mental health challenges for emancipating dependents · health and mental health issues compared to...
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MENTAL HEALTH CHALLENGES FOR EMANCIPATING DEPENDENTS
FROM FOSTER CARE TO…
DOES ANYONE CARE?
Ross Andelman, MD, MFA & Patrick Harrington, PhD
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Overview
Why is it important to focus upon these youth?
What issues do TAY face when emancipating?
What are some etiological explanations?
Our Contra Costa County TAY
Mental Health and Foster Care
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Difficulties of Emancipated Youth
Education
~5 times fewer graduate from HS compared to non foster youth
Employment/Economics
< 50% employed
Far more earning < $10,000/year than other 19 year-olds
~50% living in the poverty range
10% report not having enough money for food
30% to 50% enrolled in at least one public assistance program
14% homeless at some time in first year after emancipating
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Emancipating Youth and The Criminal Justice System
Arrests before emancipation
30-40% of youth in foster system
6.9% of youth outside of the foster system
Within first year after emancipation
~1/3 of youth arrested
15-20% of youth spent at least one night in a correctional facility
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Disconnected Youth
Defined as “out of work” and “not in school”
12 months after emancipation, ~1/3rd of youth can be described as “Disconnected Youth”
3 times higher than other 19 year-olds
Risk factors for disconnectedness
History of Incarceration
Protective factors against disconnectedness
Closeness to at least one family member
Desire to attend college
General satisfaction with their out-of-home care experiences
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Health and Mental Health Issues
Compared to other 19 year olds, emancipated youth have
> health problems
> visits to the ER
> hospitalizations
~50% of emancipated females have been pregnant by age 19
compared to 20% of a non-foster care population
~1/3rd of emancipated youth have sought MH care
2x the rate of non-foster care youth at age 19
Males more likely to report substance abuse problems
Females more likely to report symptoms of depression and PTSD
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Developmental Challenges
Trust vs. Mistrust
Will the world give me what I need?
Neglect
Autonomy vs. Shame
Can I exert my will over my environment?
Abuse and abandonment
Initiative vs. Guilt
What can I imagine becoming when I grow up?
Paucity of role models; Limited opportunity to play
Industry vs. Inferiority
What can I learn to do?
Learning Disabilities, emotional and behavioral impediments
Erik Erikson
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Developmental Challenges
Identity vs. Role Confusion
Who am I?
What is my relationship to those around me?
To whom can I look for my moral compass?
What is my philosophy of life?
Paucity of role choices
Bankruptcy of available models
Foreclosure on sense of identity
Erik Erikson
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Biological, Genetic, Environmental Risk Factors
Genetic loading
Intra-uterine exposure / trauma
Early childhood abuse and neglect
For TAY,
Failure of family reunification
Failure to be adopted
Placement instability
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Placement Instability
For youth in care >1 yr:
The older they are, the more they have moved
TAY have moved > 5 times; some > 20 times
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Contra Costa County
Population >> 1,000,000
Population growing ~1% per year
East county growing > 12% per year
9th most populous county in state
Population under age 18 ~270,000
Increase of > 20,000 between 1998 and 2006
Increase predominantly in Hispanic population
Asian and African American #s virtually unchanged
Caucasian #s declined
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Trends in Population of Youth
Extrapolation of White and Hispanic Child Populations in Contra Costa County
020,00040,00060,00080,000
100,000120,000140,000
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Year
Num
ber
WhiteHispanic
Number of Latino/Latina youth under age 18 likely to surpass that of White youth sometime around 2014
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Children in Foster Care
TAY account for 22% (n = 363) of the total number of foster care youth in CCC
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Foster Youth Rates by Age Group
For 2006, youth in foster care represented
TAY in care relative to state pop = 7.6/1000
Children under 2 years in care relative to state pop = 8.5/1000
TAY in care relative to CCC pop = 7.3/1000
Relative to CCC foster care rates of other age groups, TAY represents the highest proportion
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TAY by Gender and Ethnicity
Gender
TAY: More females
Pre-TAY: More males
Ethnicity
TAY : >50 % AA
Pre-TAY: <50 % AA
Pre-TAY TAY
F 47.9% 56.2%
M 52.1% 43.8%
AA 46.1% 54.8%
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Placement Type
