As youth develop and grow into adulthood, it is common for some to develop a mental health condition that can impact their well-being and day-to-day functioning. Research shows that 1 in 5 teens and young adults struggle with their mental health, with half developing a mental health disorder by age 14 and three quarters by age 24. There are many layers of biological and social factors that can influence a youth’s mental health, one of which is the process of coming into foster care.

Trauma and Mental Health

Out-of-home placements disrupt healthy attachments at any age and often remove a sense of security and stability that is vital to a person’s wellbeing and identity. The trauma of being removed from the home, coupled with the experience(s) that brought them into care in the first place, can place a strain on a youth’s mental health that can have significant repercussions for other aspects of their life, from relationships to school to placement. Trauma sends negative messages to a youth, which become internalized as negative feelings and behaviors.

Because trauma can both mirror mental health disorders and exacerbate or trigger existing conditions, to be in foster care means a youth is at a higher risk of developing psychological and emotional issues than the general population. Foster youth are three times more likely to receive a mental health diagnosis than their non-foster youth peers; research shows that nationally up to 70% of juvenile justice-involved youth and 80% of youth in foster care experience significant mental illness, in comparison to 18-22% of the general population.

Foster youth are often inadvertently caught in a vicious mental health cycle; if they are struggling with their mental health and exhibit certain behaviors, they may be removed from their placement, suspended or expelled from school, hospitalized, and/or placed on psychotropic medications. Each of these experiences has a high likelihood of retraumatizing the youth and exacerbating their mental health struggles.

Diagnoses and Forms of Support

While it can be difficult to diagnose young people because their brains are still developing, foster youth nonetheless may receive a number of diagnoses. These include mood disorders (such as depression or bipolar disorder), anxiety disorders, psychotic disorders (such as schizophrenia), personality disorders, eating disorders, trauma-related disorders (such as post-traumatic stress disorder), developmental disorders (such as ADHD and autism spectrum disorder), behavioral disorders (such as oppositional defiant disorder), substance use disorders, and obsessive-compulsive disorders.

Foster youth either receive or should be receiving support in managing their mental health needs. This support can include a variety of modalities, such as psychotropic medication; traditional therapeutic support like behavioral therapy, cognitive behavioral therapy, play therapy, and child-parent psychotherapy; and non-traditional therapeutic support like equine therapy and recreational activities. Any treatment that a youth’s team explores should be trauma-informed and culturally rooted.

Psychotropic Medications

As mentioned above, psychotropic medications, which affect the central nervous system to treat psychiatric disorders, are one form of support for youth with high behavioral needs. Different medication types include antidepressants, antipsychotics, mood stabilizers, anti-anxiety medications, and stimulants.

Psychotropic medication can be a valuable tool to provide stability and promote well-being when used as a part of a larger treatment plan and when other evidence-based treatment options have been tried. Psychotropic medications should not markdown be used as a first line of treatment, alone without other forms of non-medication support, or to mask the side effects of different medications.

The use of psychotropic medication to treat behavioral health needs has skyrocketed over the last decade for foster youth, who are disproportionately prescribed such medications. Studies indicate that foster youth are prescribed psychotropic medications 3 to 11 times more than non-foster youth, and approximately 70% of those on medication are prescribed two or more from different medication classes. There have been many issues identified with prescribing psychotropic medication for foster youth, such as too many medications being prescribed (known as polypharmacy, which is a layering of medication), too high of dosages, little to no monitoring, and prescribing based on inaccurate diagnoses. When any one of these issues arises, it can be unsafe for the youth, potentially resulting in long-term and permanent health issues.

CASAs can and should play a central role in advocating for appropriate oversight of psychotropic medication usage in foster youth. While the number of foster youth being prescribed psychotropic medication in California has declined in recent years, those youth still on medication need support from their team, including their CASAs, to ensure they are being prescribed medications safely and effectively.

How to Advocate

As a CASA, remember that it is not your job to diagnose a youth or act as their therapist or doctor. However, there are many different ways a CASA can actively support their youth’s mental health needs, both behind-the-scenes and directly with their youth. Check out some of our ideas below!

