Psychotropic Medication Use in Older Foster Youth: A Focus on Racial Differences

Problem: The use of psychotropic medications among foster youth has received growing national attention due to high rates of use and concerns about the appropriateness of prescribing. Understanding medication use in older foster youth is of heightened concern as these youth are preparing to transition out of the state custody and assume the management of their mental health care. While it has been established that rates of medication use are high among this population, little is known about the demographic and clinical factors associated with high rates of medication use and what patterns of use look like over time. Methods: This study used data from a sample of 404 foster youths in Missouri from 2001-2005 to examine situations associated with medication use at age 17, then characterize patterns of use over the subsequent year for those who remained in state custody: n=294). Data were collected through structured interviews with youths including interviewer derived diagnoses using the Diagnostic Interview Schedule. Analyses focused specifically on examining racial differences between white youths and youths of color. A proposed model of pathways to medication use was tested using multi-group structural equation modeling, patterns of medication use were examined, and youths were classified into medication use subgroups using latent growth mixture modeling. Results: While rates of medication use were significantly different between white youths and youths of color, the strength of the relationship between mental health problems and psychotropic medication use was not significantly different. White youths were more likely to be taking medications in conjunction with outpatient therapy, while youths of color were more likely to be connected with mental health treatment through the psychiatric hospital or emergency room. No racial differences were identified in the types of psychotropic medications youths were taking, however, youths of color were more likely to discontinue medications over the study year. Four medication use subgroups were identified - a low/no use group: 74%), a medium stable medication use group: 14%), a declining use group: 4%), and a high stable use group: 9%). Youths in the declining and high stable use groups were not significantly different from one another at age 17 and were most likely to be taking antipsychotic medications in addition to antidepressant medications. Youths in the medium use group were primarily taking antidepressant medications and had lower rates of comorbid behavioral disorders than youths in the highest use group. Conclusion: These results suggest need to further examine racial differences in mental health treatment overall but did not point to racial disparities in medication use. High rates of antidepressant use suggest the potential to reduce medication use through evidence based treatments targeting depression and anxiety. Additional information is needed to better understand the underlying needs that are generating medication use, particularly polypharmacy, in order to develop alternative responses. Youths that took the highest number of medications also presented indicators of complex needs. Targeted interventions to assess and clarify the mental health problems of these youths could improve the quality of their treatment and prevent abrupt discontinuation as they leave state care

Then You Fall Off : Youth Experiences and Responses to Transitioning to Homelessness

Introduction: This study aims to broaden our understanding of the experience of homelessness and unstable housing in youth. While quantitative research highlights risk factors associated with experiencing homelessness as a youth, little qualitative research has been conducted to explore the lived experience of this transition to homelessness or unstable housing and how youth respond to becoming homeless. This study utilizes data from youth descriptions of their experiences to understand the context of the transition to homelessness and how youth manage this transition. Methods: A qualitative study with a quantitative component was conducted with a nonprobability sample of homeless youth aged 14-24 recruited from shelters, drop-in centers, and magnet events in a large urban area in the Southwest. Four qualitative researchers used content analysis to assess themes that emerged related to transitions to homelessness. Results: A predominately minority (88%) sample of sheltered (67%) and unsheltered (33%) youth (n=64) described their experience of and responses to transitioning to homelessness. Three main themes emerged relating to transitioning to homelessness; family homelessness, histories of foster care, and non-supportive family processes. Youth described how these experiences manifested and influenced their transition into homelessness. In response to homelessness three dominant themes emerged; self-reliance, hope, and resilience. Discussion: The data highlight the unique issues of homeless youth and how they respond to circumstantial challenges. While homeless youth experience lifetime adversities that lead to homelessness, they respond to these circumstantial challenges with self-reliance, hope, and maintaining resilience. Interventions aiming to facilitate health behaviors and improve self-sufficiency in homeless youth should tap into these positive responses to improve self-care strategies, service utilization, and help homeless youth reduce risk behaviors

Perspectives on Psychotropic Medication Treatment Among Young Adults Formerly Served in Public Systems of Care: A Thematic and Narrative Analysis

