Mental health needs and therapeutic service utilization of young children in foster care in Germany
Introduction
Children in foster care are an extremely vulnerable population with mental health needs that often require individual and family interventions (Leve et al., 2012). Their risk for developmental and mental health problems is elevated due to high exposure to traumatic events and neglect prior to their placement (Vasileva & Petermann, 2016). Potentially traumatic events include actual or threatened death, serious injury, or sexual violence that the child experiences directly or witnesses (American Psychiatric Association, 2013).
Despite the general awareness of the vulnerability of young children in foster care, in Germany, they are often not or not early enough introduced to mental health specialists (Oswald, Fegert, & Goldbeck, 2013). In the clinical work different reasons for that can be identified – e.g., the often insufficient information about the child's biography, loss of information as a result of frequent placement disruptions, and lack of the solicitude of the biological parents who may still have custody of the child (Oswald & Goldbeck, 2009). Nützel, Schmid, Goldbeck, and Fegert (2005) described a “revolving door” effect as regards the mental health care of children and adolescents in out-of-home placements, claiming that the responsibility is being constantly devolved between the child welfare services and child and adolescent psychotherapists. As a result, about 50% of the children and adolescents with mental health problems in out-of-home care receive no treatment. These findings, however, refer to older children and adolescents whose mental health care may differ from that of younger children. Research on the general population in Germany showed that parents of young children with psychological complaints are more likely to seek help from pediatricians and social pediatric centers; the likelihood that the child would be introduced to psychotherapists increases from age eight (Lehmkuhl, Köster, & Schubert, 2009). Considering this present tendency, the mental health care of young children in Germany includes a range of therapeutic services such as animal-assisted, occupational, and play therapy alongside psycho- and trauma therapy. Some of these interventions lack empirical support of their efficacy (Chur-Hansen, McArthur, Winefield, Hanieh, & Hazel, 2014) or are not specifically indicated for mental health problems (e.g., occupational therapy). Thus, the current study focuses on therapeutic service utilization of young children in foster care in relation to their mental health needs and other factors that promote its initiation.
When discussing the need for therapeutic services for children in foster care, the responsible individuals and institutions should be clarified. On the one hand, children are integrated into the new foster care family, so foster parents could initiate therapeutic service utilization. On the other hand, foster care families are an arm of the welfare services, which are the institutions in charge of the foster children. Every child is first introduced to the child welfare services before being placed in a foster family (an exception could be a kinship foster care). Child welfare services are supposed to make a plan for further care, placement, and support. Worldwide, decisions in this planning process are made on the grounds of the “best interest of the child”, a legal term that is internationally inconsistently defined. Eight states of the USA and the District of Columbia, for example, define particular indicating factors – one of them is the child's physical and mental health (Children's Bureau, 2012). Considering mental health as an objective sign of children's best interest, encourages the integration of psychological interventions in the catalogue of the welfare services or a standard referral process to mental health providers.
In Germany, welfare services are also supposed to plan and coordinate supportive strategies regarding foster children's well-being. Theoretically, this includes directing children at mental health providers. In practice, since there is no standard definition of the term “best interest of the child”, there are neither routine diagnostics nor standard referral processes. Thus, therapeutic services are primarily initiated by the foster parents and their perception of the need for therapeutic help. This raises the questions of how many children in foster care with mental health problems receive treatment at all and which are the variables that predict therapeutic service utilization.