As level of restrictiveness increases, the percentage of TAY youth increases
TAY %’s
FH = 9.9%
FFA = 16.3%
GH = 50.2%
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Long Term Planning
41% of current TAY have spent > ½ of their lives in foster care
FR
Pre-TAY n=485 (92.6%)
TAY n=39 (7.4%)
PP
Pre-TAY n=781 (70.7%)
TAY n=323 (29.3%)
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Open CFS CasesWith MH Records
~2/3rds of open CFS cases have had mental health involvement
~2/3rds of those who have had MH involvement still have an open case
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Age of Child and MH Involvement
Likelihood of mental health involvement increases with age
Median Age = 12
Modal Age = 16
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Diagnostic Information
1/3rd - Adjustment D/O
1/3rd - Anxiety or Depression
9% - “acting out”
7% - ADHD
2% Attachment D/O
17% - missing or deferred
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Age and Diagnosis
Adjustment Disorders
Fairly evenly distributed by age – after age 3
Anxiety Disorders
Over 200 children diagnosed with PTSD
Highest % aged 16 now
Depressive Disorders
Majority in “teens”
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MH Involvement By Placement TypePercentage of Children
in Out of Home Care with MH Involvement by Placement Home Type
0.0
10.020.0
30.040.0
50.0
60.070.0
80.090.0
100.0
Gro
up H
ome
FFA
Rel
ativ
e/N
REF
M
Fost
er F
amily
Hom
e
Smal
l Fam
ilyH
ome
Cou
rt Sp
ecifi
edH
ome
Gua
rdia
n H
ome
YesNo%
In general, as restrictiveness increases, so does MH involvement
Over 95% of youth in group homes have had MH involvement
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Psychiatric Dxs
& Psychotropic Meds Data from CCC JV220 Process
Application from physician for court authorization to prescribe psychotropic meds to dependents placed out-of-home
05/2000 –
today
> 2700 applications
> 760 unduplicated dependents
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Inventory of Diagnoses
Psychotic D/Os
Schizophreniform D/Os
Psychotic Mood D/Os
Mood D/Os
Depressive D/Os
Bipolar D/Os
Anxiety D/Os
Posttraumatic Stress D/O
Generalized Anxiety D/O
Obsessive Compulsive D/O
Impulse Control D/Os
Intermittent Explosive D/O
Disruptive Behavior
ADHD
ODD / CD
Autism Spectrum D/Os
Learning D/Os & MR
Substance Related D/Os
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Non-specific Signs & Symptoms as Targets of Intervention
Impulsivity & hyperactivity
Depressed mood
Irritability or expansive mood
Agitation
Aggressive & assaultive behavior
Worries and fears
Hallucinations & delusions
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Medication Considerations
Efficacy
Diagnostic specificity
Symptom specificity
Co-occurring conditions
Dosing & adherence
Response time-line
Safety
Adverse effects
short term & long term
Drug interactions
Availability of alternative effective interventions
Stigma
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Psychotropic Medications
Antidepressants –
SSRIs and others
Antipsychotics –
1st, 2nd, & 3rd
generation
Mood stabilizers –
lithium and beyond
Psychostimulants
–
the amphetamine family
Alpha agonists & beta blockers
Anxiolytics
–
benzodiazepines, diphenhydramine
Over the counter, herbal, & ‘natural’
drugs
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Foster Youth with Court Authorization for
Meds
8% (n=126) of all youth currently in foster care have current court authorization for psychotropic medications
Percentage with court authorization by age group
Ages 5-11 (9.3%)
Ages 12-15 (12.5%)
Ages 16-18 (7.4%)
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Diagnostic Data for TAY with Court Authorization for
Meds
Diagnoses of TAY with Court Authorization for Psychotropic Meds
0 2 4 6 8 10 12 14
Depressive D/Os
ADHD
PTSD
Bipolar D/O
Int Explosive D/O
Substance D/Os
Schizophreniform D/O
Other Anxiety D/Os
Psychotic Mood D/Os
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History of Diagnostic Data from JV220 Database -
TAY to Pre-TAY
Diagnoses for TAY Vs. Pre-TAY from JV220 Database
0 10 20 30 40 50 60 70 80
ADHD
PTSD
Depressive D/Os
Bipolar D/O
Int Explosive D/O
Other Anxiety D/Os
Schizophreniform D/O
Psychotic Mood D/Os
Substance D/Os
%TAY%Pre-TAY
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Meds Currently Authorized for TAY
Court Authorized Psychotropic Meds for TAY
0 2 4 6 8 10 12 14 16 18
Antipsychotics
Antidepressants
Psychostimulants
Mood Stabilizers
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History of Authorized
Meds Comparing TAY and Pre-TAY
Court Authorized Psychotropic Meds by Age
0 10 20 30 40 50 60 70
Antipsychotics
Psychostimulants
Antidepressants
Mood Stabilizers
%TAY%Pre-TAY
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TAY Obstacles to Continuity of MH Care
Logistical support
Motivation and engagement
Cost of care & cost of medications
Lack of “SPMI”
diagnosis
Lost history
Lack of appreciation for history
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Some Good News!
Keep youth engaged!
Increased services better outcomes
- Economics- Housing- Education- Criminal behavior- Connectedness