This study examines the perspectives of psychotropic medications held by young adults with mood disorder diagnoses. This article presents an analysis of qualitative interviews with 52 young adults who had been involved with public systems of care during adolescence and had used psychiatric medications. A concatenated analytic approach was used. First, we used a thematic analysis across cases, then a narrative analysis within selected cases. Two main themes emerged from the thematic analysis that captured aspects of the experience of taking medication. First, young adults described the effects of the medications and how they thought the medications were working. They described the impact on their moods, thinking, bodies, and functioning, and the ways in which these effects related to their lives. Second, the process of taking medications emerged as an important aspect of the medication treatment experience, including the trial-and-error nature of treatment and interactions with psychiatrists. The narrative analysis within cases identified that some youth created a medication narrative composed of three elements: why medications were needed, what medications do, and participants’ outlook on future medication use. These narratives are helpful in understanding prior patterns of service use and are instructive in framing young people’s future intentions to use medications. Findings support the importance of eliciting the perspectives of young adults about their treatment and ensuring that services are designed and delivered in developmentally appropriate ways tailored to this group

Knowledge of and Attitudes toward Behavioral Health Services among Older Youth in the Foster Care System

This study examined knowledge of and attitudes toward services among 268 17-year olds with psychiatric diagnoses preparing to exit foster care. A structured interview assessed knowledge of services with vignette scenarios and attitudes with a standardized scale. Descriptive statistics described the extent of knowledge and attitudes among this population and regression analyses examined predictors of these dimensions of literacy. Most youth suggested a help source, but responses often lacked specificity. Gender and depression were the strongest predictors of knowledge and attitudes, respectively. Knowing which aspects of literacy are low, and for whom, can inform education efforts to improve access to care in adulthood

Development and piloting of a treatment foster care program for older youth with psychiatric problems

BACKGROUND: Older youth in out-of-home care often live in restrictive settings and face psychiatric issues without sufficient family support. This paper reports on the development and piloting of a manualized treatment foster care program designed to step down older youth with high psychiatric needs from residential programs to treatment foster care homes. METHODS: A team of researchers and agency partners set out to develop a treatment foster care model for older youth based on Multi-dimensional Treatment Foster Care (MTFC). After matching youth by mental health condition and determining for whom randomization would be allowed, 14 youth were randomized to treatment as usual or a treatment foster home intervention. Stakeholders were interviewed qualitatively at multiple time points. Quantitative measures assessed mental health symptoms, days in locked facilities, employment and educational outcomes. RESULTS: Development efforts led to substantial variations from the MTFC model and a new model, Treatment Foster Care for Older Youth was piloted. Feasibility monitoring suggested that it was difficult, but possible to recruit and randomize youth from and out of residential homes and that foster parents could be recruited to serve them. Qualitative data pointed to some qualified clinical successes. Stakeholders viewed two team roles – that of psychiatric nurse and skills coaches – very highly. However, results also suggested that foster parents and some staff did not tolerate the intervention well and struggled to address the emotion dysregulation issues of the young people they served. Quantitative data demonstrated that the intervention was not keeping youth out of locked facilities. CONCLUSIONS: The intervention needed further refinement prior to a broader trial. Intervention development work continued until components were developed to help address emotion regulation problems among fostered youth. Psychiatric nurses and skills coaches who work with youth in community settings hold promise as important supports for older youth with psychiatric needs

Postsecondary Employment Experiences among Young Adults with an Autism Spectrum Disorder

Objective: We examined postsecondary employment experiences of young adults with an autism spectrum disorder (ASD) and compared these outcomes with those of young adults with different disabilities. Method: Data were from Wave 5 of the National Longitudinal Transition Study 2 (NLTS2), a nationally representative survey of young adults who had received special education services during high school. We examined the prevalence of ever having had—and currently having—a paid job at 21–25 years of age. We analyzed rates of full employment, wages earned, number of jobs held since high school, and job types. Results: About half (53.4%) of young adults with an ASD had ever worked for pay outside the home since leaving high school, the lowest rate among disability groups. Young adults with an ASD earned an average of $8.10 per hour, significantly lower than average wages for young adults in the comparison groups, and held jobs that clustered within fewer occupational types. Odds of ever having had a paid job were higher for those who were older, from higher-income households, and with better conversational abilities or functional skills. Conclusions: Findings of worse employment outcomes for young adults with an ASD suggest this population is experiencing particular difficulty in successfully transitioning into employment. Research is needed to determine strategies for improving outcomes as these young adults transition into adulthood

