It takes a team: Improving placement stability among children and youth with Fetal Alcohol Spectrum Disorder in care in Canada

Concerted efforts have been devoted to improving placement stability for children in care. These efforts have been driven by evidence of negative outcomes for foster children who experience frequent placement changes. Of particular concern are significantly higher rates of placement disruptions among children in care who experience Fetal Alcohol Spectrum Disorder (FASD). This mixed methods study examines the impact of enhanced child welfare practice interventions on placement stability for 182 children in care who experience FASD. A quasi-experimental matched comparison group design was employed, where rates of placement change were compared between children in the Project Regions who received enhanced practice standards to those in the Comparison Regions who did not. The sample included 182 participants including 98 children and youth in care from the Project Region and 84 cases from the Comparison Region. The Project Regions reported considerably lower placement changes (M = .33) than the Comparison Region (M = .98). Logistic regression analysis revealed that worker contact was found to be predictive of placement stability. Specifically, as worker contact increased, the likelihood of placement change decreased [B = − .28, W (5.35, p = .02)]. In keeping with the adage that it takes a village to raise a child, one could add for children affected by FASD, that it takes a dedicated team to promote placement stability and better life trajectories.     

The Brief Assessment Checklists (BAC-C,BAC-A): Mental health screening measures for school-aged children and adolescents in foster,kinship, residential and adoptive care

More than half of children and young people in foster, kinship, and residential care, as well as those subsequently adopted from care, have mental health difficulties that require clinical formulation and intervention. While an increasing number of alternate care jurisdictions are instituting universal mental health screening, existing measures may not adequately screen for a range of attachment- and trauma-related mental health difficulties observed among these populations. The Brief Assessment Checklist for Children (BAC-C), and the Brief Assessment Checklist for Adolescents (BAC-A) are 20-item caregiver-report psychiatric rating scales designed to: 1. screen for and monitor clinically-meaningful mental health difficulties experienced by children and adolescents in various types of care; and 2. be safely administered and interpreted by health and social care professionals other than child and adolescent mental health clinicians. The BAC-C/A were also designed to be used as brief casework monitoring tools by foster care and adoption agencies, and for treatment monitoring in CAMHS. The BAC-C and BAC-A were derived from the Assessment Checklist for Children (ACC, 120 items) and Assessment Checklist for Adolescents (ACA, 105 items) respectively. Internal consistency of BAC-C (N = 347) and BAC-A (N = 230) scores were 0.89 and 0.87 respectively. The BAC-C/A were highly accurate in screening for clinical range ACC and ACA scores (area under the curve (AUC) ranging from 0.96 to 0.99), as well as for CBCL clinical range scores (AUCs: BAC-C = 0.89 to 0.92; BAC-A = 0.93 to 0.94). They were moderately accurate in screening for children that caregivers reported had been referred to mental health services (AUCs: BAC-C = 0.74; BAC-A = 0.79). Initial BAC-C/A psychometric properties compare favourably with that of existing screening instruments, including the Strengths and Difficulties Questionnaire and the Brief Problem Monitor (CBCL short form).     

Are maternal and community risk factors associated with the presence of asthma among children placed in foster care?

Objective

The occurrence of pediatric asthma has been associated with exposure to chronic stress. This study examined the relationship between maternal and community risk factors and asthma in a sample of maltreated children in foster care.

Method

Interviews were conducted with 365 maltreated children in foster care. Measures included youth/caregiver reports of asthma, an index of maternal risk based on data abstracted from child welfare records and community violence exposure.

Results

After controlling for demographic variables, maternal risk was associated with the presence of asthma (OR = 1.314, 95% CI = 1.09–1.58). Community violence exposure, however, was not related to the presence of asthma.

Conclusion

Maternal risk factors were significantly associated with the presence of asthma in a foster care population. Physicians who care for maltreated children in foster care should be particularly attuned to the presence of these additional risk factors that may place high-risk children at increased risk for chronic health problems.     

