Trajectories of depression symptoms among older youths exiting foster care.

Author:Munson, Michelle R.

The purpose of this study was to determine the trajectories of depressive symptoms as older youths from the foster care system mature while also examining the correlates of these trajectories. Data came from a longitudinal study of 404 youths from the foster care system in Missouri, who were interviewed nine times between their 17th and 19th birthdays. Depression was assessed with the Depression Outcomes Module and the Diagnostic Interview Schedule for DSM-IV Data best fit a model of three trajectory classes, describing young people (1) maintaining low levels of depressive symptoms (never depressed class, 78%), (2) with increasing symptoms (increasing class, 6%), and (3) with decreasing symptoms (decreasing class, 15%). The increasing depression group was mostly male youths who were working or in school; the decreasing class was mostly highly maltreated female youths exiting the foster care system from residential care, with low levels of employment, and in school. Implications for social work practice are discussed.

KEY WORDS: depression; foster care; trajectories; transition


Foster youths are at increased risk of depression due to a variety of factors, including inherited vulnerability, child maltreatment, and the potential insults of the foster care system itself, including multiple moves and repeated relationship losses (Kaufman, 1991; McMillen et al., 2005). The over 26,000 young people who "age out" of the U.S. foster care system each year (U.S. Department of Health and Human Services, 2008), however, are thought to be at even greater risk for depression when they leave care. Some reasons for this may be the density of life transitions they experience, including the loss of mental health services, and a potential realization that their skills and resources are not adequate to meet the demands of living life more independently. The purpose of this study was to understand the nature of depressive symptoms among older youths transitioning from one mid-western state's foster care system. This was achieved through examination of the rates of past-year depression at ages 17 and 19, depressive symptom trajectories, the correlates of trajectory classes, and the relationships between trajectory class membership and functional outcomes. Social work plays a leading role in serving older youths exiting foster care, and this study informs the field on how their depressive symptoms present during the transition to adulthood.


Clinical Course of Depression during the Transition Years

Older adolescence is often filled with dense transitions in education, living situation, employment, and relationships (Rindfuss, 1991). Scholars have suggested that this can be a time when "things come undone" for vulnerable youths, especially if the resources and supports necessary to make the transition to adulthood are not available (Osgood, Foster, Flanagan, & Ruth, 2005). Epidemiological research has revealed high prevalence rates of depressive disorders during the transition years, roughly ages 16 to 25 (Giaconia et al., 1994; Kessler et al., 1994; Newman et al., 1996). Prevalence rates for depression steadily increase with age, peaking during adolescence and into adulthood (Burke, Burke, Regier, & Rae, 1990). Although depression is treatable, scores of youths with depression do not seek treatment (Keller, Lavori, Beardslee, Wunder, & Ryan, 1991), and many with mental disorders often drop out of services prematurely (Kazdin, 1996). This magnifies concerns, given that depression among adolescents has been associated with substance use, academic underachievement, unemployment, and teenage pregnancy (Diego, Field, & Sanders, 2003; Fergusson &Woodward, 2002; Lewinsohn, Rohde, Seeley, Klein, & Gotlib, 2003). Increasing knowledge about depression during the transition years for our most vulnerable citizens is critical to understanding how to best target both depression prevention and management efforts.

Theories of Depression

There are multiple pathways to experiencing the onset of a depressive episode. One of the most empirically supported theoretical perspectives on the etiology of depression is the stress-diathesis model (Abramson, Metalsky, & Alloy, 1989; Beck, 1976; see Stark et al., 2006, for a review), which purports that stressful life circumstances--such as poverty, victimization, or family dysfunction--interact with a genetic vulnerability to cause depression (Costello et al., 2002; Garber, Keiley, & Martin, 2002; Stark, Laurent, Livingston, Boswell, & Swearer, 1999). Behavior geneticists add support to the gene-environment theory, as they have found that response to stressful environmental situations is moderated by a person's genes (Caspi et al., 2003). Of particular interest for the present study is the relationship between victimization and depression (Turner, Finkelhor, & Ormrod, 2006; Widom, DuMont, & Czaja, 2007; Wise, Zierler, Krieger, & Harlow, 2001). Widom et al. (2007) used prospective data and found that childhood abuse and neglect were associated with roughly a 1.5 increase in the odds of adult depression, with even higher odds when adults had experienced multiple types of abuse.