Engagement intervention versus treatment as usual for young adults with serious mental illness: a randomized pilot trial

Background: Young adults have elevated rates of mental health disorders, yet they often do not receive consistent care. The challenge of continuing to engage young adults has been pervasive worldwide. Few engagement interventions have been designed for young adults with serious mental illness. Just Do You is a theoretically guided engagement intervention. It uses innovative modalities (i.e., technology, expressive arts activities, narrative expression, mentoring) to engage participants in conversations about services and how they work, while simultaneously orienting them to treatment. Methods/design: This pilot and feasibility study utilizes a hybrid research design, examining feasibility, acceptability, and preliminary impact, alongside implementation. The study combines qualitative methods, a small pilot randomized trial, and a small cost-benefit analysis. Respondents are clinic staff and young adults who have made initial contact with the Personalized Recovery Oriented Services (PROS) program. Quantitative survey data are collected at baseline, 2 weeks (post-intervention), 1 month, and 3 months. The assessments focus on measuring feasibility, acceptability, engagement, and mental health outcomes. Medical record extraction will be used to triangulate self-report data. We will conduct single degree of freedom contrasts to examine whether Just Do You leads to improved outcomes relative to Treatment-As-Usual using robust regression for each outcome measure. We will examine whether changes in the proposed mediating variables occur across groups using a similar contrast strategy. In addition, we will use structural equation modeling to examine the contribution of mediators to ultimate outcomes. Finally, we will use constant comparison coding techniques for qualitative analyses. Discussion: The aim of this study is to examine the feasibility of a young adult engagement meta-intervention through an intensive preliminary pilot trial, learning through collaboration with stakeholders. Just Do You has the potential to fill a gap in the service system for young adults with serious mental illnesses, improving the seemingly intractable problem of disengagement. The program uses culturally responsive strategies, is recovery-oriented, and builds upon the best evidence to date. Our efforts align with local and national health care reform efforts embedding people with lived experience. Trial registration: This trial was registered with ClinicalTrials.gov (Identifier: NCT03423212) on April 18, 2018, as Protocol Record R34 MH111861-01, New York University, as the Just Do You Program for Young Adults with Serious Mental Illness

Substance Use and Substance Use Disorders as Foster Youth Transition to Adulthood

Little research has previously examined substance use and substance use disorders as youth age out of foster care. This study examined rates of getting drunk, marijuana use, and substance use disorders over time for a cohort of 325 older youth in foster care in Missouri. Rates of past month marijuana use increased from 9% at age 17 to 20% at age 19. Rates of getting drunk in past year increased from 18% at age 18 to 31% at age 19. Compared to the general population, older foster youth had lower rates of substance use but higher rates of substance use disorders (SUD), with 15% of youth meeting criteria for a SUD at age 19. Youth who had left the custody of the state had significantly higher rates of alcohol and marijuana use at ages 18 and 19. Transitions out of residential care and into independent living situations were associated with use of substances at age 18. Different risk factors were associated with substance use at ages 18 and age 19 while risk factors for SUDs were more stable over time. Findings highlight the need to screen and provide treatment for SUDs before youth leave state custody and to consider substance abuse treatment in decisions to extend care beyond age 18

Post High School Service Use for Youth with Autism Spectrum Disorders

Objectives: To produce nationally representative population estimates of rates of service use among young adults with an autism spectrum disorder during their first few years after leaving high school and to examine correlates of use. Design : Nationally representative telephone survey from April 2007 to February 2008. Setting: United States. Participants: Parents and guardians of young adults with autism spectrum disorders aged 19 to 23 years. Main Exposure: Autism spectrum disorder. Main Outcome Measures: Use of the following services in the prior 2 years or since leaving high school: mental health services, medical evaluation and assessment, speech therapy, and case management. Results: Rates of service use ranged from 9.1% for speech therapy to 41.9% for case management; 39.1% of youths with an autism spectrum disorder represented by the survey received no services. The adjusted odds of no services were higher among African American participants and those with low incomes. The adjusted odds of case management were lower among youths with high functional skills and those with low incomes