|Home | About | Journals | Submit | Contact Us | Français|
While foster care placement is often preceded by stressful events such as childhood abuse, foster care itself often exposes children to additional severe stressors. A history of foster care, as well as the childhood abuse that often precedes it, is common among homeless young adults. However, whether a history of foster care elevates the likelihood of psychiatric disorders and treatment among homeless young adults, after adjustment for childhood abuse, is unknown. This study examined whether a history of foster care was associated with psychiatric disorders, prior psychiatric counseling, prescription of psychiatric medications, and prior psychiatric hospitalization among newly homeless young adults, controlling for childhood abuse and other covariates.
Among a consecutive sample of 424 newly homeless young adults (18 to 21 years) in a crisis shelter, logistic regression analyses determined the associations between foster care and any psychiatric disorder (affective, anxiety, personality, psychotic) and psychiatric treatment, adjusted for demographics, childhood abuse, substance abuse, prior arrest, unemployment, lack of high school diploma, and histories of psychiatric disorders and drug abuse among biological relatives.
Homeless young adults with histories of foster care were 70% more likely to report any psychiatric disorder (AOR=1.70) and twice as likely to have received mental health counseling for a psychiatric disorder (AOR=2.17), been prescribed psychiatric medication (AOR=2.26), and been hospitalized for psychiatric problems (AOR=2.15) than those without such histories.
Histories of foster care should trigger screening for psychiatric disorders among homeless young adults to aid in the provision of treatment (counseling, medication, hospitalization) tailored to their psychiatric needs.
Homeless young adults are at elevated risk for psychiatric disorders (1, 2), with affective and anxiety disorders nearly twice as likely compared to housed individuals around the same age (3, 4). Psychiatric disorders are associated with considerable impairment in functioning (5) that may impede the development of independent living skills and efforts to obtain and retain housing (6–8). Better understanding the factors that increase the risk for psychiatric disorders among homeless young adults is of considerable importance and may point the way to delivery of more effective services.
A history of foster care is one risk factor for psychiatric disorders among homeless young adults that has received little attention, even though such a history is reported by a disproportionate number of homeless young adults (8–11). Among the estimated 25,000 older adolescents and young adults who exit foster care each year, psychiatric disorders have been consistently reported at rates higher than those in the general population (12–17). Additionally, older adolescents in foster care utilize mental health services at 10–20 times the rate of those older adolescents who live at home and 5–8 times the rate of those who live in poverty (18–21).
Moreover, older adolescents still in foster care have exceptionally high rates of lifetime psychiatric hospitalization, up to 42% of 17 year olds in foster care (19, 22, 23). Among foster care adolescents in residential treatment in New York City, those with histories of psychiatric hospitalization are more likely to have histories of being prescribed medication (24); rates of psychotropic medication prescription/use for samples of adolescents in foster care range from 13% to 37%, as compared to the approximately 4% among the general adolescent population (19, 22). Given that psychiatric disorders are likely to result in poor outcomes for homelessness (3, 25), understanding whether a history of foster care is associated with psychiatric disorders and treatment for these disorders (psychiatric counseling, medication, and hospitalization) among homeless young adults is highly important. However, no study to date has performed this investigation.
To conduct such an investigation, the circumstances that commonly give rise to foster care placement should be taken into account. Of the over 500,000 individuals currently placed in the U.S. foster care system, most were removed from their homes due to neglect, caretaker absence, physical abuse, and/or sexual abuse (26–28). The long-term consequences of childhood abuse in terms of risk for later psychopathology have been documented extensively (29–31). Thus, studies of the associations among a history of foster care and psychiatric disorders (and treatment for these disorders) should account for the influence of childhood abuse.
Another important factor to take into account is substance abuse. Both childhood abuse (29, 30) and history of foster care (32) increase the risk for later substance abuse, which occurs more often among adolescents and young adults who exited foster care than among the general population (12, 33–37). Because substance use disorders are considerably more prevalent among homeless young adults than their housed counterparts (3, 4, 38) and since substance and psychiatric disorders are highly associated in the general population (39, 40), substance abuse should also be accounted for when examining the relationship between foster care and psychiatric disorders and treatment among homeless young adults.
