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Ethnic group comparisons in mental health outcomes of adult alumni of foster care
Children and Youth Services Review 32 (2010) 171–177
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Children and Youth Services Review j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h
Ethnic group comparisons in mental health outcomes of adult alumni of foster care Marian S. Harris a,⁎, Lovie J. Jackson b,1, Kirk O'Brien c,2, Peter Pecora c,3 a b c
University of Washington Tacoma, Social Work Program, 1900 Commerce Street, Tacoma, WA 98402-3100, United States University of Pittsburg, School of Medicine, Bellefield Towers 544, 3811 O'Hara Street, Pittsburg, PA 15213, United States Casey Family Programs, 1300 Dexter Ave N—3rd Floor, Seattle, WA 98109, United States
a r t i c l e
i n f o
Article history: Received 27 May 2009 Received in revised form 31 July 2009 Accepted 12 August 2009 Available online 21 August 2009 Keywords: Foster care Foster care alumni Mental health outcomes of foster care alumni Adult foster care alumni Racial differences in mental health outcomes of foster care alumni Child welfare Ethnic group differences
a b s t r a c t Racial similarities and differences in mental health outcomes of African American and White adults placed in foster care as children were examined. Existing general population studies present mixed findings as to whether racial differences in mental health exist, therefore, the current study sought to test the null hypothesis of no racial group differences in this sample of young adult alumni of foster care who were all placed as children with a private foster care agency. Specifically, logistic regression analyses were used to compare mental health outcomes among African American and White alumni. Race/ethnicity was significant only for the diagnosis of 12-month Modified Social Phobia. When controlling for demographic background, risk factors, and foster care experiences, race/ethnicity ceased to be a significant factor. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction
1.2. Racial disproportionality in child welfare
1.1. Children in foster care
Disproportionality occurs when a group of children and youth is represented at higher rates at various stages of decision-making in the child welfare system than in the general population (Magruder & Shaw, 2008). Children of color continue to be disproportionately represented in the foster care system in America. For example, according to the U.S. Census (2000), African American children comprised 15% of the total U.S. child population under the age of 18; however, African American children accounted for 37% of the total number of children placed in foster care (Harris & Hackett, 2008; Trocmé, Knoke, & Blackstock, 2004); Native American children also experience disproportionate rates in foster care; in 2004, Native American children represented less than 1% of the total child population in the United States; however, 2% of children in foster care were Native American. Hispanic/Latino children are 19% of the child population and 17% of the children in foster care (Berger, McDaniel, & Paxson, 2005; Church, 2006; Hill, 2006). African American children represent the largest proportion of children of color placed apart from their birth families (U. S. Department of Health and Human Services, 2008). For example, although they comprise 15% of the U. S. child population, African Americans represent 32% of the foster care population (Annie E. Casey Foundation, 2007; U. S. Department of Health and Human Services, 2008). Further, African American children enter care at a higher rate and stay longer
In 2006, over 3.5 million U.S. children were reported as abused and neglected, with 905,000 confirmed victims (U. S. Department of Health and Human Services, Administration on Children, Youth and Families, 2008). When a child's safety cannot be assured in the home, they are most often removed. About one-fifth of the victims are placed in foster care in family and non-family settings. Another 110,000 children are placed in such care each year because of child behavior problems or because of re-entry of children who were previously in care— “reunification failures.” While the overall numbers of children placed in out of home care have decreased slightly since 2003, as of September 30 2007, there were 496,000 children in foster care and about 783,000 children served during the 2006 federal fiscal year (U. S. Department of Health and Human Services, 2009).
⁎ Corresponding author. Tel.: +1 253 692 4554; fax: +1 253 692 5825. E-mail addresses: [email protected] (M.S. Harris), [email protected] (K. O'Brien), [email protected] (P. Pecora). 1 Tel.: +1 412 578 9485 (voice). 2 Tel.: +1 206 352 4273; fax: +1 866 321 9665. 3 Tel.: +1 206 270 4936; fax: +1 866 322 7863. 0190-7409/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2009.08.010
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than white children (Harris & Courtney, 2003; U. S. Government Accountability Office, 2007). Prior work has also documented that Hispanic/Latino children also have higher entry and slower exit rates in the foster care system (Bowser & Jones, 2004; Church, 2006). 1.3. Mental health among youth in foster care Many policy-makers and researchers are calling for a critical examination of child welfare practices and evidence of their effectiveness, including core areas of practice such as adoption (Wulczyn, Chen, & Hislop, 2003), kinship care (Hegar & Scannapieco, 1998), and neighborhood-based foster care (Berrick, 2006). Further, foster care placement experiences, such as placement changes and type of placement, have important influences on child development and are the focus of a resurgence of research (Benedict, Zuravin, & Stallings, 1996; Connell et al., 2006; James, 2004; Kessler et al., 2008; Wulczyn, Kogan, & Harden, 2003). Still, growth in research with young people who have exited foster care remains slow. Few studies look at a range of outcomes that might be indicators of a quality adult life. Most children who enter the foster care system have experienced some type of maltreatment and are at risk for a number of long-term problems because of the impact of abuse or neglect. Many children develop psychological problems such as depression, anxiety, or posttraumatic stress syndrome (PTSD) as a result of prior trauma or an accumulation of traumatic stress in their lives (Cook et al., 2007; Walker & Weaver, 2007). The Child Welfare League of America (2006) estimated that over 80% of the children in foster care have some type of behavioral, emotional, or developmental problem. These children are faced with the loss of their birth parents and extended family, and familiar environments. They also have to adjust to life in the foster care system, which can contribute to or exacerbate behavior and emotional problems (Cook et al., 2007; Pecora, Wiggins, Jackson, & English, 2008). Findings from a study by Lenz-Rashid (2005) indicated that alumni of foster care had more mental health issues than participants who had never been in foster care. Unfortunately, the child welfare system generally fails to provide the mental health services required to address these issues, including for youth of color in foster care (Bergman, 2000; Landsverk, Burns, Stambaugh, & Reutz, 2006). This problem is not limited to child welfare: on average, only one-fourth of America's children in need of mental health treatment get the services they need (RAND, 2001). Given racial disproportionality and some inequities in services to children of color, would we expect to find that adult alumni of foster care would differ in their rates of emotional and behavioral disorders? The current study will help increase understanding of how race/ethnicity influence the mental health outcomes of African American and White foster care alumni, while controlling for several factors related to the foster care experiences of these alumni. 1.4. Racial and ethnic group differences in mental health functioning Although African Americans in the U.S. experience higher rates of poverty (Fass & Cauthen, 2007), CPS-substantiated child maltreatment, and foster care than their White counterparts (Ards, Myers, Malkis, Sugrue, & Zhou, 2003; Lau et al., 2003), little evidence exists in regard to mental health differences between racial groups. While most studies group people of color together, studies examining disparities between African Americans and Whites have yielded mixed results (Fryers, Melzer, & Jenkins, 2003; Satcher et al., 2005; The National Academic Press, 2004; Wallman, Evinger, & Schechter, 2000). Zuravin and Fontanella (1999), controlling for age at interview, several family characteristics, and verbal and physical abuse, emotional and physical neglect, and sexual abuse, found that being African American reduced the likelihood of depression by 41% in a low-income sample of African American and White women. Abram et al. (2004) found no differences in the prevalence of PTSD among African American, Hispanic, and White
youth in a juvenile detention center and Franko et al. (2004) found no differences between African American and White females and the relationship between negative life events, traumatic experiences, and subsequent depressive symptoms. A study of the general population, the National Comorbidity Survey, revealed that African Americans had significantly lower odds of lifetime mood, anxiety, and substance use disorders than Whites but greater persistence of any chronic disorder and chronic anxiety, less persistence of lifetime or 12-month substance use disorders and any 12month diagnosis (Breslau, Kendler, Su, Aguilar-Gaxiola, & Kessler, 2005). Breslau et al. (2006) found that in the National Comorbidity Survey Replication (NCS-R), also a study of the general population, African Americans had significantly higher prevalence of bipolar disorder but significantly lower lifetime prevalence of depression, generalized anxiety disorder, social phobia, panic disorder, early-onset impulse control disorders, and substance use. Additionally, African Americans in the National Survey of American Life had significantly lower lifetime prevalence of Major Depressive Disorder (MDD) but significantly higher chronic course of lifetime MDD (Williams et al., 2007). Given the results of a limited set of studies in the general population and other areas (low income, juvenile detention), would the pattern of ethnic group differences (or the lack thereof in some studies) be the same for young adults who had been served in foster care? Outcome studies on the mental health of youth in foster care and of alumni are limited. However, in a Wisconsin study, significant differences were found in a comparison of the mental health of alumni and youth in the general population (Courtney & Piliavin, 1998). Both African American and White youth who had exited foster care 12 to 18 months prior to assessment had higher rates of psychological distress than their counterparts. 1.5. Methodological limitations of previous studies Some limitations in previous studies of alumni of foster care and the dearth of existing research involving alumni of foster care make the current study useful for prevention and intervention work with this population. Previous studies have tended to report alumni outcomes at young ages—in their late teens rather than early twenties and beyond. Additionally, few studies used standardized mental health measures relating to diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). Further, race/ethnic differences were rarely reported. Therefore, the current study will help increase understanding of whether race/ethnicity influence the mental health outcomes of African American and White foster care alumni while controlling for several factors related to the foster care experiences of these alumni. 1.6. Study purpose The purpose of the current study was to examine differences between two racial/ethnic groups (African American and White) of adult alumni of foster care on mental health outcomes, including depression, anxiety, and post-traumatic stress disorder. The sample included young adults who were placed in foster family care between 1966 and 1998 in 23 field offices of a private foster care agency in the United States (Casey Family Programs, 2007). While the services provided were more extensive, note that this agency focused on serving children referred by public child welfare agencies that were less likely to be returned home or adopted (Pecora, Kessler, & Williams, in press). The current analysis will help determine if racial differences exist among the alumni of this agency despite the higher quality of the program in terms of greater youth access to mental health services. Therefore, the results have generalizability to this population of youth. Study findings must be married with other studies of alumni to portray the complete picture of mental health functioning of alumni of foster care.