Predictors of foster care exits to permanency: A competing risks analysis of reunification, guardianship, and adoption

Although foster care is intended to be temporary, and policy explicitly requires permanency outcomes, many children experience lengthy stays and exit foster care without a permanent family. This study sought to identify which child and placement characteristics were important predictors of exit to three types of permanency outcomes: reunification, guardianship, and adoption. A sample of 3351 children who entered foster care in 2006 was observed for 30 to 42 months. Permanency outcomes were analyzed using competing risks survival analysis. Children exited foster care to different types of permanency at different rates and frequencies. Reunification occurred most quickly and frequently. Guardianship was second in terms of median duration but third in frequency. Adoption was the second most common exit but had the longest median duration. One in four children remained in foster care or exited without permanency. While patterns varied by type of permanency, three major categories of important predictors were identified: 1) demographic characteristics of age at entry and race, 2) clinical needs related to children's disabilities and mental health problems, and 3) continuity and connections represented by kin placements, sibling placements, early stability, and absence of runaway events. Implications for practice, policy, and research are discussed.     

Ethnic Identity Development Among Adolescents in Foster Care

Because past research indicates that stronger ethnic identity is related to better outcomes in areas such as academic achievement and mental health, it is important to provide youth in foster care with opportunities to develop their ethnic identity. Using data from in-person interviews with 188 youth aged 14–17 in foster care (88.7% response rate), this paper explores two areas related to ethnic identity: (1) youth perceptions about their own ethnic identity, and (2) attitudes about ethnic identity development specific to the experience of being in foster care. Results suggest that black youth and Hispanic/Latino youth have a stronger sense of ethnic identity than white youth. Most youth are interested in learning more about their ethnic background. Understanding how youth in foster care identify ethnically and understanding their beliefs related to ethnic identity may lead to the enhancement of services provided to youth across child welfare, education, and mental health systems.

Abused children and foster care—the need for specialist resources

Estimates vary on how many abused and neglected children are admitted to care and how many children in care are there because of abuse and neglect. Nevertheless, it is important to examine their special needs and the problems they present to carers. Although research findings are difficult to interpret, there is enough evidence to show that abused and neglected children in care have special needs in three particular areas: education, health and social behaviour. The evidence is available from research into children in care and research into child maltreatment. Children in care run the risk of disrupted educational careers; abused and neglected children have additional problems in school. Many children in care have a patchy and neglected medical history; abused and neglected children are seriously at risk of further ill-health. Abused and neglected children have been shown to have behaviour problems that jeopardize their relationships with peers and adults; they run the risk of placement breakdown. Foster care of abused and neglected children is a specialist and demanding task, requiring knowledge of, and sensitivity to special needs. Because many abused and neglected children return to their parents, foster carers also need to include the natural family in their task. High expectations of these foster carers, however, should not lead to exploitation but rather an enhancing of fostering assessment, preparation, support and training.     

Externalizing problems in young foster children: Prevalence rates,predictors and service use

Objective

Examining the prevalence of externalizing problems, their predictors and mental health service use for these problems by foster children and foster parents in a representative group of foster children aged 3 to 12 in Flanders.

Method

Survey data were collected on 212 foster children, who had been in the foster family for approximately four months. Foster parents filled out a Child Behavior Checklist to measure foster children's externalizing problems. Foster care workers reported on several potential risk variables for externalizing problems and on foster children's and foster parent's mental health service use. Predictors of externalizing problems were identified from a large number of variables using the method of purposeful selection of variables in linear regression.

Results

40.6% of the foster children had externalizing problems. Foster children who were placed because of behavioral problems had more externalizing problems. Only 20.9% of the foster children with externalizing problems and only 13.9% of their foster parents received professional help.

Conclusions

This study showed that externalizing problems are prevalent in this young foster care population, that it is hard to predict which foster children had externalizing problems, and that foster children and their foster parents rarely receive services for these problems. These findings call for a standard protocol of assessment of foster children's externalizing problems. Moreover, from a preventive viewpoint, guidelines are needed to systematically link young foster children with externalizing problems and their foster parents to appropriate services.     