The present study, with its focus on foster youths, involved a highly victimized sample. It is probable that leaving foster care carries different risks for older youths, depending on their genetic makeup, their pre- and postnatal environments, their early childhood experiences, and their adolescent experiences. Although not testing the stress-diathesis model, we used an integrative framework to understand depressive symptom trajectories among older youths exiting foster care by modeling individual, parental, and environmental factors to examine depressive symptom changes as these youths move toward adulthood.

Depression among Older Youths Nearing Their Exit from Foster Care

Child welfare professionals have long viewed young people in and leaving the foster care system as particularly vulnerable to depression. Even before the burdens of transitioning out of the care system, these children are thought to be at increased risk for depression as a result of both the adversities they have faced and the potential genetic liability inherited from parents who struggled to care for them (Kaufman, 1991;Widom et al., 2007). A recent study by McMillen et al. (2005) supports this view, as they found a lifetime prevalence rate of 27% for major depression among a group of 17-year-old youths in the foster care system, a rate higher than those found in the general population--that is, 18% (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993) and 16.8% (Newman et al., 1996). In an earlier article, Anderson and Simonitch (1981) suggested that reactive depression was likely common among these youths as they left foster care. They speculated that older youths initially feel elated at leaving controlling public systems, but this is quickly followed up by fear, loneliness, irritability, and, ultimately, depression as they realize their resources are not adequate to meet life's demands. In a small volunteer sample of older youths who left the foster care system approximately three years prior, Barth (1990) found that the mean score on the Center for Epidemiologic Studies Depression Scale was above the clinical cutoff score. To further investigate the reactive depression hypothesis, the present study examined whether there is a spike in depressive symptoms as older youths leave foster care. Understanding the prevalence of reactive depression among older youths leaving public service systems can help determine the need for depression prevention or depression management efforts that can be implemented for young people while they are in public care.

Trajectories of Depression

As methods to investigate depression have improved, studies examining depressive trajectories, or patterns of symptoms over time, have come to the forefront. Studies often identify three or four distinct paths of depressive symptoms, namely a consistently high group, a consistently low group, and one or two other groups that vary depending on the study.

Stoolmiller, Kim, and Capaldi (2005) reported that negative life events and parental depression predicted a greater likelihood of membership in a trajectory class evidencing high-persistent depressive symptoms during the transition to adulthood. Garber et al. (2002) found that adolescents with mothers who live with mood disorders had higher initial levels of depressive symptoms when compared with those with mothers who had no such history. Although research has shown that girls have higher rates of depression during adolescence (Birmaher et al., 1996), the evidence regarding gender and growth in depressive symptoms has been mixed. In an early study of adolescents, there were no significant gender differences in the presentation of depressive symptoms over a two-year period (DuBois, Felner, Bartels, & Silverman, 1995); however, another study found that depressive symptoms among girls increased at an earlier age and among boys they remained more stable (Ge, Conger, & Elder, 2001). The present study further examined gender as a predictor of trajectory class. As the literature on depression trajectories remains in its infancy, this study drew from literature examining factors related to depression, including minority race status (that is, Rushton, Forcier, & Schectman, 2003) and substance use (that is, Schuckit et al., 1997). We examined other potential predictors of depressive trajectories among foster care youths, such as living situation, juvenile justice involvement, teenage parenthood, and changes in mental health service use.

Finally, this study examined whether depressive trajectory class is associated with functional outcomes. Dekker et al. (2007) found that among boys, those in the elevated trajectory classes had lower educational attainment. As reviewed earlier, research has shown that the presence of...

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