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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: Child Youth Serv Rev. 2022 Jul 8;140:106599. doi: 10.1016/j.childyouth.2022.106599

Trajectories of mental health services for youth in foster care with attention deficit hyperactivity disorder

Orion Mowbray a,*, Kylee Probert b, Jamie Jaramillo b, Brianne H Kothari b, Bowen McBeath c
PMCID: PMC9337625  NIHMSID: NIHMS1824589  PMID: 35910531

Abstract

Youth in foster care with Attention Deficit Hyperactivity Disorder (ADHD) often have significant needs for mental health services. The degree to which youth taking medication for ADHD use mental health services in relation to sibling co-placement and their level of need over time is unclear. To examine these issues, caregivers (N = 54) provided information on youth mental health service use across an 18-month study period. Results show that siblings living apart had a higher probability of mental health service use. For youth with higher CBCL scores, probability of mental health service use was both high and stable over time. However, youth with lower CBCL scores showed a decrease in probability of mental health service use over time. The sustained commitment to receipt of mental health services among youth with ADHD is something all behavioral health providers who work with foster care involved youth can benefit from, as well as the youth themselves.

Keywords: Mental health services, Medication use, ADHD, Foster care

1. Introduction

Youth in foster care often have significant needs for mental health services that stem from compounding risk factors including maltreatment, household poverty, family substance use, exposure to domestic violence, and adverse child experiences while in foster care (Courtney et al., 2004; Mowbray et al., 2017; Kohl et al., 2005; Pecora et al., 2009; Smith, & Marsh, 2002). Moreover, entry into foster care can be a traumatic event in and of itself. In addition to the experiences of abuse and/or neglect that precipitate state intervention, involuntary separation from family members can result in considerable trauma for youth, especially if they are separated from siblings (Mitchell, 2018). Furthermore, trauma exposure can be linked to diminished physical and mental health in childhood (De Bellis et al., 2001; Pecora et al., 2009). Such traumatic experiences and compounding risk factors can result in increased risk for experiencing mental health problems that require treatment among youth in foster care. In fact, up to 49% of youth in foster care meet criteria for a diagnosable mental health disorder (Bronsard et al., 2016).

As such, research on the behavioral health needs and subsequent health service use of youth in foster care has paid considerable attention to services received for the most common behavioral health problems including hyperactivity, oppositional defiant disorder and major depressive episodes (Pecora et al., 2009; Turney & Wildeman, 2016). Studies have suggested that between 25% and 53% of youth in foster care use mental health services (Bellamy et al., 2010; Petrenko et al., 2011; Rodrigues, 2004; Stein et al., 2016), including both inpatient and outpatient mental health services. Research comparing various health service outcomes has shown that youth in foster care use mental health services and multiple classes of psychotropic medications at higher rates than those not in foster care (Keast et al., 2019).

Yet among youth in foster care, considerably less research has been devoted to uncovering characteristics that may increase one’s risk for health service use. Given current efforts in research and practice to ensure that youth in care are receiving appropriate, sufficient, and high-quality services to meet their behavioral and mental health needs (Pecora et al., 2009), and as a large portion of youth in foster care have been diagnosed or treated for Attention Deficit Hyperactivity Disorder (ADHD) (Raghavan et al., 2005; Zito et al., 2008), the current study examines outpatient mental health service use and characteristics associated with service usage over time among youth in foster care with ADHD.

1.1. Mental health service use

Mental health services are broad and include services to address emotional, behavioral, learning, attention, and/or substance use problems, that are delivered by a professional (e.g., psychologist, psychiatrist, physician, social worker, psychiatric nurse, or school guidance counselor) (Gudiño et al., 2012; Leslie et al., 2004; Stein et al., 2016). Child welfare research on youth mental health service use typically rely on caregiver reports (Gudiño et al., 2012; Leslie et al., 2004; Stein et al., 2016) or state administrative data (Farmer et al., 2001; Yampolskaya et al., 2017).