A common theoretical model for investigating predictors for therapeutic service utilization that found empirical support in studies with children and was also evident in the context of foster care (Zima, Bussing, Yang, & Belin, 2000) is the Andersen's (1995) model of health service use. This model describes three main sets of predictors of service use – predisposing, enabling or inhibiting, and need factors. Predisposing factors represent biological and social structure variables that determine the likelihood of health problems and the ability to cope with them. The initiation of the therapeutic help is then facilitated or impeded by personal, organizational, and family variables which represent predisposing factors. Finally, crucial to initiate therapeutic service use is to perceive need for help. Hence, need factors embrace the subjective perception of symptoms and worries about the problem. Andersen (1995) considers predisposing, enabling/inhibiting, and need factors to have an isolated direct impact on service utilization and to also be part of a process. The model accurately addresses the initiation of therapeutic services in children, who cannot decide for or against a therapy on their own, by acknowledging organizational and family predictors. Research on predisposing variables for US-American children in foster care identifies the effects of child's race and foster parent's education on therapeutic service utilization. Enabling or inhibiting factors, such as placement history, kinship foster care, the level of monthly benefits, and number of caseworker visits, also had an impact on service use, as well as on foster parents' perceived need for therapeutic help. Further predictors were need factors (i.e., mental health problems and potentially traumatic events or neglect; Leslie et al., 2000, Jackson et al., 2015). On symptom level, studies yielded inconsistent results. Zima et al. (2000) reported on greater service utilization for children in foster care aged 6–12 years, when they were diagnosed with attention deficit hyperactivity disorder. In another sample of children aged 5–17 years, Conn, Szilagyi, Alpert-Gillis, Baldwin, and Jee (2016) found that, although specific mental health problems were associated with therapeutic service utilization when tested on their own, in a multiple analysis, only peer relationship problems and low prosocial behavior predicted being in therapy. Further, Tarren-Sweeney, Vetere, and Tarren-Sweeney (2010) demonstrated that there is no predictive effect of specific mental health problems when controlled for enabling/inhibiting factors such as “having an assigned caseworker”. Particularly for the preschool age, ethnicity, previous reports on maltreatment, chronic physical conditions, deficits in personal and social skills, and elevated mental health problems predicted higher service utilization for children in foster care in the USA (Horwitz et al., 2012).
Previous research, however, has concentrated mainly on organizational variables when examining the enabling or inhibiting factors (Staudt, 2003). Especially for young children, family characteristics should be considered when investigating therapeutic service utilization since children do not seek professional help on their own (Costello et al., 1998, Ryan et al., 2014). In the general population, for instance, parental stress and family functioning were found to be significant predictors of service utilization (Ezpeleta et al., 2002, Horwitz et al., 2014, Zwaanswijk et al., 2003, Zwaanswijk et al., 2005), while family social connectedness, environment, conflict and, again, family functioning did not have any impact (Ford et al., 2008, Ryan et al., 2014).
The purpose of this investigation is to identify mental health needs and predictors of therapeutic service utilization of young children in foster care in Germany. In particular, it aims to find out which are the best predictors of the initiation of treatment and foster parents' perceived need for therapeutic help for the child. Predictors were analyzed as a set following Andersen's (1995) model in order to explore the independent impact of each set of predisposing, enabling/inhibiting, and need variables. Additionally, since predictors have concurrent effect, they were explored in a joint model that simultaneously includes all significant variables of each set. To fill the gap of previous research on predictors of service use in young children in foster care, alongside organizational variables, enabling/inhibiting characteristics of the foster family, such as stress, role division problems, social connectedness, foster parent's partnership, and family functioning, were considered. Knowing predictors of the utilization of therapeutic services can contribute to policy implications for increasing their use and access in this risk population. For this purpose, foster parents of children aged 3–7 years were questioned about children's therapeutic service use, their perceived need for child therapy, posttraumatic stress symptoms (PTSS), mental health, foster family characteristics, and placement history.
Section snippets
Procedure
The sample is part of a cross-sectional study of PTSS and foster family characteristics of the Center for Clinical Psychology and Rehabilitation at the University of Bremen, Germany. Participants were recruited through contact with statewide governmental and private welfare services, self-help organizations, and password protected forums for foster parents. Children were eligible for the study if (a) they were in long-term foster care, (b) had no diagnosed autism spectrum disorder, and (c) had
Mental health needs and therapeutic service use
About 61.9% (n = 177) of the children showed abnormal symptoms in at least one of the problem areas. Of these children, n = 88 (49.7%) received therapeutic services, n = 11 (6.2%) had been in therapy but were not anymore, and for n = 13 (7.3%) therapeutic services were planned. A total of n = 76 (36.7%) children received no therapy and neither was such service planned. The most common problems were conduct symptoms, followed by PTSS, and hyperactivity/inattention (Table 2). Children who have experienced
Discussion
The results indicate that, although most young children in foster care showed psychological symptoms of clinical relevance, every third of these children receive no treatment. Enabling/inhibiting as well as need factors increased the probability for therapeutic service use and for foster parents' perceived need for therapeutic help for the child.
These results partly support the service-utilization model of Andersen (1995) according to which predisposing, enabling or inhibiting, and need factors
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