Foster parent decision-making and the Health Belief Model.

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                Foster parent decision making and the HBM                 


Foster parent decision-making and the Health Belief Model

Lin Marklin

Western Michigan University

A note about the APA format.

I realize that many of my in-text citations should be shortened when the citations appears a second time in the paper.

The strategy that works best for me is to get all my sentences and paragraphs into final order, and then do the final edit of my in-text citations.


Foster children have more mental health needs than children in the general population (Blumberg, & Landsverk, 1996). The number of children in foster care is mounting, and children with high mental health needs are becoming a larger percentage of this population. Despite a strong need for services, many children in foster care have mental health needs that are unmet  (Rosenfeld, Pilowsky, & Fine, 1997). Foster parents are primarily responsible for securing mental health services, but health communication research into the variables that influence a foster parent’s decision to use mental health services is lacking.  The Health Belief Model (HBM) could be insightful in understanding these parental decisions.  This study will assess the contribution of the variables described in the Health Belief Model (HBM) to foster parents’ decisions regarding mental health services.

The Foster Care System


Providing care for children with abusive, neglectful, or indigent parents has long been a concern in this nation, and some form of foster care has been in place in America since colonial time. In the 1600’s and 1700’s abused, neglected, and poverty-sticken children were placed either in the poorhouses or with other families as indentured servants, to be released upon adulthood (Schor, 1982). In the 1800’s orphanages became popular repositories for these  children, and this remained the choice until the first two decades of the twentieth century. In response to a desire to better meet the needs of abused, neglected, or poverty-striken children, a 1909 White House conference acknowledged that home environments were preferable to institutions, and poverty did not predetermine removal from the home. American law makers then responded to the desire to better serve these children by opening up the public purse, and by the 1920’s, all states had all some form of Aid to Families of Dependent Children  (Schor, 1982).  With the use of federal and state monies, many at-risk children were able to remain at home. For the next thirty years, children were placed in foster care primarily in response to family illness, extreme poverty, or parental mental illness (dosReis, Zito, Safer, & Soeken, 2001; Schor, 1982), and foster care was a final safety net for families in medical or financial crisis. The causes for foster care placement changed throughout the 1960's and the 1970's, and in the early 1980's, it was reported that parental abuse and neglect was "one of, if not the most important, precipitating circumstances" (Schor, 1982, p. 523). Finally, in August 1997, the National Center for Policy Analysis indicated that a larger number of placements since 1987 were the result of parental abuse and neglect (Craig, & Herbert, 1997). Increasingly, prolonged exposure to emotionally and mentally damaging environments are the precursors to placement for many foster children today, and the reason for placement can have a great influence on the child's mental health (e. g., Blumberg, & Landsverk, 1996; Rosenfeld, Pilowsky, & Fine, 1997; Zima, Bussing, Yang, & Belin, 2000).  The current foster care system is a reflection of society's basic desire to meet the needs of  “the nation's most vulnerable children” (Craig, & Herbert, 1997, p. 1), but the task of caring for such children is becoming more complicated due to the changing pre-placement factors.

Foster Children

Foster children are at high risk for mental disorders due to the risk factors of their pre-placement environment and as a result of their post-placement separations and losses. The fact that foster children have more mental health needs than children in the general population has been shown by numerous studies (e.g., Blumberg, & Landsverk, 1996; Bondy, & Davis, 1990; dosReis, Zito, Safer, & Soeken, 2001; Pilowsky, 1995).  Mental health professionals have indicated that intervention, usually indicative of moderate to severe mental health disorders, is necessary for up to 57% of foster children as compared to a maximum of 22% of children in the general population (Blumberg, & Landsverk, 1996). A study of 213 California foster children found that 80% of those children had developmental, behavioral, and emotional problems which have been linked to mental health disorders (Schneiderman, & Connors, 1998). The behavioral and emotional problems of many foster children are significant (Pilowsky, 1995). Furthermore, many of these same children are at risk for developing additional or more severe behavioral and emotional problems due to the abusive, neglectful, or drug-using home environments that most likely brought the children into the foster care system (e. g., Blumberg, & Landsverk, 1996; Rosenfeld, et al., 1997). Adding to these risk factors for mental disorders is the fact that a large portion of foster children come from poverty-stricken environments where criminality, violence, and maternal drug abuse is prevalent (Pilowsky, 1995).   Potentially compounding the pre-placement risk factors is the foster care placement itself where children experience a temporary or permanent separation from parents, neighborhoods, school systems, religious organizations, and a potential loss of sibling and cultural ties (Schneiderman, & Connors, 1998).  Thus, the actual movement into and potential subsequent movements within the foster care system could be seen as traumatic even though the relationship between placement into foster care and children's mental health is not well documented (Orme, 2001).  It is essential that foster children get assistance is dealing with the mental trauma of past neglect and abuse and with multiple losses precipitated by placement in foster care (Bondy, & Davis, 1990). Because children in foster care generally come from chaotic home situations, and the placement into foster care is often seen as traumatic, foster children are more predisposed to mental disorders.