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Thus, this set of special analyses focused on detecting similarities or differences between African Americans, the most overrepresented population in foster care, and Whites. The White racial group was selected for the comparison because they are underrepresented in foster care nationally (percentage-wise), but comprise a sizable number of children in care. 2. Theoretical foundation An ecological risk and protective factors model was used as a framework for this examination. Ecological theory, developed by Bronfenbrenner (1977), explains and links developmental outcomes across the life-course to the multiple and diverse environmental contexts to which a person is exposed. The five environmental systems in this theory range from intricate personal interactions to extensive cultural inputs. As diagrammed in Fig. 1, personal characteristics (e.g., biological and genetic makeup, personality, and cognitive ability), as well as how one interacts with others in the context of family systems, culture, and broader social systems all influence one's ability to achieve optimal success (Cicchetti & Aber, 1998; DeBellis, 2001). To increase understanding of the determinants of health and positive adult functioning among alumni of foster care, this research empirically examines risk and protective factors at individual, family, and systems levels. Based on this conceptualization, outcomes are expected to be affected by transactions within the alumnus' ecological systems. For instance, individual-level factors such as mental/physical health problems diagnosed before or during foster care (e.g., Attention Deficit Hyperactivity Disorder or ADHD) would interact with other domains of risk or protection within the biological family environment (e.g., parental mental health) and foster family (e.g., helpfulness of foster parents), and other factors associated with the broader context of foster care (e.g., placement history, or supports and services) to influence the likelihood of psychological disorders, educational achievements, and financial status. As it relates to the current examination, the model uses demographic and contextual factors as controls while analyzing the role of race/ethnicity in predicting the probability of several mental health diagnoses.
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3. Method 3.1. Participants A sub-sample (N = 708) of the Casey National Foster Care Alumni Study was examined. The sample included 134 (21.9%) African American and 574 White (78.1%) adult foster care alumni served by foster families and caseworkers of the Casey Family Programs (Casey) between 1966 and 1998. Demographic characteristics by race/ethnicity for each group are shown in Table 1. The two groups were closely matched in terms of gender, with females accounting for 52.6% of the African American subgroup and 48.3% of the White subgroup. On average, African Americans were younger than Whites at the time of the interview and were served mostly in the Southwest (Austin and San Antonio, Texas), and Northwest (Portland, Oregon, and Tacoma, Seattle, and Yakima, Washington) regions. Most White alumni were served in the Great Plains and the Northwest. 3.2. Agency description Study participants were served by the Casey Family Programs, a national operating foundation that supports youth in care and foster families through direct services and system improvement efforts in child welfare. All alumni were served in Casey's field offices in operation in 1998 in 13 states: Arizona (Phoenix and Tucson); California (Walnut Creek/Bay Area and San Diego); Hawaii (Hilo and Honolulu); Idaho (Boise); Louisiana (Baton Rouge); Montana (Helena and Missoula); North Dakota (Bismarck and Fort Berthold); Oklahoma (Oklahoma City); Oregon (Portland); South Dakota (Pine Ridge, Rapid City, and Rosebud); Texas (Austin and San Antonio); Washington (Seattle, Tacoma, and Yakima); and Wyoming (Cheyenne). 3.3. Measures 3.3.1. Demographics, risk factors, and foster care experiences Case records included demographics (e.g., decade entered foster care and region served in care); risk factors (e.g., reasons for foster care placement, child maltreatment); and foster care experiences
Fig. 1. Ecological–transactional model of child maltreatment.
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Table 1 Demographic characteristics by race/ethnicity. African American n = 134
% of study sampleb Gender Male Female Age at time of interviewa,b 20–25 26–29 30–34 35–49 Mean age at time of interviewa,b Decade entered Casey foster carea 1966 to 1979 1980 to 1989 1990 to 1998 Region served in carea Southwest Great Plains Hawaii California Northwest
White n = 574
% (SE)
% (SE)
21.9 (1.7)
78.1 (1.7)
47.4 (4.5) 52.6 (4.5)
51.8 (2.1) 48.2 (2.1)
37.8 30.7 18.9 12.7 28.0
20.4 20.9 26.6 32.2 31.5
(4.3) (4.1) (3.4) (3.0) (0.5)
18.7 56.7 24.6
31.7 55.9 12.4
24 9 6 17 43
8 42 1 6 42
(1.7) (1.7) (1.9) (2.0) (0.3)
a Indicates a significant difference between African American and White alumni as tested by chi-square or t-tests, p b .05. b Weighted percentages; ns are unweighted.
(e.g., placement history). Interview data included birth parent information (e.g., health and mental health status, substance use, employment, and parenting style), and some foster family and foster care experience information (e.g., foster parent warmth and overprotection; relationships with other caring adults; child maltreatment; and access to educational and mental health services). 3.3.2. Mental health Mental health diagnoses for alumni of foster care were assessed during the interview using the Composite International Diagnostic Interview (CIDI). The CIDI is a non-clinician administered standardized interview developed by the National Institutes of Health, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) and the World Health Organization (WHO) for use in epidemiological studies, and is often used for research and clinical assessment (Clinical Research Unit for Anxiety & Depression, 2006; Harvard Medical School, 2006; Wittchen, Kessler, Zhao, & Abelson, 1995). Sections of the CIDI were used in the current study to assess lifetime and 12-month occurrence of psychological disturbances and substance dependence among alumni (e.g., Major Depression, Panic Syndrome, Social Phobia, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, and Drug and Alcohol Dependence). Additionally, the interview included the Short Form Health Survey 12 (SF-12®) to assess overall mental and physical health. The SF-12® was developed to be a shorter, yet valid, alternative to the SF-36® for use in large surveys of general and specific populations as well as for large longitudinal studies of health outcomes. The mental health summary score was used to assess overall mental health functioning (Ware, Kosinski, & Keller, 1998, pp. 11 & 60).