The presence of behavioral health problems often reflects a need for some form of treatment (Burns et al, 2004; Horwitz et al., 2012), and some research suggests a robust relationship between increased behavioral health problems and higher rates of mental health service use among youth in foster care (particularly through mid-adolescence). Yet studies have noted that many youth in foster care do not access or receive mental health services of any type (Burns et al., 2004; Farmer et al., 2001; Glisson & Green 2006; Horwitz et al., 2010), despite findings that suggest up to 80% of youth in foster care demonstrate externalizing behavioral problems that warrant treatment (Garland et al., 2003; Linares et al., 2013).

One of the most common externalizing behavioral problems is ADHD. A large proportion of youth in foster care has been diagnosed with or is being treated for ADHD, at rates up to three times higher than the general youth population (Raghavan et al., 2005; Zito et al., 2008). One explanation for the elevated rates of ADHD diagnoses among youth in foster care is misrepresentation of ADHD symptoms that may be better explained by prior exposure to traumatic events among youth (Leathers et al., 2021; Szymanski et al, 2011) or grief and loss (Harris et al, 2017). One of the most common treatments for ADHD among youth in foster care is the use of psychotropic medication (e.g., Guanfacine, Adderall, Clonidine). Usage rates of psychotropic medication among youth in foster care are 2–3 times higher than comparable at-risk youth not residing in foster care (Raghavan et al., 2005; Zito et al., 2008). Youth in foster care with ADHD represent a large portion of those receiving services, and these youth are also likely to receive other services beyond medication use (Ruggiero et al., 2015; Turney & Wildeman, 2016). Therefore, providing a more comprehensive understanding of the predictors of service use for this population may help researchers address the most prominent system disparities and priorities (McMillen et al., 2007).

1.2. Predictors of mental health service use among youth in foster care with ADHD

The predictors of service use among youth in foster care with ADHD remain an understudied area. Youth in foster care with ADHD tend to receive more invasive and stigmatizing services (McMillen et al., 2007). As such, tracking over- and under-use of services and medication in relation to underlying mental health needs for youth in foster care with ADHD is critical. For example, although studies have examined the relation between indicators of mental health problems, such as Child Behavior Checklist (CBCL) total scores (Farmer et al., 2010; Leslie et al., 2004; Leslie et al., 2000; Stein et al., 2016), few have examined how externalizing and internalizing behavioral health problems (as identified by the CBCL) may predict service use (Martinez et al., 2013) among youth in foster care with ADHD. Research suggests that several characteristics are likely to impact service use while in care, including age, gender, race/ethnicity, living situation, and behavioral health needs (Pecora et al., 2009). We briefly review these salient factors here.

Age at entry into foster care has been associated with mental health service use over time for youth with ADHD (Leslie et al., 2003). As compared with younger children, older youth in foster care are more likely to receive mental health services between the start of child welfare investigation and 18 months after investigation (Burns et al., 2004; Farmer et al., 2010; Leslie et al., 2000; Leslie et al. 2004; Stein et al., 2016; Yampolskaya et al., 2017). However, the strength of this relationship is mixed. At least one study shows no association with service use by age (Linares, et al., 2013). Findings connecting gender and mental health service use for youth in foster care with ADHD have also been mixed. In the general population, research shows a higher prevalence for ADHD diagnoses among boys compared to girls (Rucklidge, 2010). However, girls in foster care with ADHD tend to receive services for depression and PTSD at higher rates than boys (Pecora et al., 2009). Further, Cuffe et al. (2009) found no association between gender and mental health service utilization for youth with probable ADHD. And as pertaining to race and ethnicity as a predictor, over a decade of empirical research has consistently demonstrated that youth of color in foster care access fewer mental health services compared to White non-Hispanic youth in foster care (Burns et al., 2004; Garcia & Courtney, 2011; Garcia et al., 2016; Gudiño et al., 2012; Leslie et al., 2004; Stein et al., 2016; Yampolskaya et al., 2017). Among youth in foster care with ADHD, this difference is amplified. White non-Hispanic youth are 5 times more likely to receive mental health services than both Hispanic and Black youth (McMillen et al., 2007).

