Young Adults Aging Out of Foster Care With PTSD

Introduction

One in four youth in foster care will exhibit symptoms of posttraumatic stress disorder (PTSD). Approximately 26,000 youths age out of foster care each year, and a majority of them will suffer from PTSD (Pecora, 2010; Sakai et al., 2014). Youth who age out of foster care face the difficulty of transitioning to adulthood without adequate social and emotional supports, which can complicate existing mental health issues (Ai et al., 2013). While laws mandate that youth should be allowed to continue receiving mental health services, fewer than half of former foster care youth remain engaged in those services. Discontinuation is largely due to the cost of care and lack of insurance after aging out. Youth may also feel dissatisfied with services or believe those services do not improve their well-being.

Samuels and Pryce (2008) indicate that youth aged 19–30 years have PTSD rates up to twice as high as those of United States war veterans. PTSD is often triggered by traumas experienced in childhood, particularly emotional and physical abuse. Children who face such traumas may be placed in foster care by Child Protective Services (CPS), and some may remain in foster care until age 21 (Salazar, Keller, Gowen, & Courtney, 2013). Youth in foster care have high rates of trauma exposure, approaching 90%. Although many youth in the general population have experienced some form of traumatic event, those in foster care experience far higher rates than their peers. The childhood maltreatment and adverse experiences these youth endure occur during a critical developmental phase, potentially compromising emotional functioning and placing them at risk for adverse mental health consequences.

Even after leaving foster care, Valdez, Bailey, Santuzzi, and Lilly (2014) note that one in four youth will still cope with PTSD symptoms. Youth in foster care carry a lifetime prevalence of PTSD. There is therefore a need to assess their access to mental health services and make recommendations to ensure they continue to receive the support necessary to manage their mental health.

Literature Review

Ai et al. (2013) posit that child abuse leads to a chronic inability of the brain to regulate emotions in adolescence and later in life. The National Comorbidity Survey (NCS) indicates that children who were repeatedly maltreated are likely to develop drug abuse, dysthymia, and childhood conduct disorder in adulthood. For foster youth aging out of care, they are still attempting to process highly traumatic childhood experiences while lacking the emotional, financial, and social support that a typical young adult would have during the transition to independence (Pecora, 2010). Foster youth experience negative outcomes and face considerable challenges as they attempt to secure the opportunities and resources needed to lead independent lives (Ai et al., 2013; Samuels & Pryce, 2008). Those struggling with PTSD symptoms will also experience increased depressive symptoms as they transition out of foster care. Without adequate mental health support, youth are left to suffer in silence, as they often lack the coping mechanisms necessary to manage the transition. As youth move out of care, they leave a system that required their dependence and enter an abrupt expectation of full independence (Pecora, 2010). Upon leaving foster care, youth must fend for themselves and may need to seek mental health assistance elsewhere—a challenge for most, as they lack medical insurance (CARE, 2012). The financial burden of self-pay leads many youth to abandon mental health treatment, resulting in further deterioration of PTSD symptoms (Hayes, 2017).

According to Hayes (2017), allowing youth to decide for themselves what is best regarding their mental health often proves ineffective, with 60% of youth discontinuing mental health services within a year of leaving foster care. There is therefore a strong case for follow-up services in which a social worker is assigned to youth with PTSD to ensure continued appointment attendance. While in foster care, youth are rarely involved in decisions about their care (Ai et al., 2013); when they finally gain decision-making authority, many opt to suspend mental health services—even when they recognize the need for them. Prior experiences with mental health professionals may also influence this decision.

As of January 2014, the Affordable Care Act added a provision making all youth in foster care who reach age 18 eligible for Medicaid until age 26 (Sakai et al., 2014). Despite this provision, most youth are unaware of the coverage. A significant knowledge gap hinders the use of health insurance, and many youth report difficulties when attempting to use Medicaid (Valdez et al., 2014). Some have reported being told their costs would be covered at a health facility, only to receive a bill by mail afterward (Sakai et al., 2014). These knowledge gaps make it difficult for youth to utilize available services. Access to medication also presents a challenge: obtaining a prescription requires an appointment with a mental health professional, and appointments often must be scheduled a month in advance. This delay can leave youth without medications for extended periods, negatively affecting their mental health.