Behind-the-scenes:

Determine if your youth is being prescribed psychotropic medication. If so, please review these resources to inform your advocacy:

Psychotropic Medication Roadmap for CASAs

Psychotropic Medication Forms De-Coded

Psychotropic Medication Flowchart

JV-217 Guide to Psychotropic Medication Forms

Effective Communication with Stakeholders

Questions to Ask Team Members as a CASA

Court Report Checklist

Comprehensive list of best practices (from the American Academy of Child and Adolescent Psychiatry)

SFCASA Psychotropic Medication Advocacy Webinars (please scroll down to view this webinar series in “CE Opportunities” below)

If your youth is in an out-of-home placement, obtain a copy of their latest Health and Education Passport (HEP) from their social worker. This documents their academic information as well physical and mental health status, detailing any known diagnoses and treatments like psychotropic medications and dosages.
Determine if your youth is receiving therapy services and if so, what type(s). A CASA can learn this through discussion with the youth’s social worker, Wraparound care coordinator, and/or clinician. It can also be determined by reviewing the latest Status Review Report and the Health and Education Passport (HEP). Be prepared to advocate for any obstacles that prevent therapy from taking place, such as transportation issues or access to a culturally-appropriate clinician.
Speak to the youth’s team about what types of mental health assessments have taken place, such as a psychological evaluation or a CANS (Child and Adolescent Needs and Strengths) assessment. The CANS assessment is a tool that helps a foster youth’s team determine the level of care and services they may need, including mental health needs.
Connect with relevant mental health professionals on your youth’s team in order to ask relevant questions and gain relevant information (please review this document for guidance on important questions to ask various team members). This can include:
- The public health nurse at the Human Services Agency. Each youth is assigned a public health nurse at the Human Services Agency to assist with their medical needs, from making appointments to referring them to specialists to participating in medically-related CFT meetings. Ask the social worker to connect you with this individual so you can begin partnering with them on all things health.
- The psychiatric nurse specialist at the Human Services Agency, if they are being prescribed psychotropic medication. Your case supervisor can connect you with this person, who will be a good point person should you have any questions about their medication and related mental health services.
- Their prescribing physician if they are being prescribed psychotropic medication
- Their therapist
- The individuals on their Wraparound team
- Their school’s Foster Youth Liaison to ensure their mental health needs are being met in the school setting.
If they are being prescribed psychotropic medication, work with the team to ensure there is a treatment plan in place that pairs medication with therapy services. Additionally, make sure they are receiving regularly check-ins about the treatment plan.
Work with the team to connect your youth to healthy extracurricular activities and resources. This can include joining a sports team, taking cooking lessons, buying a bike, etc. – whatever your youth is interested in! Please check out our “Financial Support” page to learn about grant funding that can be used to cover these needs.
Learn the warning signs of mental illness and a mental health crisis to feel prepared to identify any possible concerns when working with your youth. Share any concerns about your youth’s behaviors with your case supervisor immediately. These may include changes in their eating and sleeping habits, low energy; withdrawal from people and activities; frequent complaints about physical symptoms like stomach aches, headaches, feeling tired; and schoolwork decline.
Make sure to add all relevant mental health information to the “Health” section of your court report. It is appropriate to list information here about their therapy services, any medications they are on, and any observations you have.
Remember that youth are not their diagnosis!

With your youth:

Establish a safe and supportive environment. This can be accomplished through setting boundaries, showing up regularly and building structure, being consistent in messaging, and modeling positive and healthy relationships.
Encourage the expression of their feelings. This can be accomplished by validating the feelings your youth may be indicating or sharing and helping your youth to identify their feelings. If you suspect that your youth is struggling with their mental health, ask them questions like, are you feeling sad? Are you thinking about hurting yourself/have you ever thought about hurting yourself?
Support their use of positive, constructive coping skills and self-regulation. This can include self-care, mindfulness, and practicing breathing techniques. Please be in touch with your youth’s clinician if they have one to learn if they are working on any regulation tools that you can support during visits or should be aware of.
Explore trauma-informed, healing activities with your youth that can have a therapeutic effect. This can include:
- Doing a body scan and practicing deep breathing
- Taking a body movement class together, such as yoga, boxing, dance or self-defense
- Creating and decorating a family tree or family photo album
- Journaling and writing or telling stories
- Participating in a team sport such as soccer
- Horseback riding
As appropriate, start a conversation with your youth about:

