Advocacy strategies and resources

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.  

Because trauma can mirror mental health disorders and exacerbate or trigger existing conditions, foster youth are three times more likely to receive a mental health diagnosis than their non-foster youth peers. 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.  

While it can be difficult to diagnose young people because their brains are still developing, foster youth nonetheless may receive several diagnoses, and sometimes misdiagnoses. 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, 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 grounded.   

Psychotropic medications affect the central nervous system to treat youth with high behavioral needs, while providing stability and promoting well-being when used as part of a larger treatment plan. Different medication types include antidepressants, antipsychotics, mood stabilizers, anti-anxiety medications, and stimulants. However, psychotropic medications should not 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.  

Over the last decade, foster youth have been disproportionately prescribed medications. 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), dosages that are too high, 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, to ensure they are being prescribed medications safely and effectively. 

As a CASA, remember that it is not your job to diagnose a youth or act as their therapist or doctor. Each youth responds to trauma and mental health challenges differently, and many behaviors can be a coping mechanism and/or a form of communication influenced by their experiences.  

It is essential that CASAs take a nonjudgmental, strength-based approach when it comes to supporting their youth’s behavioral health needs. A CASA can actively support their youth’s mental health needs, both behind-the-scenes and directly with their youth. 

• 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 

Comprehensive list of best practices 

• Obtain a copy of your youth’s latest Health and Education Passport (HEP) from their social worker. 

• Determine if your youth is receiving therapy services and if so, what type(s). 

• 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 to gain relevant information. This can include:

  •  The public health nurse at the Human Services Agency. Each youth is assigned a public health nurse to assist with their medical needs. Ask the social worker to connect you with this individual so you can begin partnering with them on all health-related needs. 

  • The psychiatric nurse specialist at the Human Services Agency, if they are being prescribed psychotropic medication. 

  • Their prescribing physician if they are being prescribed psychotropic medication – partner with the team to ensure there is a treatment plan in place, that includes regular check-ins.  

  • Therapist 

  • Wraparound team 

  • School’s Foster Youth Liaison to ensure their mental health needs are being met in the school setting. 

• If your youth is interested, work with the team to connect them to healthy extracurricular activities and resources. 

• Learn the warning signs of mental illness and a mental health crisis and be prepared to identify any possible 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. 

• Establish a safe and supportive environment – set boundaries, show up regularly and build structure, consistent communication, model positive and healthy relationships.  

• Encourage the expression of their feelings – validate and help identify their feelings, to create a safe space. 

• Support their use of positive, constructive coping skills and self-regulation – self-care, mindfulness, and breathing techniques.  

• Explore trauma-informed, healing activities with your youth that can have a therapeutic effect. You can use the self-care guide in your Getting Started documents!  

  • Having a crisis and safety plan 

• If they are being prescribed psychotropic medication: 

  • Help your youth track any symptoms or side effects of the medication. This information can help inform the JV-218 and JV-224, both legal forms that the youth should be completing for each psychotropic medication hearing, that states their opinion about their medication. The JV-224 needs to be completed by the youth and their social worker. 

• Talk to them about their mental health rights - if appropriate, encourage and empower your youth to advocate for their own needs and make healthy lifestyle choices that work for them.

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.

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 any mention of self-harm or suicide with care and caution: explore whether the youth has thoughts or a plan to act. 

• Go ahead and ask - “Are you thinking about killing yourself?” Talking about suicide does not cause suicide. If you have difficulty asking, enlist another adult to help you.  

• Show care and support without judgment; listen actively, avoid giving advice, and reassure the youth that together you can find a way forward. 

If the young person shares a detailed plan 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 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 create a safety plan that can be shared with the team. 

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.

• 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 of any major changes. It often takes time and persistence to find the medication or therapy that’s right. 

• Encourage and offer to assist with positive lifestyle changes, such as healthier food choices, plenty of sleep, and getting out in the sun or into nature for at least 30 minutes each day. Follow their lead.  

If appropriate, the young person must create a safety plan with their team and their therapist. Together, they should develop a set of steps he or she will 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 and can cause 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 

Foster Care Mental Health Program (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 – Support for Crisis Preparedness, Mental Health, Suicide, Psychotropic Medication) 

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.