While foster care placement is typically preceded by stressful events, this placement and foster care itself often exposes children to additional severe stressors. Removal from home and placement into foster care with strangers can be stressful and associated with many additional traumatic experiences, such as frequent residential and school changes (41) and further neglect and abuse of different types than those experienced with biological parents (42, 43). These experiences can have additional devastating and long-lasting emotional and psychological effects over and above exposure to childhood abuse (44, 45). However, whether a history of foster care elevates the likelihood of psychiatric disorders and treatment among homeless young adults, after adjustment for childhood abuse, is unknown. Thus, this study examined whether a history of foster care was associated with psychiatric disorders, prior psychiatric counseling, prescription of psychiatric medications, and prior psychiatric hospitalization, controlling for childhood abuse and other covariates, among newly homeless young adults seeking crisis shelter in New York City. Specifically, the following hypothesis was tested: A history of foster care would be associated with increased likelihood of psychiatric disorders and treatment among homeless young adults, controlling for demographic characteristics, childhood emotional, physical, and sexual abuse, substance abuse, and other known risk factors (arrest, unemployment, lack of high school diploma, and histories of psychiatric disorders and drug abuse among biological relatives).
Data were obtained from structured psychosocial assessments given at intake at the Crisis Shelter at Covenant House New York (CHNY), the largest provider of crisis, transitional living, and community-based educational and employment services to young adults who are homeless or at immediate risk of becoming homeless in New York City (NYC). The Crisis Shelter provides emergency services, shelter, case management, and referrals to supportive services for young adults 18 to 21 years of age.
After receiving informed consent, psychosocial assessments were conducted as part of regular service provision by shelter clinical staff, all of whom had at least bachelor-level training. The assessment utilized a structured instrument developed by CHNY. Sections of this instrument included: childhood abuse, foster care placement, school and work, health and mental health, drug and alcohol use, legal issues, and family histories of psychiatric disorders and drug abuse. The assessment took 1 to 1.5 hours.
The daily shelter census report was used to identify clients who entered the shelter for the first time between October 1, 2007 and February 29, 2008. A sample of 424 young adults (18–21 years) who entered the crisis shelter for the first time during the specified time period were evaluated. The Institutional Review Board of Columbia University Medical Center approved all study procedures. Assessment information was coded and entered into SPSS/PASW Statistics, version 18.0.
Clients were asked if they had ever been diagnosed with the following disorders: depression, bipolar, post-traumatic stress disorder, anxiety, oppositional defiant disorder, attention deficit disorder, borderline personality, schizophrenia, and psychosis. Given the distribution of psychiatric disorders in the sample, a binary variable was created indicating client endorsement of any of these psychiatric disorders. Lifetime Psychiatric Treatment. Clients were asked if they ever received psychiatric counseling, psychiatric medication via prescription, and if they had ever been hospitalized for psychiatric problems.
Clients were asked if they had ever been placed in foster care (yes/no).
Clients were asked if, prior to age 18 years, they had been: “emotionally abused, such as, repeatedly intimidated, put down and criticized often, taken advantage of, frightened repeatedly, or controlled;” “physically abused, such as, beaten with a belt, extension cord, hands, or fists, kicked, pushed, or shoved;” and “sexually abused, such as, being touched sexually without your permission, being forced to touch someone sexually, or having sexual intercourse against your wishes.” Types of abuse were measured and analyzed separately, as each has been shown to be independently associated with specific types of psychiatric and substance use disorders (29, 30, 46).
Three separate binary variables were created to represent use of alcohol, marijuana, and cigarettes (yes/no). Other substances were not analyzed, since < 1% of the sample reported their use (32). As a proxy measure for any substance use disorder, clients were asked if they had ever received drug treatment, also analyzed as a binary variable (32). Other Covariates. Additional control variables included the following: ever arrested (47), currently unemployed (48), graduated from high school (17), and histories of psychiatric disorders and drug abuse among biological relatives (i.e., biological parents or other family members) (49), all known to be associated with psychiatric disorders, substance abuse, childhood abuse, and homelessness (31). Data on age, race, and gender were ascertained as well.
