Wonk Data Drop: The Other Pediatric Mental Health Crisis
By Robin Ghertner, MPP
Wonk Data Drop
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The Other Pediatric Mental Health Crisis: Children in Foster Care Face an Alarming Burden
Robin Ghertner, MPP
BLUF:
The percentage of children in foster care with disorders grew by 14 percentage points between 2018 and 2023 – much faster than children not in foster care.
In 2023, children in foster care were nearly 20 percentage points more likely to have a mental health condition than children not in foster care.
Medicaid cuts could make access to treatment even worse. More kids with disorders are at risk of being untreated, putting a greater burden on foster care systems.
The Big Picture: A Crisis Within a Crisis
In 2021, 25% of children had a diagnosis for a mental, behavioral, or developmental disorder.1
The COVID-19 pandemic contributed to a surge in children’s mental health care needs, high use of psychotropic medications, and increased suicidality.
For example, anxiety rose by 29 percent between 2016 and 2020.2
The American Academy of Pediatrics and other health organizations declared a national emergency in child mental health.3
This crisis is particularly acute for children in foster care, who face a significantly higher burden of these disorders.4 Research has shown that kids in foster care have high prevalence of mental health conditions and use of psychotropic medications.5
These disorders may arise as a response to either the conditions that led to being removed from their homes or due to their experiences while in foster care.6
What Was Missing Before Our Analysis
We haven’t yet seen the most recent data trends for children in foster care. The post-COVID landscape of mental health conditions, treatments and providers has changed substantially.
This analysis uses nationally-representative data from the National Survey of Children’s Health, sponsored by the Health Resources and Services Administration and conducted by the US Census Bureau.
In the survey, parents were asked whether a health care provider had told them their child currently has a range of mental health problems, including neurological and developmental disorders (defined under the figure).
What We Found: Faster Rise, Sharper Disparities
Children in foster care saw a 14-point increase in reported disorders—from 23% in 2018 to nearly 37% in 2023.
Children in foster care were nearly 20 percentage points more likely to have one of these disorders compared to non-foster care children in 2023.
As shown in the figure, in 2023 almost 36.9% of children in foster care had a disorder, compared to 17.8% of children not in foster care.
And while all children experienced increases in mental health issues, the increase was much higher for those in foster care.
Prevalence for children not in foster care only grew by 4 points, compared to the 14 point rise for children in foster care. In 2018, 14.1% of children not in foster care had a disorder, rising to 17.8% in 2023.
Figure: Two Aspects of the Foster Care Mental Health Crisis: Higher Rate For Children in Care, and Sharper Rise in Rates
Trends in Mental Health and/or Neurodevelopmental Disorder Among US Children, 2018-2023
Notes: Weighted estimates shown. Unweighted total N=262,097. Mental health and/or neurodevelopmental disorder defined as having one or more of the following: anxiety problems, depression, behavior or conduct problems, attention-deficit/hyperactivity disorder, or autism spectrum disorder. Data source: National Survey of Children’s Health 2018-2023. Estimates by Child Welfare Wonk.
Why This Difference Matters for Decision Makers
There are key issues for leaders to consider when grappling with the policy response to the rising need for pediatric mental health services, based on what evidence suggests drives this difference.
We expect more understanding to emerge as we further analyze this issue.
Trauma and instability: Children entering foster care have experienced neglect, abuse, or chronic instability.7
Diagnosis on entry: Many children are newly screened after removal, surfacing previously undiagnosed conditions.8
Eligibility and access: Children in foster care are enrolled in Medicaid and receive mandatory health screenings—exposing unmet needs.
Children with disorders are more likely to be removed from their families.
If families can’t support their children with disorders and don’t have access to therapies, children may come to the attention of the child welfare system.
Some parents relinquish custody solely to access treatment. One study suggests that up to 5% of children enter foster care to access behavioral health services.9 10
If parents can’t get treatment for their children, more may end up in foster care.
