Mental health outcomes among child welfare investigated children: In-home versus out-of-home care

BackgroundChild welfare has increasingly focused on alternatives to out-of-home (OOH) placement. In-home services, such as parent training, have increased and more maltreated children remain in-home. Yet, little is known about the effect on mental health of maintaining vulnerable children in-home vs placement in stable OOH care.ObjectiveTo evaluate and compare difference in mental health among children investigated by child welfare and who remained in-home vs. those who were placed in stable OOH care.Design/methodsWe examined a cohort of children (aged 1.5–18 years) from a nationally representative sample of children investigated by child welfare using the National Survey of Child and Adolescent Well-Being II (NSCAW II). We compared changes in mental health functioning over 18 months for children who remained in-home with parent training versus those placed in stable OOH care.ResultsAmong the 749 children in our sample, baseline characteristics of children who remained in-home with parent training and those placed in stable OOH care were similar. Among school-aged children placed in stable OOH care, mental health problems decreased from 26% to 13% (p = .003). This differed significantly from school-aged children who remained in home, for whom mental health problems increased (50% decrease stable OOH care vs. 23% increase in home; p = .007). Among pre-school aged children, mental health problems increased in both settings, particularly stable out-of-home care (p = .008).ConclusionsFor school aged children with a history of maltreatment, mental health outcomes improve following stable OOH placement, yet worsen when remaining in-home with parents. Pediatricians should be watchful for mental health problems among children who remain home after maltreatment and should advocate for high-quality stable OOH care when it is necessary. Child welfare may need to monitor the outcomes of children remaining at home more closely and provide more intensive preventive and treatment services to families.     

Young People Transitioning from Out-of-Home Care: A Critical Analysis of Australian and International Policy and Practice

Abstract

Young people transitioning from out-of-home care comprise arguably one of the most vulnerable and disadvantaged groups in society. They experience multiple disadvantages resulting from their abuse or neglect prior to entering care, their often negative experiences in care, and the lack of support provided to them as they transition from care. Compared to most young people, they face particular difficulties in accessing educational, employment, housing, and other developmental and transitional opportunities. This paper critically analyses the pathways taken by care leavers, and the Australian and international policy and practice responses. We conclude by suggesting some policy and program reforms that are likely to lead to improved outcomes for care leavers.     

Why do children placed out-of-home because of parental substance abuse have less mental health problems than children placed for other reasons?

The purpose of this paper was to compare children placed out-of-home because of parental substance abuse (PSA) with children placed for other reasons (NPSA), and to explore the association between PSA and mental health problems in a Norwegian sample of 6- to 12-year-old children in out-of-home care (N = 109). Several group differences were found related to the children themselves, their families and the Child Welfare case. The PSA children had less total difficulties, conduct problems and emotional problems than the NPSA children assessed by the teachers on the Revised Rutter Scale. However, both groups had far more mental health problems than children in general. The most important variable explaining the group difference in all subgroups of mental health problems was the extent of prosocial behavior in the children, but being placed for behavioral problems also explained a significant part of total difficulties and conduct problems. Variables like gender, discipline problems and socioeconomic conditions did not have a significant effect. The conclusion of the study was that prosocial behavior might be regarded as an important protective factor against mental health problems, which is an argument for investing in programs focusing on enhancing the placed children's mastering strategies.     

Do youth in out-of-home care receive recommended mental health and educational services following screening evaluations?

For children in out-of-home care, a significant gap exists between those who need services and those who receive them. Screening all children in out-of-home care is recommended to reduce this gap. This study was designed to determine if recommendations from mental health and educational screening evaluations were related to service implementation for youth in out-of-home care. Screening evaluations were completed with 171 maltreated youth (ages 9 to 11) who had been placed in out-of-home care within the prior year. Written reports summarizing the findings were provided to children's caseworkers. Service utilization was assessed at baseline (T1; before screening reports were completed) and follow-up (T2; 9–12 months later) interviews. For children not already receiving services at T1, logistic regression analyses tested the association between T1 recommendations for services and new service implementation by T2. Mental health (youth-report) and educational (teacher-report) outcomes were analyzed separately. Screening evaluations identified 22% of children with unmet mental health needs and 36% with unmet educational needs at T1. Children who received a recommendation for new services (i.e., all of those with unmet needs) were more likely to receive mental health (OR = 2.50, p = .06) and/or educational (OR = 3.54, p = .04) services by T2 than children who did not receive recommendations for services. While recommendations increased the odds of receiving services, almost half of the children with unmet mental health needs did not receive services, and 84% of children with unmet educational needs did not receive services by T2. Much work remains to ensure youth receive needed services.     

