Analysis of Barriers in Mental Health Care for Foster Children: Challenges and Solutions

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Children in foster care represent one of the most vulnerable sections of the population, as they are at an elevated risk of experiencing mental health challenges. These difficulties may be caused by past traumas, ongoing instability, and the emotional turmoil associated with separation from their biological family. Studies have shown that children in foster care have higher levels of psychopathology compared to those living with their biological parents; however, results can vary based on factors like type of disorder, comparison group, informant, placement stability, and type of care—family vs non-family.¹

The transition into foster care itself can be distressing, involving sudden changes in living arrangements, schools, and relationships, which can further exacerbate emotional and psychological distress. Given these challenges, it is essential to assess the availability and accessibility of health care resources that meet foster care children's needs. The AAP recommends initial health care screening within 72 hours and at least 3 visits within 3 months of placement for foster care children. A study shows that while Texas law requires a visit within 3 business days and a well-child visit within 30 days, adherence to guidelines has been inconsistent.² Adequate mental health support and interventions can play a crucial role in lowering the impact of trauma and instability, promoting resilience, and improving overall outcomes for these vulnerable young individuals. However, numerous barriers may prevent foster children from receiving services, including a lack of resources and placement instability within the foster care system. This article explores these barriers and examines current evidence on mental health care access for foster children.

Foster children face multiple barriers to accessing mental health care, and these challenges can significantly impact their overall well-being and development. According to the Centers for Disease Control and Prevention (CDC), only about 20% of children within the foster care system receive any care from a specialist within the mental health field.³ Placement instability is a significant issue in the foster care system, with many children experiencing multiple moves during their time in care. Each move can disrupt relationships with mental health providers, leading to gaps in treatment and increased emotional and psychological distress. Placement instability negatively affects various developmental outcomes of foster children, including increasing the risk of behavioral, social, and academic problems, negative self-esteem, psychopathology, and distrust in adults.⁴ The foster care system's primary goal should be to provide a stable environment for foster children, minimizing the potential negative impacts on their mental health and ensuring continuous access to mental health care, which is especially crucial as these children are already vulnerable due to pre-foster care risk factors.

Many foster care children face a shortage of resources for comprehensive mental health services. This issue is particularly pronounced in rural areas, as there are limited mental health services for all youth, not just foster children, which often means that accessing care requires lengthy travel times. Accessibility issues like limited awareness, inadequate funding, transportation difficulties, and social isolation can create barriers to behavioral health services for youths in rural areas, and these challenges also hinder the recruitment and retention of specialized providers.⁵ The compounded effect of these barriers means that foster children in rural areas may have to travel long distances to reach specialized mental health care. This increased travel distance often comes with additional financial costs, including transportation expenses and time off work for foster parents. Such burdens can be discouraging, leading foster parents to forgo or delay seeking necessary treatment for their foster children. As a result, the mental health needs of these foster children may remain unmet, further exacerbating their vulnerability and potentially impacting their overall well-being and development.

During my clinical experience, I had the opportunity to work with children within the foster care system. I gained valuable insights into the barriers they face when accessing mental health services, as well as the psychopathology stemming from their challenging circumstances. Foster children are often displaced due to safety concerns, which can include parental substance abuse, physical and sexual abuse, incarceration, neglect, abandonment, or severe psychological disorders, which affects their parents' ability to care for them.

One case involved a child from a home affected by parental substance abuse and legal issues. He and his sibling were placed with an experienced foster parent, but the family faced ongoing challenges, including frequent visits from child protective services and barriers to accessing consistent mental health care due to long travel distances and financial constraints. The boy was previously diagnosed with attention-deficit/hyperactivity disorder (ADHD)-combined type and oppositional defiant disorder (ODD), with elopement and aggression being 2 major presentation issues. When his foster mother could not consistently get his medication or bring him to behavioral therapy appointments, his behavior worsened, requiring a reevaluation of his treatment and the involvement of a new behavioral therapist. The barriers of distance and financial constraints further complicated the situation, discouraging the foster mother from pursuing necessary care while she was already managing the needs of other foster children.

Another case involved a child placed with a relative after experiencing instability in several previous foster placements. The child’s parents struggled with substance abuse and legal issues, leading to multiple placements before finally being placed with a family member. This ongoing instability began to affect the child’s behavior, resulting in a diagnosis of ODD and ADHD at a young age. Once placed with the relative, the child started receiving more consistent psychiatric care, though the effects of previous instability were already apparent.

Reflecting on research findings and clinical experience highlights several key improvements that could significantly enhance foster children's access to mental health care. First, enhancing stability and continuity in care would be a high priority. Developing and implementing protocols to minimize placement instability and ensure consistent care can help maintain ongoing relationships with mental health providers for children. Research has indicated that targeted support for youth, foster parents, and birth parents can significantly improve mental health, but the routine use of evidence-based practices in foster care remains lacking.⁶

With the implementation of new protocols and policies based on current evidence-based best practices, the foster care system could improve and change the mental health outcomes for foster children. Second, improving access to mental health services in rural areas is essential. Creating telehealth options and mobile mental health services can address long travel times and limited services, making care more accessible. These solutions would also alleviate the financial strain on foster parents, making it easier for them to obtain the necessary support for these children. Lastly, an important aspect to address would be strengthening care coordination by developing integrated care models that facilitate better and more efficient communication among mental health providers, foster parents, and caseworkers. Improved coordination would ensure that all parties involved are well-informed and can collaborate effectively, leading to higher quality and more consistent care for foster children. By focusing on these essential areas—ensuring stability in care, enhancing access to services in rural areas, and improving coordination within the foster care system—barriers to mental health care for foster children can be significantly reduced. Ultimately, these improvements have the potential to lead to better outcomes and overall well-being for this vulnerable population.

Ms Guidry is a first-generation college student currently pursuing a master's degree to become a psychiatric mental health nurse practitioner at the University of Mississippi Medical Center.

References

1. Dubois-Comtois K, Bussières EL, Cyr C, et al. Are children and adolescents in foster care at greater risk of mental health problems than their counterparts? A meta-analysis. Child Youth Serv Rev. 2021;127:106100.
2. Cummings ADL, VanHorne BS, Avritscher EBC, et al. Healthcare utilization among children in foster care in the greater Houston area. Child Youth Serv Rev. 2020;116.
3. Improving access to children’s mental health care. Centers for Disease Control and Prevention. Accessed September 19, 2024. https://www.cdc.gov/childrensmentalhealth/access.html#ref
4. KonijnC, Admiraal S, Baart J, et al. Foster care placement instability: a meta-analytic review. Child Youth Serv Rev. 2019;96:483-499.
5. Robinson LR, Holbrook JR, Bitsko RH, et al. Differences in health care, family, and community factors associated with mental, behavioral, and developmental disorders among children aged 2–8 years in rural and urban areas—United States, 2011–2012. Surveillance Summaries. 2017;66(8):1-11.
6. Pecora PJ, Jensen PS, Romanelli LH, et al. Mental health services for children placed in foster care: an overview of current challenges. Child Welfare. 2009;88(1):5-26.