Data collection for the Casey National Foster Care Alumni study was completed between 2000 and 2002. Professionally trained interviewers from the University of Michigan Survey Research Center, unfamiliar with study hypotheses, collected data from 1582 Casey alumni case records and conducted one-on-one interviews with 1068 alumni. The adjusted response rate was 73.4% [(adjusted for the 8% of the sample who was inaccessible due to incarceration (3.4%), psychiatric institutionalization (0.7%), or death (3.9%)]. A random sample of 40 case records was selected for an inter-rater reliability check. Each record was reviewed by a trained staff member and a “gold standard” reviewer who had the most extensive case record review training and the most consistent performance (of which there were four); they also randomly reviewed a random sample for verification purposes. Only variables that had acceptable inter-rater reliability (Cohen's Kappa greater than or equal to .70) were retained. 3.5. Analysis plan 3.5.1. Weighting Case records were available for 1068 alumni of Casey foster care. However, because some alumni were unavailable for interviews, weights were created to account for non-responses. Because they were available for the entire sample of 1582, case record variables were used to create the statistical weights and included age, gender, and race/ ethnicity. The weighting improved the ability to generalize to the population of adults from which the sample was drawn by estimating data as if the entire sample of 1582 alumni had been interviewed. Specifically, propensity score matching was used to weight the data by estimating a logistic regression equation (Hosmer & Lemseshow, 1989) separately that distinguished survey respondents from nonrespondents (treated as a dichotomous dependent variable) based on pre-placement characteristics. The predicted probabilities generated from these equations were used to weight the data without case-level matching so that survey respondents had distributions on pre-placement characteristics comparable to the original total agency sample. This matching improved the ability to generalize to the population from which the sample was drawn by weighting the data so that differences between the samples did not bias the results (Braitman & Rosenbaum, 2002). 3.5.2. Hypothesis testing: Examining racial/ethnic differences Due to a lack of conclusive evidence of racial/ethnic differences in the general population, we tested the null hypothesis of no difference between groups on mental health outcomes. Initially, the data were examined using bivariate chi-square analyses. Any outcomes with statistically significant differences between African American and White alumni were retained and analyzed by race/ethnicity in logistic regression models while controlling for ecological factors: demographics, risk factors, and foster care experiences. If race/ethnicity was not significant in the regression when entered alone (Step 1), it was concluded that no differences existed between the two groups on this outcome and no further analyses were necessary. If there was a difference between the two groups, the next set of predictor variables—demographics, risk factors and foster care experiences (see Table 2)—was entered into the logistic regression model in addition to race/ethnicity. All significant variables were retained in subsequent models. When race/ethnicity was no longer significant, no further steps were taken.
3.4. Procedure 4. Results Inclusion criteria for alumni in the study were: (a) placement in Casey foster care between 1966 and 1998; (b) placement with a Casey foster family for at least 12 consecutive months; and (c) exit from Casey foster care for at least 12 months prior to being interviewed (Pecora et al., 2003, 2006).
4.1. Bivariate analyses As presented in Table 3, bivariate analyses were conducted for mental health outcomes. A substantial percentage of both ethnic
M.S. Harris et al. / Children and Youth Services Review 32 (2010) 171–177 Table 2 Variables in logistic regression models.
Table 3 Bivariate results: Alumni mental health diagnoses by race/ethnicitya.
Step Domain
Variable
Source
1 2
Race/Ethnicity Age at time of interview Gender Decade entered child welfare Region served in Casey foster care Age entered child welfare Relationship with birth parents Birth parent employment Number of places lived before foster care Birth parent mental health Birth parent physical health Birth parent substance abuse Birth parent criminal problems Birth parent warmth Birth parent overprotection Number of abuse types Type of abuse/neglect (emotional, physical, sexual, neglect) Number of reasons for placement Placed due to child behavior problems Placed due to child maltreatment Placed due to parental substance abuse Other reason(s) for placement Attention Deficit Hyperactivity Disorder (ADHD) Physical or learning disability Other impairments (i.e., drug exposed as an infant, fetal alcohol effect, fetal alcohol syndrome, or vision or hearing impaired) Number of placements Length of time in care Placement change rate Number of reunification failures Number of runaways Number of unlicensed living situations with friends/relatives Number of school changes Could participate in supplemental Educational services/tutoring (access) Could participate in therapeutic service and supports (access) Participated a lot in activities with foster family Degree of preparation for leaving care Number of resources when left care Foster parent warmth Foster parent overprotection Foster family helped with ethnic issues Had a close and confiding relationship with an adult while growing up Felt loved while in foster care Overall, foster parents were helpful Child maltreatment while in foster care
I I CR CR CR CR I I I I I I I I I CR CR
3
4
Demographics Demographics
Risk Factors
Foster care experiences
175
CR CR CR CR CR CR CR CR
CR CR CR CR CR CR I I I I I I I I I I I I I
groups exhibited symptoms of at least one mental health disorder (African American: 42.0%; White: 43.7). But among the mental health variables, only Modified Social Phobia showed statistically significant differences (p b .05) between African American and White alumni. More African Americans had no Social Phobia diagnosis compared to Whites (93.0% versus 86.6%). 4.2. Multivariate analyses After determining where bivariate differences existed, a series of logistic regressions was run to determine whether being African American or White continued to contribute to different prevalence rates on the one emotional or behavioral disorder where there was a bivariate difference: Modified Social Phobia.
Mental health
No 12-month CIDI DSM diagnosis
African American White n = 134 n = 574
b
Odds Ratio (Confidence Interval)
% (SE)
% ( SE )
58.0 (4.3)
56.2 (2.1) 0.9 (0.7–1.6) 87.9 (1.4) 0.9 (0.6–2.1) 85.6 (1.5) 1.2 (0.5–1.4) 89.7 (1.3) 0.7 (0.9–2.4) 86.6 (1.4) 2.1 (0.2–1.0) 91.4 (1.2) 1.3 (0.4–1.6) 79.1 (1.7) 1.1 (0.6–1.5) 97.9 (0.6) .468 (0.8–5.9) 96.9 (0.8) 0.6 (0.6–4.0) 56.3 (2.1) 1.1 (0.6–1.4)
Total number of CIDI diagnoses in 89.2 (2.6) the past 12 months is less than 3 No major depression in last 87.8 (2.8) 12 months No panic syndrome in last 12 months 86.5 (2.9) No modified social phobia in last 12 monthsc No generalized anxiety in last 12 months No PTSD in last 12 monthsd
93.0 (2.2)
No alcohol dependence in last 12 months No drug dependence in last 12 months SF-12 mental health score of 50 or abovee
95.6 (1.8)
93.1 (2.1) 80.1 (3.4)
95.1 (1.8) 54.2 (4.4)
a
Percentages are weighted; n,s are unweighted. The CIDI is the Composite International Diagnostic Interview Schedule that produces a score that is associated with a diagnosis from the American Psychiatric Association, Diagnostic and Statistical Manual. c Indicates a significant bivariate difference between African American and White alumni, p b 05. d PTSD is Post-Traumatic Stress Disorder. e SF-12Health Survey is a standardized scale that measures physical and mental health functioning. Fifty or above is considered “good” mental health. b
significant contribution to differences between groups when controlling for demographic factors (i.e., gender, age at time of interview, decade entered care, and region served in care). The only factors that remained significant were gender and age at the time of interview.