If they are being prescribed psychotropic medication, help them track any symptoms or side effects of the medication. This information can help inform the JV-218, a legal form that the youth should be completing for each psychotropic medication hearing that states their opinion about their medication. Please review this document for guidance on important questions to ask your youth.
If they are being prescribed psychotropic medication, advocate around psychotropic medication hearings, which happen every six months if your youth is being prescribed medication. This advocacy should entail knowing when the hearing is taking place and working with their social worker to ensure they are filling out a JV-224 (County Report on Psychotropic Medication) and filing it along with a JV-218 (Child’s Opinion about the Medicine).
Talk to them about their mental health rights. See our Legal section below to learn more.

Appropriate language to use as a CASA

Each youth’s response to trauma and their mental health challenges can be different, and it is important to recognize that many behaviors, coping skills, and communication patterns are tied to this. It is vital that CASAs take a nonjudgmental, strengths-based approach when it comes to supporting their youth’s behavioral health needs, and recognize that a person is not defined by their behaviors.

Do not be intimated to ask open-ended questions of both your youth and their team to invite discussion about your youth’s mental health needs. With your youth, follow these questions up with active listening and validation to ensure there is an atmosphere of acceptance. Within this safe space, explore and harness their own personal motivation and confidence in their abilities, empowering them to advocate for their own needs and make healthy lifestyle choices that work for them as an individual.

Please reference this resource from California CASA about how to navigate a conversation with the foster youth you serve.

Legal Rights

Foster Youth Mental Health Bill of Rights

Youth Suicide

Foster youth are 3-5 times more likely to commit suicide than same age peers, two and a half times more likely to think about possibly committing suicide, and four times more likely to make a suicide attempt (source: National Center for Prevention of Youth Suicide). Understanding the risk factors, early warning signs, and preventative factors related to youth suicide can inform your advocacy and support for the young person you serve.

Risk Factors

Previous suicide attempt
Strong family history of suicide
Strong family history of severe depression/severe mental illness
Bullying
History of child sexual abuse
Lack of access to help, isolation
LGBT youth (bullying and discrimination)
Access to lethal weapons
Engaging in high-risk behaviors
Substance abuse/dependence
Loss of family contact, support and connection
Poor impulse control and low frustration tolerance
Feeling stuck, trapped, or caged with no hope of escape
Communicating about suicide: Journaling about suicide or writing about it, or talking to friends

Early Warning Signs

Withdrawal and isolation, and alienation, i.e., inability to reach out for help due to poor coping skills
Saying that life has no value or this earthly existence is meaningless
Odd behaviors and sudden changes in behaviors that are high risk or dangerous
Personality changes, social relationship changes, sleep disturbances, nightmares, lack of social acceptance, self-loathing
Obsessions with thoughts of death and dying, focus on music that is violent or reflecting death themes
Loss or death of loved one, such as an idolized parental figure 4/5 suicides are usually preceded by warnings by the person who is planning to commit suicide and often these are not taken seriously.

Protective Factors

Determination to succeed
Refusal to accept the norm
Positive self-esteem
Strong support system: family, friends, biological connection
Willingness to accept society
Academic achievement
Sense of optimism
Involvement in sports and other activities
Peer support and acceptance
Religion and spiritual practice
Sense of having personal control
Support through mental health and other services
Safe school
school connectedness
Caring adult
Coping skills
Frequent, vigorous physical activity, sports
Reduced access to alcohol, drugs, lethal weapons, medications

Strategies to help prevent suicide in foster youth

Help them feel that they are wanted, that they belong, and that they are important to you.
Use I statements and say how glad you are that they are around
Ask for their opinion, views, and even if you disagree, allow independence of spirit and opinion
If the youth seems “out of control” try to find the cause – in foster care, it is more often about escaping from pain and grief than about wanting to be defiant or being mentally ill
Talk, talk and be there for your young person
Be watchful and mindful of access to alcohol, drugs and illicit activities: often these are ways to escape from traumatic memories
Promote school activities, sports, drama, art, and community activities. The more youth are involved in positive activities the less likely they are to engage in negative self-talk
Involve youth in decision making for visits and time spent together
Be open to talking about suicide, depression and feelings of isolation and alienation from society Above all, accept the youth for whom and what they are; you cannot take away their memories, but you can provide happier events that leave positive memories for the future. Each positive memory is a mental health bank for healthier self-esteem and self-worth.