Studies have consistently demonstrated that foster care involved youth who are placed in non-kinship care receive more mental health services than those placed in kinship care (Farmer et al., 2010; Leslie et al., 2004; Leslie et al., 2000; Swanke et al., 2016). In a recent study, Blakeslee et al. (2017) suggested that kin caregivers may be more likely to normalize child behavioral problems, which may also be true for youth already displaying behavioral health problems related to ADHD. Sibling co-placement may also relate to mental health needs and subsequent service use. While placing siblings together may reduce the effects of traumatic family separation, to our knowledge, no study has systematically examined sibling co-placement in relation to mental health service use among youth in foster care. Some research suggests that placing siblings together in a foster home can provide emotional support, a sense of continuity, facilitate foster home integration, and advance placement stability for youth with depressive symptoms (Barth et al., 2006; Leathers, 2006; Waid, 2014). Yet other studies suggest that siblings living together can experience increased interpersonal conflict and socioemotional needs (Linares, 2006; McBeath et al., 2014). Longitudinal findings from Linares et al. (2007) suggest that living apart from a sibling may be beneficial for children that have more behavioral health problems, but living apart may worsen these problems over time for those with few behavioral health problems to begin with.

When examining behavioral health problems and its relationship to mental health service use, Yampolskaya et al. (2017) show that initial levels of high need upon entry into foster care, was not associated with changes in mental health service use over time. Conversely, behavioral health problems as measured through the CBCL (via the externalizing and internalizing problems subscales and total CBCL scores) have been associated with increased ADHD medication use (Breland-Noble et al. 2004; Raghavan & McMillen, 2008). However, few studies have examined how CBCL scores may predict service use for youth in foster care with ADHD (Raghavan et al., 2005), particularly over time.

1.3. Current study

The current study examined 18-month trajectories of mental health service use for foster care-involved youth currently using medications for ADHD, and associations of service use with demographic and child behavioral health factors. Through this approach, this study addresses multiple need and gaps in knowledge, including examining longitudinal data of foster care-involved youth who have been in care for longer periods of time and the mental health service use rates of youth in foster care using medications for ADHD (Alavi & Calleja, 2012; Raghavan et al., 2005).

For this study, we sought to address the following research questions:

  1. What is the prevalence of mental health service use for youth in foster care with ADHD?

  2. Does service usage vary over time by demographic and foster care placement characteristics?

2. Materials and method

2.1. Sample

Our sample consisted of 54 youth in foster care between the ages of 7 and 16, drawn from a multi-county, largely metropolitan region in a Pacific Northwestern state. Participants were recruited as part of an evaluation of a sibling enhancement intervention (Supporting Siblings in Foster Care study: “SIBS-FC”). In this larger SIBS-FC study, the relational intervention was designed to build youth skills (e.g., self-soothing, sibling collaboration, joint problem solving, connecting with adult allies) and improve sibling relationship quality for foster care siblings living together in the same placement and siblings who were living in different placements (Kothari et al, 2014; Kothari et al., 2017). The SIBS-FC study used a multi-method and multi-agent data collection strategy across 18-months which focused on the domains of sibling relationship quality, mental health, permanency, and education.

The current study focused on the service-related needs of youth in foster care with attention deficit hyperactivity disorder (ADHD). While there was no formal diagnostic assessment completed by SIBS-FC participants, ADHD was assessed through a broad medication use measure developed by the SIBS-FC investigator panel. Specifically, the Principal Investigator was a clinical and family psychologist whose practice and research involved over two decades of serving at-risk youth and youth in foster care. The Principal Investigator developed the medication use measure in collaboration with a consulting MD-level family physician whose practice focused specifically on adolescent behavioral disorders.