Mental health service utilization in children adopted from US foster care,US private agencies and foreign countries: Data from the 2007 National Survey of Adoption Parents (NSAP)

Aims

In this analysis, we (1) described the rate of mental health service utilization for children from domestic foster care adoption, domestic private adoption, and international adoption and (2) analyzed the effect of common risk factors on mental health service utilization.

Data

As part of the 2007 National Survey on Adoptive Parents (NSAP), parents with children 5–17 years old (N = 1722) were asked if their children had received mental health services and how helpful these services were. Parents also provided data on the children's demographics and likelihood of pre-adoption adversity (e.g., abuse).

Results

For boys, mental health services were utilized by 52.4% of domestic foster care adoptees, 41.0% domestic private adoptees, and 40.0% of international adoptees. For girls, the corresponding rates were 36.3%, 24.8%, and 30.9% respectively. Parents reported that the services were very helpful for about half of the children. Logistic regression analyses showed that adoptees from domestic foster care were more likely than international adoptees to have received mental health services, but there was no difference between domestic private adoptees and international adoptees. Older age at placement, older age at assessment, having special health care needs, and being male all increased the odds for having received mental health services.     

Disproportionality in education and employment outcomes of adult foster care alumni

Racial similarities and disparities in the education and employment of 134 African American and 574 White adults placed in foster care as children were examined. Logistic regression was used to compare differences among these young adult alumni who were served by a voluntary foster care agency in 23 U.S. communities. When controlling for demographic background, risk factors, and foster care experiences, race/ethnicity was a significant factor only in the increased odds of White alumni having income at or above poverty level, three times poverty level, and home/apartment ownership compared to African Americans.     

Foster children placed with or separated from siblings: Outcomes based on a national sample

This study examines a range of outcomes for children in foster care who have siblings, using a large, national U.S. database. Three types of sibling placements are defined: split (child has no siblings in the home), splintered (at least one sibling in the home), and together (all siblings in the home). The study analyzes records (n = 1701) from the National Study of Child and Adolescent Wellbeing, including Child Protective Services (CPS) and Long-term Foster Care (LTFC) samples. It contributes to the literature in its inclusive definition of siblings, use of three categories for sibling placement status, and use of outcome measures that include the perceptions of foster children. The study reports limited significant findings. Neither foster parents' nor youths' reports of behavioral problems differ by sibling placement status. As rated by teachers, academic performance in the group placed together exceeds that in both of the other groups. For children in kinship homes, teachers also reported less problematic internalizing and externalizing behavior for the splintered and together groups than for the split group. Children in the splintered group also responded more favorably than those in the split group to questions of closeness to the primary caregiver and liking the people in the foster family.     

The relationship of placement experience to school absenteeism and changing schools in young,school-aged children in foster care

Background

Chronic school absenteeism and frequent school changes, particularly among younger children, may be antecedents for the high rates of school failure and subsequent dropout among youth in foster care. However, the relationship of foster care experience to absenteeism and school change has not been well studied.

Objective

This study examined the association of placement experience with absenteeism and changing schools among 209 urban children in foster care enrolled in public elementary schools.

Methods

A cohort of children aged 5 to 8 years who entered non-relative or kinship foster care from 2006–2008 were followed longitudinally for 2 years from entry into foster care. Children residing in foster care were categorized at the end of the study as early stable, late stable, or unstable, if they achieved a permanent placement prior to 45 days, between 45 days and 9 months, or failed to do so within 9 months, respectively. Children who reunified home were classified as a fourth category. Poisson regression, controlling for baseline factors, was used to compare days absent and number of schools attended across categories of placement experience.

Results

Among the 209 children, 51% were male, 79% were African American, and 55% were initially placed with kin. One third of children reunified home; among children who did not reunify, one half was early stable, and a third was unstable. Adjusted rates of school absenteeism increased in stepwise fashion as children's placements became more unstable; children with unstable placements were 37% more likely to be absent than those with early placement stability (p = 0.029). Children who reunified during the study demonstrated the highest rates of absenteeism; however, there was no significant difference in absenteeism before or after reunification. Number of schools attended increased as stability worsened, with the standardized rate of schools attended reaching 3.6 schools (95% CI 3.1–4.1) over a two year period among children in unstable placements.