If you feel concerned that the youth you serve is suicidal

Advocate for the PSW, therapist or the caregiver to perform a suicide assessment to assess risk level.
Always take talk of self-harm and suicide attempts seriously. A youth may hint or joke about suicide, but it is important to take all communications about suicide seriously.
Go ahead and ask. It is safe to ask a youth directly, “Are you thinking about killing yourself?” Talking about suicide does not cause suicide. If you have difficulty asking, enlist another adult to help you.
Really listen. Show your interest and support without judgment. Don’t interrupt, and don’t give advice. Express concern and tell the youth that together you can make a difference.
If the young person shares they have made plans for suicide, call the National Suicide Prevention Lifeline at 1-800- 273-8255, a mental health professional, a hospital emergency department or 911.
Stay with the youth. Don’t leave a suicidal youth alone. Go with them to a mental health professional, hospital emergency room, or his or her primary care physician.
Always contact your Case Supervisor to discuss the situation and strategize about next steps.

How to support a young person after a suicidal event

Follow-up on treatment. If the doctor prescribes medication, make sure it is taken as directed. Be aware of possible side effects and be sure to notify the physician if the person seems to be getting worse. It often takes time and persistence to find the medication or therapy that’s right.
Encourage positive lifestyle changes, such as a healthy diet, plenty of sleep, and getting out in the sun or into nature for at least 30 minutes each day. Exercise is also extremely important as it releases endorphins, relieves stress, and promotes emotional well-being.
Advocate for the PSW for therapist to Make a safety plan with the youth. Together they should develop a set of steps he or she promises to follow during a suicidal crisis. It should identify any triggers that may lead to a suicidal crisis, such as an anniversary of a loss, alcohol, or stress from relationships.

It takes a lot of courage to help someone who is suicidal. Dealing with someone who has thoughts about ending his or her own life can stir up many difficult emotions. As you're helping a suicidal person, don't forget to take care of yourself. Rely on your Case Supervisor for support around self-care.

Credit: Dr. Nathalia Estassi, and Dr. Kalyani Gopal, Helen Ramaglia, National Center for the Prevention of Youth Suicide

Resources/links to learn more

Foster Care Mental Health Program (a part of San Francisco’s Department of Public Health)

CASA-A Home Within Teletherapy culturally responsive virtual therapy that follows a youth wherever they live.

Foster Care Providers: Helping Youth at Risk of Suicide

Guide to Accessing MediCal Mental Health Services for Current and Former Foster Youth

Trauma Recovery Center mental health services, and comprehensive case management for survivors of trauma

Preventing Suicidal Behavior Among Youth in Foster Care

National Child Traumatic Stress Network

Facts for Families Guides by the American Academy of Child & Adolescent Psychiatry

NAMI (National Alliance on Mental Illness)

Seneca Family of Agencies (provides Wraparound care for many San Francisco County foster youth)

Edgewood Center for Children and Families (provides Wraparound care for many San Francisco County foster youth, also provides acute intensive services)

Hotlines:

Bay Area Youth Line: 888-977-3399
California Youth Crisis Line: 800-843-5200
San Francisco Suicide Prevention Hotline: 415-781-0500
Crisis Text Line: Text Line is free, 24/7 support for those in crisis. Text 741741 from anywhere in the U.S. to text with a trained Crisis Counselor. Crisis Text Line trains volunteers to support people in crisis. With over 79 million messages processed to date, they are growing quickly, but so is the need.

CE opportunities

Nora Landis-ShackAugust 18, 2022