. ACEs 5.91 (2.27) –
Adolescence (Waves 3–7)
2. Mental Health Symptoms 0.67* (0.52) .21* –
Young Adulthood (Waves 8–13)
3. Mental Health Service Utilization 0.22 (0.55) .07 .06 –
4. Trauma Symptoms 39.43 (20.66) .11 .36** .23**
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Notes: M = mean, SD = standard deviation, ACEs = adverse childhood experiences.

*

p < .05

**

p < .01.

Path Analysis

Results from the path analysis suggested that higher ACE scores were associated with higher adolescent mental health symptom scores (b = 0.20, p < .01). Adolescent mental health symptoms were, subsequently, associated with more young adult trauma symptoms (b = 0.35, p < .01) and more young adult mental health service utilization (b = 0.19, p < .05). In addition, there was an indirect effect from ACEs to young adult trauma symptoms (b = 0.07, p = .03) and a trending indirect effect from ACEs to young adult mental health service utilization (b = 0.04, p = .09), indicating that more ACEs were indirectly associated with the young adult outcomes.

Discussion

This study examined the relationship between ACEs, adolescent mental health symptoms, and young adult trauma symptoms and mental health service utilization for females with dual-system involvement. First, females from both conditions had similar symptomatic levels of depression and anxiety during adolescence; however, those in SAU were more likely to engage in young adult mental health service utilization compared to their TFCO counterparts. Second, higher ACEs scores were associated with higher adolescent mental health symptom scores. Third, those with higher adolescent mental health symptom scores were more likely to endorse higher levels of young adult trauma symptoms and more mental health service utilization. Finally, ACEs had an indirect influence on young adult trauma symptoms through adolescent mental health symptoms. This study contributes to the literature on females who have dual-system involvement by demonstrating that pathways from ACEs to adolescent mental health symptoms can operate to sustain mental health risk (i.e., trauma symptoms) into young adulthood.

Similar to previous research (Baglivio et al., 2016; Grevstad, 2010), the majority (86%) of females in this study endorsed four or more of ACEs. Prior research (Baglivio et al., 2014; Oh et al., 2018) has similarly demonstrated a cumulative effect of ACEs, such that the more adversities youth experience, the more they are at risk for developing mental health symptoms during adolescence. Thus, our findings were consistent with prior literature and extended evidence to a sample of females with dual-system involvement. Further, we provided new evidence that higher levels of adolescent mental health symptoms predicted higher levels of young adult trauma symptoms in this population. These results demonstrate sustained mental health risk, thus providing insights to potential developmental periods where effective interventions might help prevent the continuation of adolescent mental health symptoms into young adulthood.

Consistent with these findings, prior research has shown that those with greater mental health symptoms use more mental health services (Dhingra et al., 2011; Young et al., 2000). Similarly, Young and col-leagues (2000) found that adults with more significant mental health symptoms used more mental health services over time compared to those with less serious mental health symptoms. Furthermore, mental health symptom severity improved over time for adults who continued using mental health services. In this study, females in the SAU condition were more likely to use mental health services as young adults, compared to those in the TFCO condition. This result could indicate that the effects of the TFCO intervention during adolescence may have a lasting benefit on mental health in young adulthood; thus, young adults who took part in the TFCO intervention may not have required as many mental health services compared to females in the SAU condition. Prior evidence from the same sample indicated a decline in depressive symptoms and suicidality from adolescence to adulthood in the TFCO group relative to the SAU condition (Kerr, DeGarmo, Leve, & Chamberlain, 2014).

Further, consistent with our hypothesis, the association between ACEs and trauma symptoms in young adulthood was linked by adolescent mental health symptoms. These findings provide support for a potential spill-over effect, where ACEs lead to an increase in adolescent mental health symptoms, that then lead to an increase in young adult trauma symptoms. Contrary to our hypothesis, there was not a significant indirect effect of ACEs on young adulthood mental health service utilization, although there was a trend. This finding may be due to the limited sample size of this study. Prior research has demonstrated that individuals with more severe mental health symptoms during adulthood tend to use more mental health services (Young et al., 2000).

Strengths and Limitations

This study had several notable strengths. First, the study had a high retention rate (92.7%) across the ten years of follow-up among this population of dual-system involved youth. Second, the longitudinal design enabled us to prospectively examine young adult outcomes for dual-system involved youth as they transitioned out of the CWS and JJS. Third, the sample included all female participants, thus providing insights on the development of females with dual-system involvement that can be used to inform future prevention and intervention approaches for this specific population. The strengths of this study should be considered in combinations with its limitations. First, the results of this study can only be generalized to samples of females with dual-system involvement. Future research should investigate whether similar results would be observed among low-risk adolescents, males, or those who have experienced CWS involvement without JJS involvement. Second, the study did not include a detailed assessment of the prior services received from CWS, so we were unable to examine outcomes of system-delivered services, specifically.