In this medication assessment, caregivers reported all current medications taken and the specific reason for taking each medication (e.g., ADHD) during each wave. Participants in this study (N = 54) were identified by caregiver self-report concerning medication use specific to ADHD. Specific, self-reported medications prescribed for ADHD in this study included amphetamine (23.8%), Ritalin (57.1%), antipsychotic (4.8%), antidepressant (4.8%), antihypertensives (4.8%), and “other” medication (4.8%). For mental health services, caregivers provided details about the services youth in their care received every 60 days across an 18-month period, totaling 10 waves of data. Data were collected from 27 sibling dyads (categorized into older/younger siblings, regardless of co-placement status).

2.2. Measures

2.2.1. Mental health service use

An original data collection instrument called the SERV, developed by the SIBS-FC investigator panel, was designed to gather information about foster youth service use across a wide variety of services. During each wave, a trained researcher asked the caregiver to provide information about the services the youth in their care received in the past 60 days in each of the following categories: intensive services, urgent care/emergency room services, hospitalization/in-patient services, general health services, dental/oral health services, outpatient mental health services, drug and alcohol treatment services, child welfare related and juvenile justice services, and school and extracurricular services. In each category, caregivers provided additional details about the specific types of services used, number of times each type of service was received, and from whom. The current study focused on caregiver reports of foster youth outpatient mental health service utilization. Caregivers were asked “since < anchor date>, did [Name of Child] see any practitioner about his or her mental health (counselor, school counselor, psychologist, psychiatrist, pastor, social worker, etc.)?” Following this question, a count-based assessment was completed of all mental health services received. Thus, mental health service utilization is considered a count measure, assessed at each wave of data collection.

2.2.2. Child behavior

The Child Behavior Checklist (CBCL; Achenbach, 1991) is a widely used caregiver report questionnaire that was developed to assess children’s behavioral and emotional problems. In this study, we examined the total CBCL score at study enrollment, which is a combination of both the internalizing and externalizing super-scales of the CBCL. The CBCL total score, was examined using standardized T-scores, permitting for comparisons across age ranges and genders (Achenbach & Edelbrock, 1978; Cicchetti & Toth, 1991). As a measure of behavioral and emotional disorders, the CBCL is used widely in research for youth aged 4 through 18 and has demonstrated sufficiently high reliability and validity in multiple samples (Ashenbrand et al., 2005; Nakamura et al., 2009). The validity of the CBCL has been documented in prior research with foster care participants like those in the current study (Clausen et al, 1998; Glisson, 1996).

2.2.3. Demographics

Demographic variables that reflected baseline youth self-report included current youth age (categorized as 7–10, 11–12, & 13–16), gender, race/ethnicity (White non-Hispanic, African American, Hispanic (any race), and other), whether youth was living with kin (yes/no), and whether the youth was living with sibling (yes/no).

2.3. Analytic strategy

Descriptive and bivariate analyses examined characteristics associated with mental health service use at baseline. To understand how CBCL scores at baseline influenced subsequent mental health service use while controlling for additional demographic factors, a multilevel mixed-effects regression model was constructed to examine change in mental health service use over an 18-month period. This statistical model accounts for correlated data from repeated observations upon the same individuals and adjust standard error calculations accordingly (Bryk & Raudenbush, 1992). The multilevel mixed-effects regression model included main effects of baseline CBCL score, the aforementioned demographic factors, and a dichotomous factor pertaining to which youth were randomly assigned to receive the SIBS-FC treatment. We also included a continuous indicator variable for time, measured in 60-day intervals, to model the time trajectory of mental health service use. Last, we included an interaction term of mental health service use with the indicator variable for time, to examine whether baseline CBCL scores influenced the trajectory of mental health service use while controlling for other demographic factors. All analyses were completed in STATA Version 16 (StataCorp, 2016). Excellent treatments of this subject can be found in several sources (e.g., Singer, 1998; Singer & Willett, 2003). Given the non-normal distribution and count-based nature of mental health service use, Poisson regression was employed in our multivariate model. Poisson regression is an analytical approach used to examine skewed distributions of count data where extreme values are rare. Given that the mental health service use measure presented as skewed counts, Poisson regression modeling was the preferred statistical modeling application (Hilbe, 2011).