Despite exhibiting a need for mental health services, research continues to show that children in foster care have mental health needs that are unmet (e.g., Halfon, Mendonca, & Berkowitz, 1995; Titterington, 1990). Orme (2001) reports mental health services are not being secured for a large percentage of foster children who have been identified as having an urgent need for such services. While a previous California study (e.g., Halfon, Mendonca, & Berkowitz, 1995) indicated that between 35-57% of foster children needed mental health intervention services, when Blumberg & Landsverk (1996) looked at 1, 352 children in the San Diego foster care system, only 17% were receiving services. These findings were based on payment/usage records within the San Diego Mental Health System, the only provider for Medicaid services, so two reasons were offered for the discrepancy: private insurance companies were paying for mental health use by foster children or there was a considerable amount of unmet need (Blumberg, & Landsverk, 1996). Because the foster care agency is the legal guardian of the children in care, and foster parents have no legal status with regard to their foster children, it would seem doubtful that private insurance could account for a large portion of the 18% to 40% of the studied population that was not receiving mental health services paid for by state monies. Takayama, Bergman, & Connell (1994) found that in the state of Washington 25% of studied foster children were receiving Medicaid funded mental health services in a population were twice that number children were judged to have the need for such services. Tittterington (1990) and Bondy (1990) both argue for the need to change the foster care system in order to better provide for the large number of foster children who exhibit mental health disorders but are not receiving any type of mental health services.  It is clear that children in foster care have unmet mental health needs, and understanding why these need are unmet can be the first step in identifying potential strategies to rectify this situation.

Meeting the mental health needs of foster children is a two-fold imperative due to the growth in the number of foster children and the changing demographics within the current foster child population. The number of children in foster care is large, and historically, it has been growing. Research has indicated that that the number of children in foster care has increased dramatically. In the 14 year period between 1982 and 1996, the number of children in care more than doubled from 262 000 to  526,112 (dosReis, Zito, Safer, & Soeken, 2001; Craig, & Herbert, 1997; Orme, 2001). According to the National Center for Policy Analysis, a total of 725,000 children received some type of foster care service in 1996 (Craig, & Herbert, 1997). In addition to the size of the foster care population, the changing characteristics of foster children are another area of concern. Orme (2001) postulates that the mental health needs within the foster care population might experience an increase due solely to the changing demographic of the children who remain in care for an extended time. In 1997, the U.S. Congress enacted the Adoption and Safe Families Act with the goal of moving children more quickly through the system (Craig, & Herbert, 1997). There is now a one-year time frame for returning children to families who can appropriately care for them or placing the children for adoption. Once available for adoption, children with relatively low mental health needs are often the first to be placed, and children with higher mental, educational, and emotional needs are often passed over (Orme, 2001). Therefore, the population of children who remain in foster care for an extended period of time will increasingly be those are not easily adopted due to mental, physical, emotional, and behavioral disorders (Orme, 2001).  Thus the demographic within the growing foster care population will probably evolve to have a greater portion of children with even more severe mental health needs.  This change in demographic will most certainly alter the types of care that foster parents must provide for these children, and mental health is a priority service that these children will need (Orme, 2001). Therefore, understanding why the mental health need of many current foster children are unmet is important if foster care professionals want to better meet the mental health needs of foster children.  