Practice & Policy Implications

This study highlights the high rates of mental health symptoms for female youth with dual-system involvement during adolescence and the persistence of symptoms into young adulthood. Further, it emphasizes the need for intervention programs to specifically target these mental health symptoms during adolescence amongst this population. It is important to recognize the average cumulative cost of services. For example, in New York City, the cost to care for young adults with prior dual-system involvement was about $65,000 in 2015, with about 16% of those costs being used specifically for mental health-related services (Center for Innovation through Data Intelligence, 2015). To reduce the long-term costs associated with prior dual-system involvement, states and counties could implement primary, secondary, and tertiary preventative forms of care to: (1) prevent youth from entering the CWS or JJS; (2) target unmet mental health needs among youth with dual-system involvement before they exit care; and (3) implement effective and targeted services for youth to assist them in transitioning into adulthood. The implementation of preventative forms of care will help reduce long-term costs and likely promote positive mental health outcomes for youth.

A primary prevention approach could help prevent youth from initially entering the CWS or JJS. For example, states could prevent the number of youth entering foster care by implementing federal legislation such as the Family First Prevention Services Act of 2018 (Bonnie & Backes, 2019). Under this act, states have the option of using federal funding to provide families of children who are at risk of entering the foster care system with up to 12 months of evidence-based preventative services (Bonnie & Backes, 2019).

A secondary prevention approach is to reduce the costs associated with mental health service utilization among adults with prior dual-system involvement by addressing potential unmet service needs during adolescence. Although many youth with dual-system involvement receive mental health service referrals, many of them do not access those services (Dierkhising et al., 2019). Consequently, a large portion of youth with dual-system involvement have unmet mental health service needs lasting into young adulthood. Prior research has demonstrated that collaboration and information-sharing between state-wide providers such as the CWS and JJS can increase the likelihood of a youth receiving treatment (Chuang & Wells, 2010). Adopting the Crossover Youth Practice Model (CYPM), a widely used program that aims to reduce the number of youths crossing over and becoming dually involved, could be a method to address a youth’s unmet mental health service needs, as it requires states to collaborate and share information between their CWS and JJS. Despite the number of services provided by the CWS and JJS, there is limited research on the type and quality of services that are accessed by youth with dual-system involvement. Future research should investigate the type and quality of services provided and used, to better identify potential areas that could be improved.

In addition, high service costs for youth with dual-system involvement speak to the need to implement effective and targeted services prior to their transition into young adulthood. Exiting the CWS and JJS in young adulthood typically terminates a youth’s eligibility for previously provided mental health services. The loss of mental health services is detrimental to the health outcomes of youth with dual-system involvement, especially among those that have unmet mental health needs. When youth with dual-system involvement transition into adulthood without access to health care, they may be resistant to seek preventative services given their costs, which can lead to exacerbated mental health problems later. Fortunately, federal legislation such as the Foster Care Independence Act of 1999 provides funding to support programs addressing the needs of these youth (Bonnie & Backes, 2019). However, service availability can vary throughout each state (Courtney & Heuring, 2005), and, as a result, it is critical that professionals from both the CWS and JJS collaborate with service providers to assist youth transitioning out of these systems to secure health care. Through collaboration, professionals can ensure that adults with prior dual-system involvement can receive the services they need.

Figure 1. Relationship Between Childhood Aces, Adolescent Mental Health Symptoms, and Trauma Symptoms and Mental Health Service Utilization in Young Adulthood.

Figure 1.

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Notes: *p < .05, **p < .01. Solid lines indicate significant paths. Bolded lines indicate a significant indirect effect; χ 2(2) = 0.28, p = .87; CFI = 1.00; TCI = 1.13; RMSEA = 0.05.

Acknowledgments:

This project was supported by the Oregon Youth Authority and by grants R01 DA024672, R01 DA015208, P50 DA035763 and P50 DA048756 from the National Institute on Drug Abuse, and by grant R01 MH054257 from the National Institute of Mental Health. Amanda Griffin’s work was supported by a training grant from the National Institute on Child Health and Human Development (F32 HD093347). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors thank Patricia Chamberlain from the Oregon Social Learning Center for her leadership as Principal Investigator of the original studies and developer of Treatment Foster Care Oregon; Sally Guyer for data management; Jennifer Volpi for editorial assistance; the team of interviewers and data management staff; and the study participants, parents, caseworkers, and foster parents.

Contributor Information

Daschel J. Franz, University of Oregon

Amanda M. Griffin, University of Oregon

Lisa Saldana, Oregon Social Learning Center.

Leslie D. Leve, University of Oregon

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