3. Results

Baseline CBCL mean score, mean mental health service use and demographic measures can be found in Table 1. At baseline, the mean CBCL total score was 66.85, with a range in scores from 36 to 86. Also, youth had used an average of 8 mental health services at baseline. There was a relatively even split in terms of age categories. Slightly more than 74% of the sample were female. About 36% of the sample identified as White non-Hispanic, 10.34% identified as African American, 25.86% identified as Hispanic (any race), and 27.59% identified as some other race. Slightly over 37% of youth lived with a relative, and 55.17% of youth lived with a sibling.

Table 1.

Baseline sample descriptives.

N = 54 % or (M) SE
CBCL total score1 (66.85) 1.37
CBCL externalizing1 (65.93) 1.37
CBCL internalizing1 (61.72) 1.35
Baseline mental health service use (8.00) 2.69
Age
7 to 10 34.48
11 to 12 29.31
13 to 16 36.21
Gender
Male 25.86
Female 74.14
Race/Ethnicity
White non-Hispanic 36.21
Black/African American 10.34
Hispanic (any race) 25.86
Other 27.59
Lives with kin 37.93
Lives with sibling 55.17
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1

CBCL standardized scores

Table 2 presents bivariate associations between demographic factors and mental health service use. These results show no significant differences between demographic factors and baseline mental health service use.

Table 2.

Bivariate associations with outpatient mental health services and ADHD medication use.

Baseline mental health service use
N = 54 M SE F or (t)
Age
7 to 10 3.92 1.02 1.77
11 to 12 4.67 1.08
13 to 16 4.64 7.22
Gender
Male 5.22 1.38 (−0.56)
Female 8.83 3.49
Race/Ethnicity
White non-Hispanic 3.87 0.91 1.26
Black/African American 5.00 1.29
Hispanic (any race) 18.48 14.67
Other 8.07 1.79
Lives with relatives
Yes 9.13 3.56 (0.71)
No 4.70 1.90
Lives with sibling
Yes 4.00 1.19 (−1.39)
No 11.43 4.83
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3.1. Mental health service use over time

To examine longitudinal trends in mental health service use, multilevel mixed effects Poisson regression models examined the relationship between CBCL scores at baseline and change in mental health service use over the 18-month period. Regression models controlled for age, gender, race/ethnicity, living with relatives, living with sibling, and treatment group. The multilevel model is presented in Table 3. This table presents a longitudinal analysis examining (1) whether baseline CBCL scores were significantly associated with mental health service use at model intercept, (2) the predicted increase/decrease over time in mental health service use for all youth in the study (Time), and (3) the predicted increase/decrease of mental health service use at each time for youth with higher CBCL scores compared to youth with lower CBCL scores (CBCL×Time). Controlling for the aforementioned factors, the multivariate model showed that youth who did not live with a sibling had significantly higher rates of mental health service use at baseline (IRR = 1.58, p <.05). IRRs are conceptualized as a standardized coefficient, enabling similar comparisons across independent variables, equivalent to standardized coefficients in linear regression.

Table 3.

Multivariate model of outpatient mental health services over time.

N = 54 IRR SE
Age
7 to 10 – –
11 to 12 0.89 0.24
13 to 16 0.87 0.22
Gender
Male – –
Female 0.95 0.21
Race/Ethnicity
White non-Hispanic – –
Black/African American 0.96 0.34
Hispanic (any race) 1.36 0.25
Other 1.25 0.23
Lives with kin (yes) 1.07 0.22
Lives with sibling (no) 1.58* 0.19
CBCL1 1.02 0.01
Time 0.87* 0.05
CBCLxTime 1.01* 0.01
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*

p <.05,

**

p <.01.

