Understanding Foster Youths’ Mental Health Services Access and Pathways to Care

Unmet mental health needs are prevalent among children in the United States, and the societal changes occurring during the COVID-19 pandemic have likely exacerbated existing barriers to service access. These issues are particularly pronounced for youth in foster care, whose access is dependent upon systems of professional decision-making. However, little is known about the pandemic-era utilization changes such youth have experienced. The three studies in this dissertation examine the system dynamics that shape access to services for youth in foster care, the shifts in their service use occurring during the pandemic, and the factors predicting their service utilization. Paper one employed a community-based system dynamics approach to elicit system actors’ perspectives on access issues and the system structures that shaped these problems. Paper two used a comparative interrupted time series analysis of North Carolina Medicaid claims data to test whether service use, residential placement, and psychotropic medication access rates for youth in foster care changed compared to youth not in foster care during the early stages of the pandemic. Paper three examined the factors at the individual and contextual level that predicted whether youth in foster care utilized mental health supports. Results from paper one highlight system limitations in residential placement capacity and community-based service provision that contribute to lengthy service delays, inappropriate care arrangements, placement disruptions, and unnecessary family separations. Results from paper two suggest that youth in foster care may have experienced higher rates of service use and less disruption in care early in the pandemic, although service use for all youth has remained concerningly low despite accounts of increased need. The findings in paper three indicate that access to proactive services may be even more limited for older and dually-diagnosed youth in foster care, as well as for foster youth of color. Overall, these studies suggest that the foster care system may act as a gateway to support for youth in need but that this gateway remains inadequate to comprehensively promote child and family well-being. Future research in this field should seek to understand service trajectories for youth in foster care in more detail and to develop interventions that target barriers to access on multiple levels.Doctor of Philosoph