In terms of demographic characteristics, 271 (64%) of the sample were male, 152 (36%) female, 242 (57%) black, 111 (26%) Hispanic, 29 (7%) white, and 42 (10%) other race. A history of foster care was reported by 147 (35%) of the sample; 179 (42%) reported childhood emotional abuse, 157 (37%) physical abuse, and 83 (20%) sexual abuse. Alcohol (n=81; 21%), marijuana (n=66; 16%), and cigarettes (n=166; 40%) were the most frequently used substances; 46 (11%) of the sample had received prior drug treatment (32). Descriptive statistics for demographic characteristics, childhood emotional, physical, and sexual abuse, and substance abuse for those with and without histories of foster care are presented in Table 1.
To determine the association of foster care with each psychiatric variable, unadjusted odds ratios (OR) were first computed. To then determine whether associations remained after accounting for the influence of demographic characteristics, history of childhood abuse, substance abuse, and other risks, multiple logistic regression analyses were conducted to derive adjusted odds ratios (AOR) for each psychiatric outcome (diagnosed with any psychiatric disorder, received prior psychiatric counseling, prescribed psychiatric medication, hospitalized for psychiatric problems) to determine the unique contribution of foster care to predicting psychiatric problems in this population.
Of the sample, 130 (31%) reported having been diagnosed with any psychiatric disorder, 149 (36%) had received prior psychiatric counseling, 87 (21%) were prescribed psychiatric medications, and 70 (17%) had been hospitalized for psychiatric problems. Specific psychiatric disorders for those with and without histories of foster care are also presented in Table 1.
Bivariate logistic regression analyses indicated that a history of foster care was significantly associated with having any psychiatric diagnosis, receiving psychiatric counseling, being prescribed psychiatric medication, and being hospitalized for psychiatric problems. After adjusting for race, gender, age, childhood emotional, physical, and sexual abuse, alcohol, marijuana, and cigarette use, prior drug treatment, and other risk factors (prior arrest, unemployment, no high school diploma, histories of psychiatric disorders and drug abuse among biological relatives), compared to homeless young adults without histories of foster care, homeless young adults with histories of foster care were over 70% more likely to report any psychiatric disorder (AOR=1.70) and two times as likely to have received mental health counseling for a psychiatric disorder (AOR=2.17), been prescribed psychiatric medication (AOR=2.26), and been hospitalized for psychiatric problems (AOR=2.15; Table 2).
Among homeless young adults, a history of foster care significantly increased the likelihood of having a diagnosis of affective, anxiety or psychotic psychiatric diagnosis, receiving psychiatric counseling, being prescribed psychiatric medication, and being hospitalized for psychiatric problems. Further, these relationships remained strong and significant after controlling for the influence of childhood abuse and other risk factors. To our knowledge, this is the first time the relationship between a history of foster care and psychiatric disorders among homeless adults has been demonstrated.
To better understand why a history of foster care remained a significant predictor of psychiatric outcomes, even after adjusting for controls, the context of foster care and additional negative experiences likely to be endured by those in its care should be given further consideration. Life in foster care, is one of general instability, with the number of residential placements ranging from an average of 2.4 to 9.5 (41, 50) and known to be linked to increased psychiatric problems and treatment (18). With each move, foster care adolescents report experiencing a loss of control over the direction of their lives (51), being further disconnected from peers, families, and social institutions (52), and reliving the trauma of separation from family. All of this occurs during a developmental period characterized by rapid physical changes, cognitive and emotional maturation, and heightened sensitivity to peer and romantic relationships (53). Thus, many learn to not trust and not form new attachments, leaving already compromised mental health to deteriorate further.
High rates of placement into group homes and residential treatment centers have been reported for older adolescents in foster care, with approximately 40% of older adolescents in NYC residing in such congregate care (54). The majority in these placements report experiences of peer-on-peer violence, stealing of personal items, unsafe physical conditions, and inappropriate staff behavior (use of corporal punishment, restraints, and isolation, bullying, and strip searches). These basic safety issues often translate into externalizing behaviors problems, such as aggressiveness, disobedience, and running away (54). Unfortunately, these behaviors, in turn, affect placement stability and subsequent psychiatric status and treatment (55, 56). Additionally, prior studies have shown that many foster care adolescents are unhappy with the way in which psychiatric medications are prescribed and tend to discontinue taking psychiatric medications (and attending psychiatric treatment) of their own volition after discharge (57).