1

CBCL scores standardized and assessed at baseline.

All analyses control for SIBS-FC group.

Model results also showed a significant decline in mental health service use over time for all youth (IRR = 0.87, p <. 01), as well as a significant difference in the trajectory of mental health service use over time for youth with high CBCL scores, as compared to youth with low CBCL scores (IRR = 1.01, p <. 05). Youth with higher CBCL scores showed mental health service use that remained relatively stable over time, while youth with lower CBCL scores showed decreases in mental health service use over time. Fig. 1 displays this pattern.

Fig. 1.

Fig. 1.

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Probability of mental health service use over time by CBCL score.

To explore further whether internalizing or externalizing CBCL scores were primarily driving the model predicting mental health service use, two additional models were examined, using these CBCL scores as independent variables. When examining the CBCL internalizing scores, the model showed no significant differences of mental health service use between youth with high vs. low CBCL internalizing scores at model intercept, and a significant difference in the trajectory of mental health service use over time for youth with high CBCL internalizing scores, compared to youth with low CBCL internalizing scores, like the findings in Fig. 1. However, when examining the CBCL externalizing scores, the model showed significant differences in mental health service use between youth with high vs. low CBCL externalizing scores at model intercept (IRR = 1.03, p <.05). However, the model showed no significant difference in the trajectory of mental health service use over time for youth with high CBCL externalizing scores, compared to youth with low CBCL externalizing scores. Thus, the findings presented in Fig. 1 are driven primarily by internalizing CBCL scores.

4. Discussion

The purpose of the current study was to identify associations with trajectories of mental health service use for youth in foster care who are currently using medication for ADHD. Prior literature has shown that youth in foster care are at increased risk for experiencing trauma because of family separation and tend to have significant trauma-related mental health needs and service use (Courtney, et al, 2004; Mowbray, et al, 2017; Kohl, et al, 2005; Pecora, et al, 2009; Smith & Marsh, 2002). Our results add to these findings by identifying additional factors associated with mental health service use. In the current study, the average number of mental health service contacts over the 60-day baseline period was 8, which on its face appears high (slightly less than 1 mental health service contact per week). Also, while the multivariate model showed a significant decline in service use over time for all, mental health service use for youth with higher CBCL scores remained significantly higher over time.

These results suggest that youth with higher levels of behavioral problems over time may consistently receive higher levels of mental health services, which may be warranted. However, this study cannot assess the relative quality of these services, youth preferences in services, and whether the overall declines in service use over time are due to decreased behavioral health problems, or other issues related to service access known from prior literature (Burns et al., 2004; Farmer et al., 2001; Glisson & Green 2006; Horwitz et al., 2010). The implication from our findings include the need for additional research to examine service delivery for youth with higher behavioral health problems over time using a fine-grained approach to understand what types of services are provided, by whom, and their relative efficacy in addressing the overall behavioral health needs of youth in foster care.

One potential service-related issue found in the current study is sibling placement. In this study, siblings who did not live together showed significantly higher baseline levels of mental health service use. In a follow-up analysis examining whether siblings placed together showed a different trajectory of service use over time, model results showed no such pattern; siblings living apart showed significantly higher levels of service use at baseline and these differences remained the same over time. These findings are aligned with previous literature suggesting that siblings who are separated in foster care experience trauma related to feelings of loss or grief from family separation (Mitchell, 2018), which could be connected to increased need for service use. Differences in service use by sibling placement could also be explained by differences in their relationship to their caregiver. Siblings living together are more likely to live with a kinship caregiver than siblings who are separated (Tarren-Sweeney & Hazell, 2005). This may have implications for mental health service use, as placing siblings together can provide emotional support, a sense of continuity, and facilitate foster home integration (Barth et al., 2006; Leathers, 2006; Waid, 2014). Further, siblings who have been separated into non-kinship care are likely to experience more placement transitions then youth living together (Waid & Wojciak, 2017), which is linked to increased behavioral health problems. The difference in rates of service use between siblings living together, siblings who are separated and even larger sibling groups should be explored further, especially as it may relate to kinship/non-kin placements.