5. Discussion 5.1. Racial differences in outcomes This article adds to the literature on mental health outcomes of African American and White adults who were placed in foster care as youth. When mental health outcomes of alumni in the study were compared by race/ethnicity, Modified Social Phobia was the only diagnostic category among seven specific diagnostic areas that showed statistically significant differences, with White alumni having more social phobia than African American alumni. Note that these findings do not rule out ethnic differences in other diagnostic areas, and studies with other foster care populations should be conducted. However, considering that only 58% of African Americans and 56.2% of Whites had no mental health diagnoses (Table 3), attending to the psychological needs of foster youth and foster care alumni remains salient. So even as young adults, once outside of the foster care system, mental health conditions remain a challenge for many alumni of foster care. Prior work has shown that 30- to 50% of youth aging out of foster care have emotional or behavioral disorders and/or a developmental disability (Courtney, Terao, & Bost, 2004; Needell, Cuccaro-Alamin, Brookhart, Jackman, & Schlonsky, 2002). 5.2. Implications
4.3. No Modified Social Phobia In Step 2 of these analyses the logistic regression model for No Modified Social Phobia showed that race/ethnicity did not make a
One of the intriguing findings of this set of analyses was how alumni race/ethnicity was not a significant factor for most mental health outcomes. The findings underscore the need for periodic evaluation
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of mental health functioning and mental health insurance coverage for youth after they leave foster care into adulthood. It is important to evaluate mental health functioning periodically to determine if there have been changes (positive or negative) in youth's behavior and functioning and if these changes can be attributed to service availability, cultural competence of services, family involvement, and interagency structure. Furthermore, periodic evaluations can be used to further assess youth's emotional and behavior status, strengths, education performance, and satisfaction or dissatisfaction with services. The distinctions and similarities among young people based on these evaluations can be used to help explain variations in the mental health treatment experiences of youth as well as used to determine the nature and extent of clinical and functional outcomes for youth served in child welfare agencies and other systems of care. Young people in foster care have emphasized the importance of exercising choices and having a role in determining the kind of mental health services and psychotropic drugs they receive while in care. They also worry about the kinds of health care coverage they will have as they transition from foster care as major gaps in coverage exist (Pecora et al., 2003; Rubin, Halfon, Raghavan, & Rosenbaum, 2005; Stanley, 2007). 5.3. Methodological advantages and disadvantages of the current study To fully understand the study findings and how they fit into the existing literature on alumni of foster care functioning, several methodological issues must be noted. First, the average age of youth in this study was around thirty. While this allows for assessment of outcomes after many life experiences, it makes it difficult to compare current findings to findings of previous studies. Second, because participants were served in a limited geographical range and by one agency, generalizations are limited to those in the examination. At the time youth were served in foster care, Casey was unique in its heavy emphasis on culturally competent services and the extensiveness of those services. The services offered may have resulted in fewer ethnic group differences. As discussed previously, the findings must be married with other research to fully understand alumni functioning. Lastly, although the interview was extensive, it was not exhaustive. Specifically, additional data could have been collected that would have more fully explained differences, or lack thereof, in the mental health functioning of alumni. 5.4. Conclusion With the lack of ethnic group differences, the importance of offering mental health services to all alumni of foster care cannot be overstated. McMillem et al. (2004) examined lifetime, 12 month, and current use of mental health services in Missouri's foster care system; findings revealed that youth of color were more likely to get residential services and less likely to get outpatient therapy, inpatient services, and psychotherapeutic medications; the child welfare system appeared to take a proactive role in referring youth for mental health services in this study. Regardless of race/ethnicity, youth need continued support to have successful outcomes in mental health after they exit the foster care system. It is imperative for youth to have ongoing post-foster care supports (such as financial, emotional, housing, education, employment) from caregivers, other significant adults in their lives, and from the broader communities in which they live. Individualized assessments and follow-up care must include cultural factors such as language, race, ethnicity, customs, family structure, sexual orientation and tribal and/or community dynamics. Youth need mental health services that are client-centered, family-focused, community-based, culturally and linguistically competent, and integrated to facilitate development of self-sufficiency and their maximum level of mental health functioning.
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S., Su, M., Aguilar-Gaxiola, S., & Kessler, R. C. (2005). Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States. Psychological Medicine, 35(3), 317–327. Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32(7), 513–531. Casey Family Programs. (2007). Disproportionality in the child welfare system: The disproportionate representation of children of color in foster care. Seattle, WA: Author. Child Welfare League of America. (2006). Child mental health: Facts and figures. Retrieved December 15, 2006, from http://www.cwla.org/programs/bhd/mhfacts.htm Church, W. T., II (2006). From start to finish: The duration of Hispanic children in outof-home placements. Children and Youth Services Review, 28, 1007–1023. Cicchetti, D., & Aber, J. L. (1998). Contextualism and developmental psychopathology. Development and Psychopathology, 10, 137–141. Clinical Research Unit for Anxiety & Depression. (2006). Composite international diagnostic interview. Retrieved December 30, 2006, from http://www.crufad.edu.au/ cidi/cidi.htm Connell, C. M., Jeffrey, J., Vanderploeg, J. J., Paul, F. P., Karol, H., Katz, K. H., et al. (2006). Changes in placement among children in foster care: A longitudinal study of child and case influences. Social Service Review, 80(3), 398–418. Cook, A., Spinazzola, J. F., Lanktree, C., Blaustein, M., Sprague, C., Cloitre, M., et al. (2007). Complex trauma in children and adolescents. Focal Point: Research, Policy, & Practice in Children's Mental Health, 21(1), 4–8. Courtney, M., & Piliavin, I. (1998). Foster youth transitions to adulthood: Outcomes12 to 18 months after leaving out-of-home care. Madison, WI: Institute for Research on Poverty, University of Wisconsin-Madison. Courtney, M. E., Terao, S., & Bost, N. (2004). Midwest evaluation of the adult functioning of former foster youth wave 1: Three state findings. Chicago: Chapin Hall Center for Children, University of Chicago. DeBellis, M. B. (2001). Developmental traumatology: The psychobiological development of maltreated children and its implications for research, treatment, and policy. Development and Psychopathology, 13, 539–564. Fass, S., & Cauthen, N. K. (2007). Who are America's poor children? The official story. New York: National Center for Children in Poverty, Columbia University, Mailman School of Public Health. Franko, D. L., Striegel-Moore, R. H., Brown, K. M., Barton, B. A., McMahon, R. P., Schreiber, G. B., et al. (2004). Expanding our understanding of the relationship between negative life events and depressive symptoms in Black and White adolescent girls. Psychological Medicine, 34, 1319–1330. Fryers, T., Melzer, D., & Jenkins, R. (2003). Social inequalities and the common mental disorders: A systematic review of the evidence. Social Psychiatry and Psychiatric Epidemiology, 38(5), 229–237. Harris, M. S., & Courtney, M. E. (2003). The interaction of race, ethnicity, and family structure with respect to the timing of family reunification. Children and Youth Services Review, 25(5/6), 409–429. Harris, M. S., & Hackett, W. (2008). Decision points in child welfare: An action research model to address disproportionality. Children and Youth Services Review, 30(2), 199–251. Harvard Medical School. (2006). The World Health Organization (WHO) world mental health (WMH) survey initiative version of the composite international diagnostic interview (CIDI). Retrieved December 30, 2006, from http://www.hcp.med.harvard. edu/wmhcidi/ Hegar, R. L., & Scannapieco, M. (1998). Kinship foster care: Policy, practice, and research. New York: Oxford University Press. Hill, R. B. (2006). Synthesis of research on disproportionality in child welfare: An update. Washington, DC: The Casey-CSSP Alliance for Racial Equity and Center for the Study of Social Policy. Hosmer, D., & Lemseshow, S. (1989). Applied logistic regression. New York: Wiley & Sons. James, S. (2004). Why do foster care placements disrupt? An investigation of reasons for placement change in foster care. Social Service Review, 78(4), 601–627.
