Predisposing, Enabling, and Need Factors Associated with Psychotropic Medication and Mental Health Service Use among Children in Out-of-Home Care in the United States: A Scoping Review


1.1. Background

In the United States, more than 600,000 children were placed in out-of-home care in 2021, including non-kinship foster, kinship, treatment foster, residential, and group care. Children in out-of-home care have higher rates of mental health disorders. For instance, 54.4% of foster care alumni in one study had mental health problems compared to 22.1% of the general population, leading to a high rate of mental health service needs. Estimates suggest that children in out-of-home care are 2.5 times more likely to have mental health service needs than the general population. Addressing children’s mental health problems via providing timely and appropriate mental health services to children in out-of-home care would reduce the adverse effects of mental health problems on their short- and long-term well-being. To provide timely and appropriate mental health services, it is important to identify factors associated with children’s use of mental health services in order to eliminate barriers. Mental health services are defined as “any interventions—assessment, diagnosis, treatment, or counseling—offered in private, public, inpatient, or outpatient settings for the maintenance or enhancement of mental health or the treatment of mental or behavioral disorders in individual and group contexts”. Psychotropic medications are among the treatments many children in out-of-home care receive for their mental health problems. In the present study, we operationalized mental health services as those offered in any setting, such as private, public, inpatient, or outpatient settings, including psychotropic medications provided to children in out-of-home care.

Despite these children’s high mental health service needs, they have limited access to appropriate mental health services, which may cause an overreliance on psychotropic medications. A prior study indicated that children in foster care are 2–3 times more likely than the general population of children in the community and 2.0–4.5 times more likely than other youth enrolled in Medicaid to receive psychotropic medications. There are increased concerns about the overutilization of psychotropic medications among children in out-of-home care, particularly second-generation antipsychotic medication and polypharmacy. An estimated 13–40% of children in out-of-home care receive at least one psychotropic medication.

Untreated mental health problems for children in out-of-home care can have detrimental effects on child development, such as increased academic difficulties, high school dropout rates, and risk of homelessness and involvement with the criminal justice system in later life. Similarly, overuse of psychotropic medication is associated with adverse outcomes. Thus, an in-depth understanding of factors associated with using mental health services, including psychotropic medications, will provide insights into how to provide accessible and appropriate mental health services to children in out-of-home care.

1.2. Andersen’s Behavioral Model of Health Service Use

Andersen’s behavioral model of health service use is a framework for mental health service utilization that distinguishes factors of service use as predisposing, enabling, and need . Predisposing factors are individual characteristics, including demographics, social structure, and attitudes or beliefs about medical care, physicians, and disease; enabling factors serve as conditions enabling mental health service utilization; and need factors are perceived needs for mental health services . We used this framework to organize our findings in the current review based on prior applications of this framework to children in out-of-home care. An adapted conceptual framework is provided in. For children placed in out-of-home care, predisposing factors include the demographics of children and their caregivers and their beliefs in mental health and mental health services. Enabling factors mainly refer to characteristics of out-of-home care and their neighborhood and community environment. Need factors are their perceived mental health needs and evaluated symptoms and diagnoses.

1.3. Study Purpose

Although unmet mental health needs have been a longstanding problem for children in out-of-home care, no prior systematic or scoping review has focused on factors associated with using mental health services, including taking psychotropic medications, among children in out-of-home care. Prior systematic or scoping reviews have primarily focused on mental disorders or mental health interventions among children involved in the child welfare system. Identifying factors associated with the use of mental health services among children in out-of-home care would help practitioners and policymakers better serve this population and improve their well-being. To fill this gap in the literature, this scoping review aimed to summarize evidence on factors associated with mental health services and psychotropic medication use among children in out-of-home care guided by Andersen’s model of health service use. Using Andersen’s model of health service use to organize factors is an innovation of this review paper, which further helps identify different layers of factors facilitating or hindering children’s use of mental health services.


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