Mental Health Service Receipt and Access Barriers Among Children In Informal Kinship Care In the United States

Background and Purpose: Most kinship care in the United States occurs informally, outside the oversight of the child welfare system. Children in these arrangements often experience elevated mental health needs, yet population‑level evidence remains limited on whether caregiving arrangement independently shapes mental health service access or whether observed disparities reflect broader structural barriers such as unmet need, socioeconomic disadvantage, and system capacity constraints. Prior research has focused largely on formal foster care populations, limiting understanding of informal kinship care contexts. This study examines mental health service utilization, access barriers, and insurance continuity among children across caregiving arrangements, with particular attention to informal kinship care.

Methods: Data were drawn from the 2024 National Survey of Children’s Health (NSCH), a national and state‑representative survey of non‑institutionalized children ages 0-17. Caregiving arrangement was derived from caregiver-child relationship indicators and categorized as informal kinship care (relative caregiver with no parent present), parent‑present kin households, or non‑kin households. Outcomes included mental health service use in the past 12 months, difficulty obtaining mental health care, unmet mental health need, and continuity of health insurance coverage across the year. Survey‑weighted descriptive analyses and complex samples logistic regression models were estimated, adjusting for child age, sex, race/ethnicity, general health status, and household poverty level. Access‑process models were estimated using hierarchical complex samples logistic regression, with structural and demographic predictors entered in the first block and unmet mental health need added in the second block.

Results: At the population level, caregiving arrangement was significantly associated with mental health service receipt. Children living in informal kinship care had lower odds of receiving mental health treatment or counseling than children in non‑kin households (OR = 0.47, 95% CI [0.37, 0.59]), accounting for insurance, socioeconomic status, and health characteristics. No significant differences were observed for children in parent‑present kin households. Difficulty obtaining mental health care was prevalent across caregiving contexts, with more than 85% of caregivers reporting a level of difficulty once services were sought. Among children with identified mental health need, over 70% experienced unmet care. In access‑process models, unmet mental health need was the strongest predictor of access difficulty (OR = 10.13, 95% CI [4.80, 21.36]). Even after accounting for unmet need, children living in informal kinship care had higher odds of experiencing difficulty obtaining care (OR = 3.84, 95% CI [1.08, 13.67]). Insurance continuity was strongly associated with household income but did not differ by caregiving arrangement.

Conclusions and Implications: Children living in informal kinship care face barriers at multiple stages of mental health service access, including lower likelihood of service receipt and greater difficulty obtaining care. The findings highlight the need for policies that address both barriers to service entry and system‑level constraints once care is sought, including provider capacity, care coordination, and navigation supports across caregiving contexts.