M.S. Harris et al. / Children and Youth Services Review 32 (2010) 171–177 Kessler, R. C., Pecora, P. J., Williams, J., Hiripi, E., O'Brien, K., English, D., et al. (2008). The effects of enhanced foster care on the long-term physical and mental health of foster care alumni. Archives in General Psychiatry, 65(6), 625–633. Landsverk, J. A., Burns, B. J., Stambaugh, L. F., & Reutz, J. A. R. (2006). Mental health care for children and adolescents in foster care: Review of research literature. Seattle, WA: Casey Family Programs. Lau, A. S., McCabe, K. M., Yeh, M., Garland, A. T., Hough, R. L., & Landsverk, J. (2003). Race/ethnicity and rates of self reported maltreatment among high risk youth in public sectors of care. Child Maltreatment, 8(3), 183–194. Lenz-Rashid, S. (2005). Employment experiences of homeless young adults: Are they different for youth with a history of foster care? Children and Youth Services Review, 28, 235–259. Magruder, J., & Shaw, T. V. (2008). Children ever in care: An examination of cumulative disproportionality. Child Welfare, 87(2), 169–188. McMillem, J. C., Scott, L. D., Zima, B. T., Ollie, M. T., Munson, M. R., & Spitznagel, E. (2004). Use of mental health services among older youths in foster care. Psychiatric Services, 55, 811–817. Needell, B., Cuccaro-Alamin, S., Brookhart, A., Jackman, W., & Schlonsky, A. (2002). Youth emancipating from foster care in California: Findings using linked administrative data. Berkeley, CA: Center for Social Services Research. Pecora, P. J., Kessler, R. K., & Williams, J. (in press). The legacy of family foster care: How are alumni faring as adults? New York: Oxford University Press. Pecora, P. J., Wiggins, T., Jackson, L. J., & English, D. (2008). Working paper no. 2: The effects of child maltreatment on children and adults: A brief literature review. Seattle, WA: Casey Family Programs. Pecora, P. J., Williams, J., Kessler, R. J., Downs, A. C., O'Brien, K., Hiripi, E., et al. (2003). Assessing the effects of foster care: Early results from the Casey National Alumni Study. Seattle, WA: Casey Family Programs. Pecora, P. J., Williams, J., Kessler, R. C., Hiripi, E., O'Brien, K., Emerson, J., et al. (2006). Assessing the educational achievements of adults who formerly were placed in family foster care. Child and Family Social Work, 11, 220–231. RAND. (2001). RAND health research highlights: Mental health care for youth, 2001. Retrieved December 15, 2006, from www.rand.org/publications/RB/RB4541/ Rubin, D., Halfon, N., Raghavan, R., & Rosenbaum, S. (2005). Protecting children in foster care: Why proposed Medicaid cuts harm our nation's most vulnerable children. Seattle, WA: Casey Family Programs. Satcher, D., Fryer, G. E., McCann, J., Troutman, A., Woolf, S. H., & Rust, G. (2005). What if we were equal? A comparison of the Black-White mortality gap in 1960 and 2000. Health Affairs, 24(2), 459–464. Stanley, N. (2007). Young peoples' and carers' perspectives on the mental health needs of looked-after adolescents. Child and Family Social Work, 12, 258–267.
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The National Academic Press. (2004). Eliminating health disparities: Measurement and data needs. Washington, DC: Author. Trocmé, N., Knoke, D., & Blackstock, C. (2004). Pathways to the overrepresentation of aboriginal children in Canada's child welfare system. Toronto, CA: Centre of Excellence for Child Welfare, University of Toronto. U.S. Census Bureau. (2000). Census 2000. Washington, DC: Author. U.S. Department of Health and Human Services, Administration on Children, Youth and Families. (2008). Child maltreatment 2006. Washington, DC: U. S. Government Printing Office. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau. (2008). The AFCARS Report No. 14: Preliminary FY 2006 estimates as of January 2008. Washington DC: Author. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau. (2009). Trends in foster care and adoption—FY 2002–FY 2007.Washington DC: Author Retrieved July 20, 2009, from http://www.acf.hhs. gov/programs/cb/stats_research/afcars/trends.htm U.S. Government Accountability Office. (2007). African American children in foster care. Washington, DC: Author. Walker, J. S., & Weaver, A. (2007). Traumatic stress and the child welfare system. Focal Point: Research, Policy, & Practice in Children's Mental Health, 21(1), 3. Wallman, K. K., Evinger, S., & Schechter, S. (2000). Measuring our nation's diversity: Developing a common language for data on race/ethnicity. American Journal of Public Health, 90(11), 1704–1708. Ware, J., Kosinski, M., & Keller, S. D. (1998). SF-12®: How to score the SF-12® physical and mental health summary scales, 3 rd Ed. Lincoln RI and Boston MA: QualityMetric Incorporated and the Health Assessment Lab. Williams, D. R., Gonzalez, H. M., Neighbors, H., Nesse, R., Abelson, J. M., Sweetman, J., et al. (2007). Prevalence and distribution of major depressive disorder in African Americans, Caribbean Blacks, and Non-Hispanic Whites: Results from the National Survey of American Life. Archives of General Psychiatry, 64(3), 305–317. Wittchen, H., Kessler, R. C., Zhao, S., & Abelson, J. (1995). Reliability and clinic validity of UM-CIDI DSM-III-R generalized anxiety disorder. Journal of Psychiatric Research, 29 (2), 95–110. Wulczyn, F. H., Chen, L., & Hislop, K. B. (2003). Adoption dynamics and the Adoption and Safe Families Act. Chicago: Chapin Hall Center for Children, University of Chicago. Wulczyn, F., Kogan, J., & Harden, B. J. (2003). Placement stability and movement trajectories. Chicago: Chapin Hall Center for Children, University of Chicago. Zuravin, S. J., & Fontanella, C. (1999). The relationship between child sexual abuse and major depression among low-income women: A function of growing up experiences. Child Maltreatment, 4(1), 3–12.
Contents lists available at ScienceDirect
Children and Youth Services Review j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h
Ethnic group comparisons in mental health outcomes of adult alumni of foster care Marian S. Harris a,⁎, Lovie J. Jackson b,1, Kirk O'Brien c,2, Peter Pecora c,3 a b c
University of Washington Tacoma, Social Work Program, 1900 Commerce Street, Tacoma, WA 98402-3100, United States University of Pittsburg, School of Medicine, Bellefield Towers 544, 3811 O'Hara Street, Pittsburg, PA 15213, United States Casey Family Programs, 1300 Dexter Ave N—3rd Floor, Seattle, WA 98109, United States
a r t i c l e
i n f o
Article history: Received 27 May 2009 Received in revised form 31 July 2009 Accepted 12 August 2009 Available online 21 August 2009 Keywords: Foster care Foster care alumni Mental health outcomes of foster care alumni Adult foster care alumni Racial differences in mental health outcomes of foster care alumni Child welfare Ethnic group differences
a b s t r a c t Racial similarities and differences in mental health outcomes of African American and White adults placed in foster care as children were examined. Existing general population studies present mixed findings as to whether racial differences in mental health exist, therefore, the current study sought to test the null hypothesis of no racial group differences in this sample of young adult alumni of foster care who were all placed as children with a private foster care agency. Specifically, logistic regression analyses were used to compare mental health outcomes among African American and White alumni. Race/ethnicity was significant only for the diagnosis of 12-month Modified Social Phobia. When controlling for demographic background, risk factors, and foster care experiences, race/ethnicity ceased to be a significant factor. © 2009 Elsevier Ltd. All rights reserved.
1. Introduction
1.2. Racial disproportionality in child welfare
1.1. Children in foster care
Disproportionality occurs when a group of children and youth is represented at higher rates at various stages of decision-making in the child welfare system than in the general population (Magruder & Shaw, 2008). Children of color continue to be disproportionately represented in the foster care system in America. For example, according to the U.S. Census (2000), African American children comprised 15% of the total U.S. child population under the age of 18; however, African American children accounted for 37% of the total number of children placed in foster care (Harris & Hackett, 2008; Trocmé, Knoke, & Blackstock, 2004); Native American children also experience disproportionate rates in foster care; in 2004, Native American children represented less than 1% of the total child population in the United States; however, 2% of children in foster care were Native American. Hispanic/Latino children are 19% of the child population and 17% of the children in foster care (Berger, McDaniel, & Paxson, 2005; Church, 2006; Hill, 2006). African American children represent the largest proportion of children of color placed apart from their birth families (U. S. Department of Health and Human Services, 2008). For example, although they comprise 15% of the U. S. child population, African Americans represent 32% of the foster care population (Annie E. Casey Foundation, 2007; U. S. Department of Health and Human Services, 2008). Further, African American children enter care at a higher rate and stay longer
In 2006, over 3.5 million U.S. children were reported as abused and neglected, with 905,000 confirmed victims (U. S. Department of Health and Human Services, Administration on Children, Youth and Families, 2008). When a child's safety cannot be assured in the home, they are most often removed. About one-fifth of the victims are placed in foster care in family and non-family settings. Another 110,000 children are placed in such care each year because of child behavior problems or because of re-entry of children who were previously in care— “reunification failures.” While the overall numbers of children placed in out of home care have decreased slightly since 2003, as of September 30 2007, there were 496,000 children in foster care and about 783,000 children served during the 2006 federal fiscal year (U. S. Department of Health and Human Services, 2009).