The proposed solution is to engage youth in their mental health treatment options while they are still in foster care. With this engagement, youth will understand what steps to take after leaving care and can seek the assistance they need (Pecora, 2010). Without proper transition planning, youth are forced to navigate adulthood independently and unprepared. The shift from pediatric to adult health care systems is a particularly challenging transition, and youth need the necessary skills to navigate it. The negative side effects of medications have also been cited as a deterrent to seeking mental health services after leaving care; actively monitoring and addressing these side effects can encourage youth to continue seeing a professional and adhering to their treatment regimen.

Application to Group Practice

A strengths-based approach is well suited to this group, as it focuses on the strengths that individuals, the group, and families possess rather than on their deficits (Lougheed, 2019). Strengths-based group work does not ignore problems; rather, it identifies the strengths that can help individuals overcome their challenges. For foster youth, the focus would be on recognizing strengths in areas such as physical and academic competencies, goal setting, past coping strategies, and hidden talents (Piel & Lacasse, 2017). Using this approach, youth can remain engaged throughout the group process and have the opportunity to interact with peers in similar situations. That interaction enables youth to bond with others who share their experiences, exchange solutions, and focus on individual strengths.

Being allowed to make decisions—and to learn from mistakes—is an essential part of the transition phase (Lougheed, 2019). The strengths-based approach builds on youth's existing capacities, treating them as resourceful and resilient individuals capable of facing adversity. It emphasizes outcomes, which benefits youth as they set future goals. Within the group setting, open communication and reflective processing allow youth to identify their values and recognize their strengths throughout the process of change (Sakai et al., 2014). Youth come to feel they are in control of their decisions in a way they were not while in foster care (Lougheed, 2019; Piel & Lacasse, 2017).

Youth aging out of foster care will face a broad range of challenges, and for many this is an especially difficult time (Sakai et al., 2014). To assess their needs effectively, it is important to engage them in a focus group. The focus group format offers vital insights into youth perceptions of their mental health needs and the supports available during the transition. In this setting, youth feel they are speaking with peers and can genuinely voice their concerns and fears (Salazar et al., 2013). This creates an opportunity to identify needs and offer strategies for navigating life outside of foster care. The focus group can generate targeted questions for youth to answer individually, eliciting information that might not emerge in a one-on-one interaction (Salazar et al., 2013). The shared experience among group members encourages open communication and candid information sharing (Sakai et al., 2014).

Educating youth about the changes they will encounter during the transition period is key to sustaining their engagement with mental health services (Valdez et al., 2014). Youth should be connected with individuals who can help them navigate the transition out of foster care and assist them in finding professional help without having to search on their own. Given the substantial knowledge gap around Medicaid access and use, youth should receive thorough guidance on what to expect from their health insurance, what is covered, and what is required of them. Filling this gap equips youth with the understanding they need to access services, continue PTSD treatment, and function successfully after leaving foster care.

Engaging, partnering with, and empowering transition-age youth increases the likelihood that they will access mental health services after leaving care. The effectiveness of an intervention can be assessed by interviewing group members and asking how they have applied what they learned. Surveys offer another mechanism for gauging whether the intervention is working. For example, three months after youth exit foster care, a survey can be sent to assess how they are coping and what challenges they are encountering. Responses can then be compared with content covered during the transition phase to determine whether youth have implemented the strategies they were taught.

Conclusion

With the increasing number of youth exiting foster care each year—and most being diagnosed with PTSD—it is vital to ensure they are prepared for life outside the system. The challenges youth face after leaving care have been shown to contribute to the discontinuation of mental health services and medication. With early intervention, however, youth can be guided on how to navigate life outside foster care and still access the services they need most.

The transition phase should include knowledge and practical information youth can use to seek professional mental health care after leaving foster care. Social workers should ensure youth have comprehensive information and are encouraged to voice their fears before exiting care. Open communication allows youth to receive answers to their questions and address concerns in a supported environment. Follow-up should be built into transition planning to ensure youth are keeping appointments and adhering to their medications, sustaining the progress made during their time in care.