Despite high need and service use rates, little is known about the impact of psychiatric treatment on psychiatric outcomes among older adolescents in foster care (58). Additionally, several studies have concluded that mental health services, in fact, are actually underutilized by adolescents in foster care (42, 59) or are untested treatments and possibly inappropriate for their needs (18, 60, 61). Improper hospitalization can have negative effects, such as the loss of social competence, opportunities to form meaningful relationships, and independence, and stigmatization (62). There has also been an increasing trend to divert those who would usually have been served by mental health programs and the juvenile justice system to foster care (16) where placements in residential treatment centers can be arranged. Unfortunately, research suggests that individual behavioral and emotional problems may be exacerbated in congregate care settings by peer problem behaviors and lack of individualized caregiver attention (63).
Study limitations are noted. Data were obtained by self-report (which could lead to under reporting of psychiatric disorders and substance use due to recall and response bias) and during intake assessment (which may lead to under-reporting due to fear of being denied services). Under reporting could also be due to poor insight into personal behaviors or simply being unaware of a diagnosis having been made. Neglect, a frequent reason for removal from the home and placement in foster care, was not covered but should be in future studies. Types of childhood abuse were measured by single (yes/no) items. However, to improve reporting, clients were provided with examples of what each type of abuse entailed. Psychiatric and substance abuse variables were coded as single (yes/no) items and clinical diagnoses were not obtained, limiting the comparability of findings to studies that employed elaborated diagnostic measures. Histories of psychiatric disorders and drug abuse among biological relatives were measured by single (yes/no) items (i.e., Have your biological parents or other family members been diagnosed with psychiatric disorders? Do your biological parents or other family members have drug abuse problems?). Future research in this area should be more specific as to which family members have psychiatric disorders or abuse drugs. Additionally, data were not available to examine the reasons respondents were removed from their families, whether their biological mothers had abused substances when pregnant with the respondent, the age respondents entered foster care, length of time they spent in foster care, and number and types of residential and educational placements. As each of these factors has been shown to increase the risk for subsequent psychiatric disorders, the effect of these factors, as well as potential genetic influences, on the risk for psychiatric disorders should be included in future research. Also, The sample for this study was comprised only of residents of a crisis shelter for young adults. Homeless young adults with foster care histories may have a greater likelihood of adverse experiences in foster care (e.g., placement changes, failure of permanence) than individuals with more positive foster care experiences, who may be more likely to successfully transition to independent living rather than homelessness. Therefore, future studies that include individuals with histories of foster care who are not homeless are needed to determine if the results are more broadly generalizeable, as well as studies that determine which specific foster care experiences are related to housing instability and homelessness. However, despite these limitations, this study is important because it is the first to identify the association between a history of foster care and psychiatric disorders among homeless young adults, a highly vulnerable population, indicating that further investigation of this relationship is warranted and important.
This study found that a history of foster care was associated with increased risk for psychiatric disorders and treatment among homeless young adults, even after adjusting for many relevant controls. Given these findings, the child welfare system should increase its efforts to better begin the processes of resolving client psychiatric problems prior to discharge from foster care and planning for their aftercare treatment. Histories of foster care should trigger screening for psychiatric disorders among homeless young adults to aid in the provision of treatment (counseling, medication, hospitalization) tailored to their psychiatric needs. As homeless young adults without foster care histories also have high rates of psychiatric problems, they should be screened for psychiatric disorders and receive individualized treatment as well. Improved coordination and continuity of services between the child welfare, mental health, and young adult homelessness service systems are needed to ensure that all young adults have stable housing, employment training and opportunities, and treatment for psychiatric problems. Further research is required on the most efficient and effective psychiatric (64) and psychopharmacological treatment (65) to improve the long-term trajectories of housing stability and psychiatric disorders among homeless young adults who exit foster care.
The authors thank the clients and staff of Covenant House New York. Support for the project was provided by R21AA017862, K23DA032323, U01AA018111, K05AA014223, and the New York State Psychiatric Institute.
Disclosures of Conflict of Interest
None for any author.