⁎ Corresponding author. Tel.: +1 253 692 4554; fax: +1 253 692 5825. E-mail addresses: [email protected] (M.S. Harris), [email protected] (K. O'Brien), [email protected] (P. Pecora). 1 Tel.: +1 412 578 9485 (voice). 2 Tel.: +1 206 352 4273; fax: +1 866 321 9665. 3 Tel.: +1 206 270 4936; fax: +1 866 322 7863. 0190-7409/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2009.08.010
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than white children (Harris & Courtney, 2003; U. S. Government Accountability Office, 2007). Prior work has also documented that Hispanic/Latino children also have higher entry and slower exit rates in the foster care system (Bowser & Jones, 2004; Church, 2006). 1.3. Mental health among youth in foster care Many policy-makers and researchers are calling for a critical examination of child welfare practices and evidence of their effectiveness, including core areas of practice such as adoption (Wulczyn, Chen, & Hislop, 2003), kinship care (Hegar & Scannapieco, 1998), and neighborhood-based foster care (Berrick, 2006). Further, foster care placement experiences, such as placement changes and type of placement, have important influences on child development and are the focus of a resurgence of research (Benedict, Zuravin, & Stallings, 1996; Connell et al., 2006; James, 2004; Kessler et al., 2008; Wulczyn, Kogan, & Harden, 2003). Still, growth in research with young people who have exited foster care remains slow. Few studies look at a range of outcomes that might be indicators of a quality adult life. Most children who enter the foster care system have experienced some type of maltreatment and are at risk for a number of long-term problems because of the impact of abuse or neglect. Many children develop psychological problems such as depression, anxiety, or posttraumatic stress syndrome (PTSD) as a result of prior trauma or an accumulation of traumatic stress in their lives (Cook et al., 2007; Walker & Weaver, 2007). The Child Welfare League of America (2006) estimated that over 80% of the children in foster care have some type of behavioral, emotional, or developmental problem. These children are faced with the loss of their birth parents and extended family, and familiar environments. They also have to adjust to life in the foster care system, which can contribute to or exacerbate behavior and emotional problems (Cook et al., 2007; Pecora, Wiggins, Jackson, & English, 2008). Findings from a study by Lenz-Rashid (2005) indicated that alumni of foster care had more mental health issues than participants who had never been in foster care. Unfortunately, the child welfare system generally fails to provide the mental health services required to address these issues, including for youth of color in foster care (Bergman, 2000; Landsverk, Burns, Stambaugh, & Reutz, 2006). This problem is not limited to child welfare: on average, only one-fourth of America's children in need of mental health treatment get the services they need (RAND, 2001). Given racial disproportionality and some inequities in services to children of color, would we expect to find that adult alumni of foster care would differ in their rates of emotional and behavioral disorders? The current study will help increase understanding of how race/ethnicity influence the mental health outcomes of African American and White foster care alumni, while controlling for several factors related to the foster care experiences of these alumni. 1.4. Racial and ethnic group differences in mental health functioning Although African Americans in the U.S. experience higher rates of poverty (Fass & Cauthen, 2007), CPS-substantiated child maltreatment, and foster care than their White counterparts (Ards, Myers, Malkis, Sugrue, & Zhou, 2003; Lau et al., 2003), little evidence exists in regard to mental health differences between racial groups. While most studies group people of color together, studies examining disparities between African Americans and Whites have yielded mixed results (Fryers, Melzer, & Jenkins, 2003; Satcher et al., 2005; The National Academic Press, 2004; Wallman, Evinger, & Schechter, 2000). Zuravin and Fontanella (1999), controlling for age at interview, several family characteristics, and verbal and physical abuse, emotional and physical neglect, and sexual abuse, found that being African American reduced the likelihood of depression by 41% in a low-income sample of African American and White women. Abram et al. (2004) found no differences in the prevalence of PTSD among African American, Hispanic, and White
youth in a juvenile detention center and Franko et al. (2004) found no differences between African American and White females and the relationship between negative life events, traumatic experiences, and subsequent depressive symptoms. A study of the general population, the National Comorbidity Survey, revealed that African Americans had significantly lower odds of lifetime mood, anxiety, and substance use disorders than Whites but greater persistence of any chronic disorder and chronic anxiety, less persistence of lifetime or 12-month substance use disorders and any 12month diagnosis (Breslau, Kendler, Su, Aguilar-Gaxiola, & Kessler, 2005). Breslau et al. (2006) found that in the National Comorbidity Survey Replication (NCS-R), also a study of the general population, African Americans had significantly higher prevalence of bipolar disorder but significantly lower lifetime prevalence of depression, generalized anxiety disorder, social phobia, panic disorder, early-onset impulse control disorders, and substance use. Additionally, African Americans in the National Survey of American Life had significantly lower lifetime prevalence of Major Depressive Disorder (MDD) but significantly higher chronic course of lifetime MDD (Williams et al., 2007). Given the results of a limited set of studies in the general population and other areas (low income, juvenile detention), would the pattern of ethnic group differences (or the lack thereof in some studies) be the same for young adults who had been served in foster care? Outcome studies on the mental health of youth in foster care and of alumni are limited. However, in a Wisconsin study, significant differences were found in a comparison of the mental health of alumni and youth in the general population (Courtney & Piliavin, 1998). Both African American and White youth who had exited foster care 12 to 18 months prior to assessment had higher rates of psychological distress than their counterparts. 1.5. Methodological limitations of previous studies Some limitations in previous studies of alumni of foster care and the dearth of existing research involving alumni of foster care make the current study useful for prevention and intervention work with this population. Previous studies have tended to report alumni outcomes at young ages—in their late teens rather than early twenties and beyond. Additionally, few studies used standardized mental health measures relating to diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). Further, race/ethnic differences were rarely reported. Therefore, the current study will help increase understanding of whether race/ethnicity influence the mental health outcomes of African American and White foster care alumni while controlling for several factors related to the foster care experiences of these alumni. 1.6. Study purpose The purpose of the current study was to examine differences between two racial/ethnic groups (African American and White) of adult alumni of foster care on mental health outcomes, including depression, anxiety, and post-traumatic stress disorder. The sample included young adults who were placed in foster family care between 1966 and 1998 in 23 field offices of a private foster care agency in the United States (Casey Family Programs, 2007). While the services provided were more extensive, note that this agency focused on serving children referred by public child welfare agencies that were less likely to be returned home or adopted (Pecora, Kessler, & Williams, in press). The current analysis will help determine if racial differences exist among the alumni of this agency despite the higher quality of the program in terms of greater youth access to mental health services. Therefore, the results have generalizability to this population of youth. Study findings must be married with other studies of alumni to portray the complete picture of mental health functioning of alumni of foster care.
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Thus, this set of special analyses focused on detecting similarities or differences between African Americans, the most overrepresented population in foster care, and Whites. The White racial group was selected for the comparison because they are underrepresented in foster care nationally (percentage-wise), but comprise a sizable number of children in care. 2. Theoretical foundation An ecological risk and protective factors model was used as a framework for this examination. Ecological theory, developed by Bronfenbrenner (1977), explains and links developmental outcomes across the life-course to the multiple and diverse environmental contexts to which a person is exposed. The five environmental systems in this theory range from intricate personal interactions to extensive cultural inputs. As diagrammed in Fig. 1, personal characteristics (e.g., biological and genetic makeup, personality, and cognitive ability), as well as how one interacts with others in the context of family systems, culture, and broader social systems all influence one's ability to achieve optimal success (Cicchetti & Aber, 1998; DeBellis, 2001). To increase understanding of the determinants of health and positive adult functioning among alumni of foster care, this research empirically examines risk and protective factors at individual, family, and systems levels. Based on this conceptualization, outcomes are expected to be affected by transactions within the alumnus' ecological systems. For instance, individual-level factors such as mental/physical health problems diagnosed before or during foster care (e.g., Attention Deficit Hyperactivity Disorder or ADHD) would interact with other domains of risk or protection within the biological family environment (e.g., parental mental health) and foster family (e.g., helpfulness of foster parents), and other factors associated with the broader context of foster care (e.g., placement history, or supports and services) to influence the likelihood of psychological disorders, educational achievements, and financial status. As it relates to the current examination, the model uses demographic and contextual factors as controls while analyzing the role of race/ethnicity in predicting the probability of several mental health diagnoses.
