Children in child welfare protective custody (e.g., foster care) are known to have increased health concerns compared to children not in protective custody. The poor health documented for children in protective custody persists well into adulthood; young adults who emancipate from protective custody report poorer health, lower quality of life, and increased health risk behaviors compared to young adults in the general population. This includes increased mental health concerns, substance use, sexually transmitted infections, unintended pregnancy, and HIV diagnosis. Identifying youth in protective custody with mental health concerns, chronic medical conditions, and increased health risk behaviors while they remain in custody would provide the opportunity to target prevention and intervention efforts to curtail poor health outcomes while youth are still connected to health and social services. This study leveraged linked electronic health records and child welfare administrative records for 351 youth ages 15 and older to identify young people in custody who were experiencing mental health conditions, chronic medical conditions, and health risk behaviors (e.g., substance use, sexual risk). Results indicate that 41.6% of youth have a mental health diagnosis, with depression and behavior disorders most common. Additionally, 41.3% of youth experience chronic medical conditions, primarily allergies, obesity, and vision and hearing concerns. Finally, 39.6% of youth use substances and 37.0% engage in risky sexual behaviors. Predictors of health risks were examined. Those findings indicate that women, those with longer lengths of stay and more times in custody, and those in independent living and conjugate care settings are at greatest risk for mental health conditions, chronic medical conditions, and health risk behaviors. Results suggest a need to ensure that youth remain connected to health and mental health safety nets, with particular attention needed for adolescents in care for longer and/or those placed in non-family style settings. Understanding who is at risk is critical for developing interventions and policies to target youth who are most vulnerable for increased health concerns that can be implemented while they are in custody and are available to receive services.

Key Take Away Points

  • Mental health and chronic medical conditions occur for 2 in 5 youth approaching emancipation from custody, while health risk behaviors occur for 1 in 3 youth.
  • Poor health outcomes identified for young adults with a history of child welfare involvement have their origins in adolescence, prior to emancipation.
  • Leveraging health care and mental health systems while youth are in protective custody may help mitigate known risks after youth emancipate.

Author Biography

Sarah Beal, PhD is a developmental psychologist and research faculty member at Cincinnati Children’s Hospital. She completed her graduate work at the University of Nebraska-Lincoln and a postdoctoral fellowship at Cincinnati Children’s. She is interested in research addressing the transition to adulthood, and what aspects of involvement in foster care contribute to poor developmental outcomes for adolescents. Katie Nause, BS is a clinical research coordinator at Cincinnati Children’s Hospital. She completed her BS in psychology at Northern Kentucky University in 2013. Her interests are in data management and leveraging existing data sources to understand health and related concerns for children in protective custody. Imani Crosby is a student at the University of Cincinnati pursuing a Bachelor of Arts Degree in Psychology, expected in 2019. She is interested in child development and plans to pursue graduate training in clinical psychology. Mary Greiner, MD, MS is a child abuse pediatrician and clinical faculty at Cincinnati Children’s Hospital. She completed medical school at Virginia Commonwealth University’s Medical College of Virginia, residency at Wake Forest University Baptist Medical Center, and her child abuse fellowship at Cincinnati Children’s. She is interested in research evaluating innovative approaches to delivering healthcare for children in or at risk of entering foster care, and identifying which clinical interventions most help to improve health outcomes for these children.


We thank Kris Flinchum and our colleagues at Hamilton County Job and Family Services for their assistance with data sharing for this study. This work was supported by the CareSource Foundation under a 2014 Signature Grant Award; the National Institutes of Health National Center for Advancing Translational Sciences under Award Number 5UL1TR001425-03, the National Institutes of Health National Institute on Drug Abuse under Award Number K01 DA041620-01, and that National Institute of Minority Health and Health Disparities under Award Number R03 MD011419-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.