Our findings on sibling placement thus imply that special attention should be paid to the reason for separation of siblings in care. Some research suggests that sibling separation may be beneficial in instances where one sibling has more behavioral health problems or if there is evidence of a negative sibling relationship (Linares et al., 2007; Tarren-Sweeney & Hazell, 2005). Youth who are separated for behavioral reasons may be especially in need of mental health services, suggesting that this topic needs to be studied further among youth displaying high rates of behavioral health problems. Overall, kinship caregiver status, reason for separation, and existing behaviors may all be things to consider when determining barriers to service use, or decisions to co-place/separate.

4.1. Limitations

While this study contributes to the knowledge base on mental health service use over time for youth in foster care who are taking ADHD medication, our study is not without limitations. Even though youth in the parent study were universally recruited from a metropolitan region, the service utilization trajectories we identified should not be presumed to generalize to either prior studies (such as NSCAW-based secondary studies or state-based samples) or to all youth in foster care. This statement is especially true for any examination of racial/ethnic disproportionality. The limited racial/ethnic composition of the participants in the current study is a primary function of the sampling strategy and geographic location of the research. Moreover, while the current study concerned basic counts and incidence of services over time, additional measurement of service accessibility, youth preferences for with and satisfaction with specific services, and treatment effectiveness is needed. While we are not aware of any current studies that track these measures over time, behavioral health providers may benefit from such data, especially those who work closely with foster care involved youth. Also, this study reflected caregiver reports of youth perspectives, and did not allow for medical record verification of service use. Thus, the identified service use trajectories should be understood as exploratory. Additionally, our sample was derived from caregiver’s report of youth medication use specific to ADHD. While the caregiver reporting process was guided by a clinical and family psychologist and a consulting MD-level family physician, future research can extend and validate the findings presented here through formal diagnostic criteria in sample selection processes. Last, it should be noted that this study cannot answer whether the service use patterns of youth who are taking ADHD medication are influenced by entering foster care or may be due to previous maltreatment prior to foster care entry. Nevertheless, the study provided a rigorous longitudinal investigation of service trajectories, while controlling for the demographic characteristics of youth in foster care as well as their placement status.

4.2. Conclusion

Youth in foster care have significant mental health needs that stem from many factors (e.g., abuse or neglect experiences, separation from family, and other stressors), and require sustained effort to address them. This may mean an increased frequency in mental health service use upon foster care entry, especially for youth who have higher rates behavioral health problems. The sustained commitment to receipt of mental health services is something that behavioral health providers who work with foster care-involved youth can benefit from, as well as the youth themselves. Additional research is needed to understand youths’ preferences about services, as well as their level of decision-making in the receipt of mental health services, especially among youth who are taking ADHD medication. Implications from this work suggest that youth who use ADHD medication and have higher CBCL scores upon entry to the child welfare system are likely to continue its use up to 18 months following, suggesting that service providers should continue to review how mental health services and CBCL scores influence each other and change over time. Additionally, consistent review and assessment for adherence to mental health services, paired with potential overlapping behavioral health problems (including trauma symptoms associated with higher CBCL scores) may be necessary to best serve those youth taking ADHD medication.

Footnotes

CRediT authorship contribution statement

Orion Mowbray: Methodology, Conceptualization, Software, Writing – original draft, Writing – review & editing. Kylee Probert: Writing – original draft, Writing – review & editing. Jamie Jaramillo: Writing – original draft, Writing – review & editing. Brianne H. Kothari: Writing – original draft, Writing – review & editing. Bowen McBeath: Conceptualization, Investigation, Supervision, Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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