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3. Method 3.1. Participants A sub-sample (N = 708) of the Casey National Foster Care Alumni Study was examined. The sample included 134 (21.9%) African American and 574 White (78.1%) adult foster care alumni served by foster families and caseworkers of the Casey Family Programs (Casey) between 1966 and 1998. Demographic characteristics by race/ethnicity for each group are shown in Table 1. The two groups were closely matched in terms of gender, with females accounting for 52.6% of the African American subgroup and 48.3% of the White subgroup. On average, African Americans were younger than Whites at the time of the interview and were served mostly in the Southwest (Austin and San Antonio, Texas), and Northwest (Portland, Oregon, and Tacoma, Seattle, and Yakima, Washington) regions. Most White alumni were served in the Great Plains and the Northwest. 3.2. Agency description Study participants were served by the Casey Family Programs, a national operating foundation that supports youth in care and foster families through direct services and system improvement efforts in child welfare. All alumni were served in Casey's field offices in operation in 1998 in 13 states: Arizona (Phoenix and Tucson); California (Walnut Creek/Bay Area and San Diego); Hawaii (Hilo and Honolulu); Idaho (Boise); Louisiana (Baton Rouge); Montana (Helena and Missoula); North Dakota (Bismarck and Fort Berthold); Oklahoma (Oklahoma City); Oregon (Portland); South Dakota (Pine Ridge, Rapid City, and Rosebud); Texas (Austin and San Antonio); Washington (Seattle, Tacoma, and Yakima); and Wyoming (Cheyenne). 3.3. Measures 3.3.1. Demographics, risk factors, and foster care experiences Case records included demographics (e.g., decade entered foster care and region served in care); risk factors (e.g., reasons for foster care placement, child maltreatment); and foster care experiences
Fig. 1. Ecological–transactional model of child maltreatment.
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Table 1 Demographic characteristics by race/ethnicity. African American n = 134
% of study sampleb Gender Male Female Age at time of interviewa,b 20–25 26–29 30–34 35–49 Mean age at time of interviewa,b Decade entered Casey foster carea 1966 to 1979 1980 to 1989 1990 to 1998 Region served in carea Southwest Great Plains Hawaii California Northwest
White n = 574
% (SE)
% (SE)
21.9 (1.7)
78.1 (1.7)
47.4 (4.5) 52.6 (4.5)
51.8 (2.1) 48.2 (2.1)
37.8 30.7 18.9 12.7 28.0
20.4 20.9 26.6 32.2 31.5
(4.3) (4.1) (3.4) (3.0) (0.5)
18.7 56.7 24.6
31.7 55.9 12.4
24 9 6 17 43
8 42 1 6 42
(1.7) (1.7) (1.9) (2.0) (0.3)
a Indicates a significant difference between African American and White alumni as tested by chi-square or t-tests, p b .05. b Weighted percentages; ns are unweighted.
(e.g., placement history). Interview data included birth parent information (e.g., health and mental health status, substance use, employment, and parenting style), and some foster family and foster care experience information (e.g., foster parent warmth and overprotection; relationships with other caring adults; child maltreatment; and access to educational and mental health services). 3.3.2. Mental health Mental health diagnoses for alumni of foster care were assessed during the interview using the Composite International Diagnostic Interview (CIDI). The CIDI is a non-clinician administered standardized interview developed by the National Institutes of Health, Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) and the World Health Organization (WHO) for use in epidemiological studies, and is often used for research and clinical assessment (Clinical Research Unit for Anxiety & Depression, 2006; Harvard Medical School, 2006; Wittchen, Kessler, Zhao, & Abelson, 1995). Sections of the CIDI were used in the current study to assess lifetime and 12-month occurrence of psychological disturbances and substance dependence among alumni (e.g., Major Depression, Panic Syndrome, Social Phobia, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, and Drug and Alcohol Dependence). Additionally, the interview included the Short Form Health Survey 12 (SF-12®) to assess overall mental and physical health. The SF-12® was developed to be a shorter, yet valid, alternative to the SF-36® for use in large surveys of general and specific populations as well as for large longitudinal studies of health outcomes. The mental health summary score was used to assess overall mental health functioning (Ware, Kosinski, & Keller, 1998, pp. 11 & 60).
Data collection for the Casey National Foster Care Alumni study was completed between 2000 and 2002. Professionally trained interviewers from the University of Michigan Survey Research Center, unfamiliar with study hypotheses, collected data from 1582 Casey alumni case records and conducted one-on-one interviews with 1068 alumni. The adjusted response rate was 73.4% [(adjusted for the 8% of the sample who was inaccessible due to incarceration (3.4%), psychiatric institutionalization (0.7%), or death (3.9%)]. A random sample of 40 case records was selected for an inter-rater reliability check. Each record was reviewed by a trained staff member and a “gold standard” reviewer who had the most extensive case record review training and the most consistent performance (of which there were four); they also randomly reviewed a random sample for verification purposes. Only variables that had acceptable inter-rater reliability (Cohen's Kappa greater than or equal to .70) were retained. 3.5. Analysis plan 3.5.1. Weighting Case records were available for 1068 alumni of Casey foster care. However, because some alumni were unavailable for interviews, weights were created to account for non-responses. Because they were available for the entire sample of 1582, case record variables were used to create the statistical weights and included age, gender, and race/ ethnicity. The weighting improved the ability to generalize to the population of adults from which the sample was drawn by estimating data as if the entire sample of 1582 alumni had been interviewed. Specifically, propensity score matching was used to weight the data by estimating a logistic regression equation (Hosmer & Lemseshow, 1989) separately that distinguished survey respondents from nonrespondents (treated as a dichotomous dependent variable) based on pre-placement characteristics. The predicted probabilities generated from these equations were used to weight the data without case-level matching so that survey respondents had distributions on pre-placement characteristics comparable to the original total agency sample. This matching improved the ability to generalize to the population from which the sample was drawn by weighting the data so that differences between the samples did not bias the results (Braitman & Rosenbaum, 2002). 3.5.2. Hypothesis testing: Examining racial/ethnic differences Due to a lack of conclusive evidence of racial/ethnic differences in the general population, we tested the null hypothesis of no difference between groups on mental health outcomes. Initially, the data were examined using bivariate chi-square analyses. Any outcomes with statistically significant differences between African American and White alumni were retained and analyzed by race/ethnicity in logistic regression models while controlling for ecological factors: demographics, risk factors, and foster care experiences. If race/ethnicity was not significant in the regression when entered alone (Step 1), it was concluded that no differences existed between the two groups on this outcome and no further analyses were necessary. If there was a difference between the two groups, the next set of predictor variables—demographics, risk factors and foster care experiences (see Table 2)—was entered into the logistic regression model in addition to race/ethnicity. All significant variables were retained in subsequent models. When race/ethnicity was no longer significant, no further steps were taken.
3.4. Procedure 4. Results Inclusion criteria for alumni in the study were: (a) placement in Casey foster care between 1966 and 1998; (b) placement with a Casey foster family for at least 12 consecutive months; and (c) exit from Casey foster care for at least 12 months prior to being interviewed (Pecora et al., 2003, 2006).
4.1. Bivariate analyses As presented in Table 3, bivariate analyses were conducted for mental health outcomes. A substantial percentage of both ethnic
M.S. Harris et al. / Children and Youth Services Review 32 (2010) 171–177 Table 2 Variables in logistic regression models.
Table 3 Bivariate results: Alumni mental health diagnoses by race/ethnicitya.