Conclusions

The relationship between placement experience and school absenteeism and school change illustrates the need to better coordinate the educational experience of high-risk children in foster care. The secondary finding of high absenteeism among children in the process of returning home illustrates that educational challenges for youth may be equally if not more concerning among the greater majority of youth in child welfare who remain home with birth parents.     

Racial/Ethnic Differences in Court Referred Pathways to Mental Health Services for Children in Foster Care

Racial/Ethnic disparity in placement patterns and service utilization among children in foster care has been documented in a variety of studies. This study examined the role of the court process in referring children in foster care to mental health services and tested for racial/ethnic differences in the patterns of referral and service use. Court records for 142 children ages 2–16, representing Caucasian, African American, and Hispanic racial/ethnic groups were reviewed. Results indicate that the court process does play a significant role in referring children to services. Significant differences by race and ethnicity in mental health service utilization prior to the child's protective placement, as well as service orders, and post-placement service use were identified. Caucasian youth were more likely to receive orders for psychotherapy and to have documented use of psychotherapy than were African American and Hispanic youth, even when the possible confounding effects of age and type of maltreatment were controlled. Implications for the effective delivery of supportive services to those children most in need are discussed.     

Mental health interventions for children in foster care: A systematic review

Children in foster care have high rates of adverse childhood experiences and are at risk for mental health problems. These problems can be difficult to ameliorate, creating a need for rigorous intervention research. Previous research suggests that intervening with children in foster care can be challenging for several reasons, including the severity and complexity of their mental health problems, and challenges engaging this often transitory population in mental health services. The goal of this article was to systematically review the intervention research that has been conducted with children in foster care, and to identify future research directions. This review was conducted on mental health interventions for children, ages 0 to 12, in foster care, using ERIC, CINAHL, PsycINFO, PubMed, ProQuest's Dissertation and Theses Database, Social Services Abstracts, and Social Work Abstracts. It was restricted to interventions that are at least “possibly efficacious” (i.e., supported by evidence from at least one randomized controlled trial). Studies were evaluated for risk of bias. Ten interventions were identified, with diverse outcomes, including mental health and physiological. Six interventions were developed for children in foster care. Interventions not developed for children in foster care were typically adapted to the foster context. Most interventions have yet to be rigorously evaluated in community-based settings with children in foster care. Little research has been conducted on child and family engagement within these interventions, and there is a need for more research on moderators of intervention outcomes and subgroups that benefit most from these interventions. In addition, there is no consensus regarding how to adapt interventions to this population. Future research should focus on developing and testing more interventions with this population, rigorously evaluating their effectiveness in community-based settings, determining necessary adaptations, and identifying which interventions work best for whom.     

Stepping Down and Stepping In: Youth's Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care

Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth's perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n = 8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.     

Establishing a mental health service for young children in out-of-home care: The Gumnut Clinic for 0 to 5 year olds in Western Sydney

Objective

Children aged 0 to 5 years in out-of-home care represent a vulnerable population at high risk of social, emotional and developmental problems, yet there are few services specifically addressing their psychological needs. This paper is the first of two concerning the establishment of The Gumnut Clinic, a specialist mental health assessment clinic in Western Sydney for this population. The current paper provides the rationale for the development of the clinic and detail of the referral and assessment processes.

Method

The paper describes the establishment of The Gumnut Clinic at Redbank House in Sydney, Australia, the approach to assessment of these young children and their carers, and the challenges encountered.

Conclusions

Young children are overrepresented in child protection and out-of-home care services. Their social, emotional and developmental needs are under-recognized. Development of a specialist mental health service is a step towards improving health outcomes for these children.     

