Mental and reproductive health in multisystem youth: An in-depth qualitative approach

Highlights

• Criminalization of behaviors and unstandardized screenings are link with mental health.

• Abnormalization of normative behaviors and limited health services affect reproductive health.

• Shared challenges across mental and reproductive health services impact youth outcomes.

Abstract

Background

Multisystem youth involved in both the child welfare and juvenile justice systems report elevated rates of risky sexual behaviors, associated health problems as well as having a disproportionally higher risk for concurrent mental health disorders.

Objective

The current study aimed to provide in-depth nuanced insights about mental and reproductive needs and challenges of multisystem youth using a multi-informant approach (youth, parole/probation officers).

Participants and setting

Qualitative in-depth interviews were conducted with multisystem youth (N = 15; 14–17-years-old; 40% females) and parole/probation officers (N = 20; 35–67-years-old; 33% females) working with foster care and juvenile justice systems.

Methods

Informed by Socio-Ecological Theory, analyses were conducted using Thematic Network Analysis (TNA) and qualitative software Atlas.ti.7.

Results

Youth and parole/probation officers identified key challenges related to mental health (e.g., criminalization of behaviors, unstandardized screening procedures), reproductive health (e.g., abnormalization of sexual behaviors, lack of parenting and comprehensive reproductive services), and shared challenges across systems (e.g., lack of data sharing across systems, overuse of “crisis” procedures, lack of trauma-informed providers and services).

Conclusions

Multisystem youth have significant mental and reproductive health needs that are not adequately met mostly due to system and institutional challenges, differences in protocols, and discontinuance of services and treatment across systems among other problems. Mental and reproductive health disparities are key factors in stigmatization, criminalization and further victimization of youth across systems. Multidisciplinary and multi-sectoral partnerships are key to advance service, protocols and procedural gaps that address the mental and reproductive health needs of multisystem youth.

Introduction

“Multisystem youth”—also known as cross-overs, joint cases, dual-systems— are those children and adolescents simultaneously involved in multiple systems such as the child welfare, foster care, and juvenile justice systems (Wylie, 2014). In the United States, it is estimated that 30% of youth are involved in multiple systems, however, the exact figures are unknown due to several challenges. For instance, some states like Texas do not collect data on youth simultaneously involved in both the child welfare and juvenile justice systems (Rose, 2016). Placement length of stay, entering/reentering care services, relocation within and across states among other factors add to the complexity of sharing data on this population which directly and/or indirectly affect their involvement across systems as well as associated outcomes (e.g., foster families, adoption agencies, schools, courts, behavioral and mental health; Herz, 2012).

Numerous factors including abuse and neglect, family context, extreme poverty, socio-economic status, gender, race, ethnicity, immigration status and sexual orientation have been identified to contribute to the disproportionate representation of foster youth involved in the juvenile justice system (Mental Health America, 2015, Vidal et al., 2017). The connections across child welfare and juvenile justice systems have been well established with approximately 50% of foster youth in the United States entering the prison system in less than 2 years after emancipation (Peak, 2018). In addition, the developmental outcomes of multisystem youth have been associated with lower academic achievement, poor general health (e.g., depression, post-traumatic stress disorder, anxiety, malnutrition, dental problems), and risk-taking behaviors among others (American Academy of Pediatrics, 2011, Hirsch et al., 2018).

Despite robust information on multisystem youth’s developmental outcomes, mental and reproductive health are two areas that have gained deep concerns during the last decade. Youth advocates and health care providers along with other professionals have raised awareness on the increased risk for mental and reproductive health related outcomes in foster youth due to previous traumatic experiences including sexual and emotional abuse as well as further abuse experienced at juvenile detention centers (Prison Policy Initiative, 2018). In addition, a robust body of evidence including national statistics and empirical studies have discussed at length the short and long-term effects of multisystem involvement on mental and reproductive outcomes particularly during a sensitive developmental period for major biological and psychological changes in adolescence (Anspach, 2018, Bilchik, 2010, Steinberg et al., 2001).

Studies have found that approximately 70% of youth simultaneously involved across several systems meet the criteria for more than one mental health disorder, with nearly 30% of those experiencing severe mental health issues (Mental Health America, 2015). Furthermore, scholars have documented the associations between abuse/maltreatment, exposure to toxic-stress and trauma, internalizing (e.g., Post-Traumatic Stress Disorder, depression, suicidal ideations, anxiety) and externalizing behaviors (e.g., aggression, violence, substance use, delinquency) in foster and juvenile justice involved youth (e.g., Bilchik, 2010, Herz, 2012).

Due to toxic stress and adverse and/or traumatic experiences, multisystem youth also present elevated rates of early sexual activity, unsafe sexual behaviors (e.g., inconsistent condom use, multiple partners, sex combined with alcohol and/or drugs), life-time history of sexually transmitted diseases (STDs) or infections (STIs) and associated health problems (e.g. Hepatitis C, HIV/AIDS) (Teplin, Mericle, Mcclelland, & Abram, 2003). Multisystem youth have also reported poor relational skills that may affect their ability to engage in healthy romantic relationships, placing them at a higher risk for intimate partner violence, abuse, and sexual exploitation (Winter, Brandon-Friedman, & Ely, 2016).

In spite of growing attention to multisystem youth’s mental and reproductive health, most of the information regarding these youth’s outcomes remain inconclusive given the lack of data sharing and continuity of services across systems (Abbott & Barnett, 2015). Furthermore, current evidence linking child welfare and juvenile justice systems as well as the potential detrimental effects of multisystem involvement has mostly used an institutional lens, a quantitative approach, and/or a practice/service angle neglecting the youth’s perspective (Trejos-Castillo & Trevino-Schafer, 2018). Therefore, other methodological approaches to studying this population are warranted to gain nuanced insights on the mental and reproductive health needs to provide better services, prevention/intervention approaches and support (Johnston et al., 2016).

In the current study, we aimed to address two significant gaps in extant scholarship on multisystem youth. First, we used a qualitative thematic analysis (Guest, MacQueen, & Namey, 2012) to provide in-depth insights about mental and reproductive health on this population. Second, we used a multi-informant approach to provide a more nuanced examination of youth’s experiences across systems as well as probation/parole officers’ experiences working with them. The study sample was drawn from a larger mixed-method study on multisystem youth examining several domains (e.g., health, behaviors, emotions, perceptions, access to services, multisystem involvement, etc) over the course of three years; mental and reproductive health were recurrent issues identified across qualitative data. The study is informed by a socio-ecological theoretical framework (Bronfenbrenner, 2000) that represents a great tool for examining the complex interplay of multilevel individual (youth and officers) and contextual (foster care, juvenile justice system, health care) factors affecting youth outcomes.

Though several theories and conceptual models have been described to possibly explicate child welfare and juvenile justice youth’s involvement and associated consequences, the socio-ecological framework allows for closely examining participant’s experiences as they interact simultaneously with diverse systems as well as exploring the direct and indirect effect of those systems in youth’s outcomes (Guest et al., 2012). This theoretical framework greatly adapts to qualitative methodologies and supports the integration of different informants and their unique perspectives to tease apart micro (individuals) and macro (systems) factors affecting youth’s developmental trajectories. Furthermore, the current study utilizes the socio-ecological theoretical framework to examine potential similarities and differences across multi-informants as they identify challenges and concerns regarding mental and reproductive health in multisystem youth.