Step Domain
Variable
Source
1 2
Race/Ethnicity Age at time of interview Gender Decade entered child welfare Region served in Casey foster care Age entered child welfare Relationship with birth parents Birth parent employment Number of places lived before foster care Birth parent mental health Birth parent physical health Birth parent substance abuse Birth parent criminal problems Birth parent warmth Birth parent overprotection Number of abuse types Type of abuse/neglect (emotional, physical, sexual, neglect) Number of reasons for placement Placed due to child behavior problems Placed due to child maltreatment Placed due to parental substance abuse Other reason(s) for placement Attention Deficit Hyperactivity Disorder (ADHD) Physical or learning disability Other impairments (i.e., drug exposed as an infant, fetal alcohol effect, fetal alcohol syndrome, or vision or hearing impaired) Number of placements Length of time in care Placement change rate Number of reunification failures Number of runaways Number of unlicensed living situations with friends/relatives Number of school changes Could participate in supplemental Educational services/tutoring (access) Could participate in therapeutic service and supports (access) Participated a lot in activities with foster family Degree of preparation for leaving care Number of resources when left care Foster parent warmth Foster parent overprotection Foster family helped with ethnic issues Had a close and confiding relationship with an adult while growing up Felt loved while in foster care Overall, foster parents were helpful Child maltreatment while in foster care
I I CR CR CR CR I I I I I I I I I CR CR
3
4
Demographics Demographics
Risk Factors
Foster care experiences
175
CR CR CR CR CR CR CR CR
CR CR CR CR CR CR I I I I I I I I I I I I I
groups exhibited symptoms of at least one mental health disorder (African American: 42.0%; White: 43.7). But among the mental health variables, only Modified Social Phobia showed statistically significant differences (p b .05) between African American and White alumni. More African Americans had no Social Phobia diagnosis compared to Whites (93.0% versus 86.6%). 4.2. Multivariate analyses After determining where bivariate differences existed, a series of logistic regressions was run to determine whether being African American or White continued to contribute to different prevalence rates on the one emotional or behavioral disorder where there was a bivariate difference: Modified Social Phobia.
Mental health
No 12-month CIDI DSM diagnosis
African American White n = 134 n = 574
b
Odds Ratio (Confidence Interval)
% (SE)
% ( SE )
58.0 (4.3)
56.2 (2.1) 0.9 (0.7–1.6) 87.9 (1.4) 0.9 (0.6–2.1) 85.6 (1.5) 1.2 (0.5–1.4) 89.7 (1.3) 0.7 (0.9–2.4) 86.6 (1.4) 2.1 (0.2–1.0) 91.4 (1.2) 1.3 (0.4–1.6) 79.1 (1.7) 1.1 (0.6–1.5) 97.9 (0.6) .468 (0.8–5.9) 96.9 (0.8) 0.6 (0.6–4.0) 56.3 (2.1) 1.1 (0.6–1.4)
Total number of CIDI diagnoses in 89.2 (2.6) the past 12 months is less than 3 No major depression in last 87.8 (2.8) 12 months No panic syndrome in last 12 months 86.5 (2.9) No modified social phobia in last 12 monthsc No generalized anxiety in last 12 months No PTSD in last 12 monthsd
93.0 (2.2)
No alcohol dependence in last 12 months No drug dependence in last 12 months SF-12 mental health score of 50 or abovee
95.6 (1.8)
93.1 (2.1) 80.1 (3.4)
95.1 (1.8) 54.2 (4.4)
a
Percentages are weighted; n,s are unweighted. The CIDI is the Composite International Diagnostic Interview Schedule that produces a score that is associated with a diagnosis from the American Psychiatric Association, Diagnostic and Statistical Manual. c Indicates a significant bivariate difference between African American and White alumni, p b 05. d PTSD is Post-Traumatic Stress Disorder. e SF-12Health Survey is a standardized scale that measures physical and mental health functioning. Fifty or above is considered “good” mental health. b
significant contribution to differences between groups when controlling for demographic factors (i.e., gender, age at time of interview, decade entered care, and region served in care). The only factors that remained significant were gender and age at the time of interview.
5. Discussion 5.1. Racial differences in outcomes This article adds to the literature on mental health outcomes of African American and White adults who were placed in foster care as youth. When mental health outcomes of alumni in the study were compared by race/ethnicity, Modified Social Phobia was the only diagnostic category among seven specific diagnostic areas that showed statistically significant differences, with White alumni having more social phobia than African American alumni. Note that these findings do not rule out ethnic differences in other diagnostic areas, and studies with other foster care populations should be conducted. However, considering that only 58% of African Americans and 56.2% of Whites had no mental health diagnoses (Table 3), attending to the psychological needs of foster youth and foster care alumni remains salient. So even as young adults, once outside of the foster care system, mental health conditions remain a challenge for many alumni of foster care. Prior work has shown that 30- to 50% of youth aging out of foster care have emotional or behavioral disorders and/or a developmental disability (Courtney, Terao, & Bost, 2004; Needell, Cuccaro-Alamin, Brookhart, Jackman, & Schlonsky, 2002). 5.2. Implications
4.3. No Modified Social Phobia In Step 2 of these analyses the logistic regression model for No Modified Social Phobia showed that race/ethnicity did not make a
One of the intriguing findings of this set of analyses was how alumni race/ethnicity was not a significant factor for most mental health outcomes. The findings underscore the need for periodic evaluation
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of mental health functioning and mental health insurance coverage for youth after they leave foster care into adulthood. It is important to evaluate mental health functioning periodically to determine if there have been changes (positive or negative) in youth's behavior and functioning and if these changes can be attributed to service availability, cultural competence of services, family involvement, and interagency structure. Furthermore, periodic evaluations can be used to further assess youth's emotional and behavior status, strengths, education performance, and satisfaction or dissatisfaction with services. The distinctions and similarities among young people based on these evaluations can be used to help explain variations in the mental health treatment experiences of youth as well as used to determine the nature and extent of clinical and functional outcomes for youth served in child welfare agencies and other systems of care. Young people in foster care have emphasized the importance of exercising choices and having a role in determining the kind of mental health services and psychotropic drugs they receive while in care. They also worry about the kinds of health care coverage they will have as they transition from foster care as major gaps in coverage exist (Pecora et al., 2003; Rubin, Halfon, Raghavan, & Rosenbaum, 2005; Stanley, 2007). 5.3. Methodological advantages and disadvantages of the current study To fully understand the study findings and how they fit into the existing literature on alumni of foster care functioning, several methodological issues must be noted. First, the average age of youth in this study was around thirty. While this allows for assessment of outcomes after many life experiences, it makes it difficult to compare current findings to findings of previous studies. Second, because participants were served in a limited geographical range and by one agency, generalizations are limited to those in the examination. At the time youth were served in foster care, Casey was unique in its heavy emphasis on culturally competent services and the extensiveness of those services. The services offered may have resulted in fewer ethnic group differences. As discussed previously, the findings must be married with other research to fully understand alumni functioning. Lastly, although the interview was extensive, it was not exhaustive. Specifically, additional data could have been collected that would have more fully explained differences, or lack thereof, in the mental health functioning of alumni. 5.4. Conclusion With the lack of ethnic group differences, the importance of offering mental health services to all alumni of foster care cannot be overstated. McMillem et al. (2004) examined lifetime, 12 month, and current use of mental health services in Missouri's foster care system; findings revealed that youth of color were more likely to get residential services and less likely to get outpatient therapy, inpatient services, and psychotherapeutic medications; the child welfare system appeared to take a proactive role in referring youth for mental health services in this study. Regardless of race/ethnicity, youth need continued support to have successful outcomes in mental health after they exit the foster care system. It is imperative for youth to have ongoing post-foster care supports (such as financial, emotional, housing, education, employment) from caregivers, other significant adults in their lives, and from the broader communities in which they live. Individualized assessments and follow-up care must include cultural factors such as language, race, ethnicity, customs, family structure, sexual orientation and tribal and/or community dynamics. Youth need mental health services that are client-centered, family-focused, community-based, culturally and linguistically competent, and integrated to facilitate development of self-sufficiency and their maximum level of mental health functioning.
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