Responsive engagement in mental health services for foster youth transitioning to adulthood

ABSTRACT

As youth near the transition to adulthood and aging out of the foster care system, exposure to stress increases, especially for youth who have less-than-adequate support systems. Although mental health problems among foster youth often continue into adulthood, service use decreases dramatically within a year of turning age 18. Understanding how foster youth experience mental health services as they transition from care provides social workers and other mental health professionals important insight that can lead to specific, targetable strategies. This study sought to explore what situations were helpful in supporting mental health as foster youth transitioned to adulthood. Focus groups and interviews with former foster youth and professionals informed the development of a quantitative instrument, which was used to identify the most supportive and frequently encountered situations former foster youth experienced. Findings indicate the most helpful situations were those in which professionals and mentors were flexible and responsive to their individual needs and trusted their ability to make decisions. Supportive adults who honored their choices and collaborated in decision-making were also helpful. Engaging, empowering, and partnering with transition-age youth may increase the likelihood of positive mental health outcomes for this population, offering implications for family-centered, strengths-based practice.     

The impact of mental health issues, substance use, and exposure to victimization on pregnancy rates among a sample of youth with past-year foster care placement

The purpose of this study is to (1) compare youth entering substance abuse treatment with and without a history of foster care placement to determine any differences in mental health, substance use, and exposure to victimization, and (2) determine if mental health, substance use, and/or exposure to victimization predict past pregnancy among the sample with a history of foster care placement. The pooled dataset consisted of 17,124 adolescents (12-17 years of age) who completed the Global Appraisal of Individual Needs at intake for substance abuse treatment in 2009. Of these, 366 (2.1%) reported having been in foster care in the past year. When compared with a non-foster care sample, the foster care sample reported significantly higher internal mental distress scores, behavior complexity scores, and general victimization scores, after controlling for race, gender, and level of care. Problems associated with substance use did not differ between groups, though regular tobacco use was present at a higher rate in the foster care sample. Multivariate logistic regression results revealed that, within the foster care sample, internal mental distress and gender predicted past pregnancy. There may be room for intervention within substance abuse treatment centers for youth with a history of foster care, who may be at risk for pregnancy if their levels of internal mental distress are high.     

Lighthouse Independent Living Program: Predictors of client outcomes at discharge

This study examined clinical risk factors and their association with client outcomes at discharge among 385 emancipating foster youth in Cincinnati, Ohio, who entered the Lighthouse Independent Living Program during the period 2001-2005. These youth averaged 18 years of age and remained in the program an average of 10 months. At the time of discharge at age 19, 58% of these young adults had completed high school, 32% were employed, and 38% were living independently; 11% had achieved all three aforementioned outcomes. An exploratory principal components factor analysis of nineteen dichotomous risk factor items assessed by clinical staff at the time of admission yielded four types of risk: mental health problems, delinquency issues, teen parenting, and cognitive impairment. Logistic regression analysis revealed a number of significant relationships between each of these four clinical risk factors and client outcomes after adjusting for demographic and program characteristics. Those with mental health problems were only half as likely as others to have attained all three outcomes. Parenting youth were only half as likely to have completed high school or to be employed as others. Those with delinquency issues were only one-fourth as likely than others to be independently housed at discharge. Finally, older youth and those remaining in the program longer showed more favorable outcomes than others. Implications for child welfare policy and practice pertaining to independent living are discussed.     

The mental health of young people aging out of care and entering adulthood: Exploring the evidence from England and France

This paper explores the research evidence from England and France on the mental health of young people aging out of care and into adulthood. It represents the first comparative review based on the evidence from these two countries. Set in the legal, policy and service framework for both countries, it reviews evidence on the mental health of young people in the general population, young people living in care, young people aging out of care, and young adults. It shows: the high levels of psychological adversity of young people entering care; the high rates of mental health problems of young people in care compared with the general population of young people; the increased risk of mental and physical problems at the time of aging out of care, and the general improvement in longer-term outcomes for young adults, although some continue to have serious mental health problems. In conclusion, it suggests that interventions across the life course of young people are needed.