Caseworkers and Foster Parents

Caseworker advocate for the needs of the foster children, but caseworker also has assorted other duties that in effect remove the caseworker from the day-to-day life experiences of the foster children. The case worker has a multitude of responsibilities in the life of the foster child that can include but are not limited to preparing legal documents for hearings, testifying in court cases, coordinating family visits, interacting with biological parents, assessing the needs of the biological family, developing a plan to meet those needs, supervising the biological parents progress toward goals, facilitating and coordinating access to social services, health care, and medical treatment for both the biological parents and the foster family, working with the school system to develop service plans for the foster children, and helping the foster care agency decide what is in the best interest of the foster child (Kessler, & Greene, 1999; Zlotnick, Kronstadt, &  Klee, 1999). Caseworkers view themselves as case managers who often are relying on the information provided by knowledgeable others in order to make informed decisions on behalf of the foster children (J. A. Tamer, personal communication, October 23, 2001). While the caseworker is definitely interested in the well-being of the individual foster child, larger issues within the biological family and paperwork required by the state agency and the courts often consume much of the caseworker’s attention (Kessler, & Greene, 1999). The caseworker is advocating for the foster child on a larger plane and can be uninformed of the day to day struggles of the individual foster child.

A child in foster care may interact with the caseworker, but no adult is more responsible for the care of the child than the foster parent. The foster parent is the individual on the front line managing, evaluating, and engaging the child, and as such it is the foster parent who plays the pivotal role in the life of the foster child (Orme, 2001). Most agencies view foster parents as part of the professional team with unique and valuable insights into the needs of the foster child (Titterington, 1990).  Caseworkers look to the foster parents for information and guidance regarding the health status of children in care:  The foster parent is a valuable resource for the caseworker, and the caseworker often relies on the foster parent to adequately evaluate and report the health concerns of the children in care (J. A. Tamer, personal communication, October 23, 2001; Zlotnick, Kronstadt, &  Klee, 1999). Foster parent can contribute meaningfully to the development of the children service plans (Titterington, 1990).  In addition, it the service plan that helps determine the foster child’s use of health related services, and this is especially true for mental health services. The role of the foster parent in reporting mental health concerns and advocating for mental health services is crucial for early utilization of mental health services (J. A. Tamer, personal communication, October 23, 2001).  While caseworkers may eventually recognize and treat mental health disorders, the foster parent is the crucial link between the foster child and mental health services. The vital role of the foster parent in the foster child’s health is obvious (Orme, 2001), but unfortunately many foster parents are not making the needed connection.

As previously stated, there is an unmet need for mental health services among foster children and some research seems to suggest that foster parents may be a weak link in the chain connecting foster children to mental health services (Blumberg, & Landsverk, 1996; Bondy & Davis, 1990; dosReis, Zito, Safer,  & Soeken, 2001). If foster parents are in some way failing to get their foster children needed mental health services, then understanding the variables that influence foster parent decision-making could be insightful.  Research has shown that foster parents are not securing the mental health services that their children need (Halfon, Mendonca, & Berkowitz, 1995; Horwitz, Owens, &  Simms, 2000). It is unclear if the basis for this lack of services is due solely to a failure to acknowledge a mental health problem or if the failure is also related to some of the variables of the HBM, such as perceived risk appraisal, perceived benefits and barriers, cues to action, and perceived self-efficacy. Research has shown that foster parents are less likely than health care professionals to diagnose mental health problems in foster children (Horwitz, Owens, & Simms, 2000). Foster parents report that 47% of the children in their care need mental health services (Zima, et al., 2000), yet professional diagnosticians report that this need is as high as 80% (Halfon, Mendonca, & Berkowitz, 1995; Horwitz, Owens, & Simms, 2000). This lack of diagnosing the problem seems almost contradicted by the fact that foster parents most commonly reported mental health services as the service their child needed most (Zima, Bussing, Yang, & Belin, 2000), and these parents specifically identified needs for counseling services (Zima, Bussing, Yang, & Belin, 2000).  More research is needed into the variables that impact the role foster parents play in securing mental health services for foster children.

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The most beneficial research could come from utilizing the Health Belief Model (HBM) as a guide for analyzing foster parents decisions either to seek and not to seek mental health services for their foster children. The socioeconomic (Blumberg, & Landsverk, 1996), demographic (Garland, Besinger, & Bridgett, 1997), and educational variables (dosReis, Zito, Safer, & Soeken, 2001) that influence the utilization of mental health services by foster parents have been investigated. Previous research has not focused on beliefs and attitudes.  It has been noted that getting foster parents to actively participate in the mental health treatment of their foster children is ...

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