And if conditions aren’t appropriately diagnosed early enough, they can worsen; more kids will enter the system with heightened needs.
What This Means for Systems and Strategy
Federal and State Policymakers
Federal and state policymakers concerned with these trends will need to come up with approaches to financing and monitoring services in the new budgetary environment.
Mental Health Providers
Mental health providers need to understand what is different about children in foster care, and why they may need different approaches to treatment.
It also might mean their own staffing and financing systems may need to adapt to heightened health needs.
Child Welfare Administrators
Child welfare system administrators and practitioners – including congregate care providers – already see the evolving complexity of needs of the children in their care.
They will face financial, policy, and logistical challenges in ensuring availability of appropriate therapies available.
Philanthropy and Non-Governmental Actors
And non-governmental players will need to understand their own role in increasing availability of services.
Hospitals already faced challenges in caring for children while awaiting access to mental health care.
Now they face these rising pressures with less financial resources. Limits on Medicaid financing tools like provider taxes constrain funding right as demand rises.
Private funders face complex tensions. Principal among them, Medicaid cuts mean there are more treatment needs to be filled by private funds.
But they face new strategic tradeoffs, given other constraints related to ongoing market volatility and changes to tax law.
Medicaid Cuts Aren’t Isolated—they Reshape the System
Cuts to Medicaid and other parts of the health care system – even if not directly for foster care – will likely have consequences on families in foster care.
Children enter foster care for many reasons. One is inability to access mental health care. Medicaid funds nearly all of that care – both directly for children on Medicaid but also indirectly, by increasing the number of providers in a community and defraying their uncompensated care costs.
When Medicaid expenditures for children in foster care go up, other Medicaid-funded services can be negatively affected.
Children in foster care make up a relatively small percentage of the total Medicaid caseload.
If more children with disorders are in foster care, the proportional cost burden on Medicaid will increase.
The more Medicaid dollars states spend on foster care, the less funds they have to spend on other Medicaid populations.
Robin Ghertner is Child Welfare Wonk’s Founding Director of Strategic Policy Intelligence.
Leeb RT, Danielson ML, Claussen AH, et al. Trends in mental, behavioral, and developmental disorders among children and adolescents in the US, 2016-2021. Prev Chronic Dis. 2024;21:E96. doi:10.5888/pcd21.240142
Lebrun-Harris LA, Ghandour RM, Kogan MD, Warren MD. Five-Year Trends in US Children's Health and Well-being, 2016-2020. JAMA Pediatr. 2022;176(7):e220056.
American Academy of Pediatrics. AAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. Updated October 19, 2021. Accessed July 3, 2025. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
US Department of Health and Human Services. Protecting youth mental health: the US Surgeon General’s advisory. 2021. Accessed March 20, 2025. https://www.hhs.gov/sites/default/files/surgeongeneral-youth-mental-health-advisory.pdf
Lieff, S, Couzens, C, Radel, L, Ali, M and West. Behavioral Health Treatment by Service Type and Race/Ethnicity for Children and Youth Involved with the Child Welfare System. 2024. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
Radel LF, Ali MM, West K, Lieff SA. Psychotropic Medication and Psychotropic Polypharmacy Among Children and Adolescents in the US Child Welfare System. JAMA Pediatr. 2023;177(10):1107-1110. doi:10.1001/jamapediatrics.2023.3068
Herd, Toria PhD; Palmer, Lindsey PhD; Font, Sarah PhD. Prevalence of Mental Health Diagnoses Among Early Adolescents Before and During Foster Care. Journal of Developmental & Behavioral Pediatrics 44(4):p e269-e276, May 2023.
Gross, M, Keating, B, Colten, J, Miller, R, Radel, L, and Abbott, M. Prevalence and Characteristics of Children Entering Foster Care to Receive Behavioral Health or Disability Services. 2025. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
Shenbanjo, T. and S. Baumgartner. Integrating Services to Strengthen Children, Youth, and Families and Prevent Involvement in the Child Welfare System. 2024. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.