Children in out-of-home care as young adults: A systematic review of outcomes in the Nordic countries

BackgroundInternationally, the Nordic countries occupy top positions in child well-being. We investigated literature on the overall outcomes of young adults from the most vulnerable backgrounds in the Nordic countries, namely young adults who were placed in statutory out-of-home care (OoHC, i.e. foster care) during childhood in the Nordic countries for the protection of their safety and welfare.MethodsWe followed PRISMA guidelines and conducted literature searches manually, as well as electronically, via EBSCO's Psychology/Sociology databases and ProQuest's Social and Behavioral Sciences databases in February 2016 for quantitative studies that compared outcomes at age 18 or later between young adults placed in OoHC as children and those never placed in OoHC. Because of the heterogeneity and small number of eligible studies on each outcome, we conducted no meta-analysis but did formulate a narrative synthesis.ResultsOf 333 studies identified, 20 met the inclusion criteria. All of these studies were cohort studies that employed social and health register data. OoHC placement was studied with nine outcome categories: self-supporting problems, educational challenges, mental health problems, criminality, teenage parenthood, mortality, suicidal behavior, alcohol and drug use, and disability pension. In each of these categories, young adults with a history in OoHC faced higher risks compared with the general population, even after adjusting for various birth parents' socio-economic, demographic, and mental health–related factors.ConclusionAlthough the Nordic countries are among the world's leading nations in promoting child well-being, the Nordic welfare model has partly failed in preventing the inequality of families with children. As young adults, children placed in OoHC in the Nordic countries face an elevated risk of experiencing adversity.     

Mental health service utilization and time to care: A comparison of children in traditional foster care and children in kinship care

Existing research indicates that children who are involved with the child welfare system and placed in various forms of out-of-home care experience emotional and behavioral problems. It is also suggested that children placed in kinship care are less likely to receive mental health services than children placed in non-kinship foster homes. This study sought to compare children in non-kinship foster homes to children in kinship care to determine their receipt of mental health services and the time it took for children in kinship care to receive mental health services compared to children in non-kinship foster homes. Using a Cox regression, researchers determined that children in kinship care had a 14% lower likelihood of receipt of mental health services compared to their counterparts in non-kinship foster placements.     

Fostering homeless children and their parents too: the emergence of whole-family foster care.

Children should not be placed in out-of-home care simply because their families lack the means to provide for their basic needs, yet this practice continues nationwide. A new program based in St. Paul, MN, gives county social service departments the placement option of whole-family foster care. The target population is adult parents and minor children without stable residences, where the children are at risk of placement in out-of-home care. Although the parents and children may have special needs, there are no safety risks that would necessitate separating children and parents. The program's design is described and policy questions discussed.     

Downward spiral: The impact of out-of-home placement on paternal welfare dependency

In this article, we test how out-of-home placement affects men's labor market attachment, and in so doing we provide a novel parallel to existing research on how fatherhood affects men, which focuses almost exclusively on a child's arrival. Using population panel data from Denmark that include all first time fathers whose children were placed in out-of-home care from 1995 to 2005, we find that having a child placed in care is associated with up to a 4 percentage point increase in welfare dependency. Having a child placed in out-of-home care appear to aggravate conditions that likely necessitated the out-of-home placement to begin with, thereby likely necessitating longer duration of out-of-home placements. Thus, out-of-home placements have substantial secondary costs for parents and society.     

Factors predicting placement of urban American Indian/Alaskan Natives into out-of-home care

American Indian/Alaskan Native children have disproportionately been placed into out-of-home care compared to White children in the child welfare system. What were the factors that child protective services (CPS) workers considered when deciding to remove a child from the home? Utilizing data from the National Survey of Child and Adolescent Well-Being, this study examined out-of-home care factors for 2215 urban American Indian/Alaskan Native (AI/AN) and White children. In the urban sample, children from White families were younger and were more likely to be investigated for lack of supervision, while AI/AN families were investigated for physical neglect. In the placement regression models, urban AI/AN children came from homes where caregivers had greater alcohol, drug and mental health problems. Decisions by CPS workers to place AI/AN children may have been influenced by racial bias. A CPS system that acknowledges culture and race may reduce overrepresentation in placement. Efforts to work with AI/AN families prior to a child's removal may prove to be beneficial and less expensive.     

A Comparison of Out-of-home Care for Children and Young People in Australia and Sweden: Worlds Apart?

Abstract

In this paper we present a comparative analysis of out-of-home care in Australia and Sweden. We compare the age structure of the out-of-home care population and the types of out-of-home care services provided to children and young people in both countries. Our analysis reveals that in Australia the out-of-home care service system is focused mainly on children who are deemed to be abused or neglected within their families, while in Sweden the majority of the out-of-home care population are teenagers who cannot live with their families for emotional or behavioural reasons. These population differences intersect with variations in the forms of service provision in both countries, with a much greater reliance on home-based care in Australia than in Sweden, while there is more extensive use of residential care in Sweden. We envisage that this paper will demonstrate how the age structure of the out-of-home care population, though rarely considered in international comparative child welfare research, reveals much about the assumptions on which State intervention with children and young people is based. We intend that this analysis will assist social workers to better understand and address the gaps in the quality and comprehensiveness of out-of-home care service provision to children and young people in both countries.     

Profile of children placed in out-of-home care: Association with permanency outcomes

The goals of this study were to explore characteristics and profiles of children who received out-of-home care services and to examine the relationship between their profiles and permanency outcomes. Results of latent class analysis suggest that there are three distinct subgroups of children served in out-of-home care (N = 33,092): Children with Complex Needs (6%), Children in Families with Complex Needs (64%), and Older Abused Children (30%). Of the three identified subgroups Children with Complex Needs consisted of youth who were at greater risk for adverse outcomes. These children were less likely to experience timely adoption, had the longest length of stay in out-of-home care, and were least likely to experience timely reunification. Although permanency outcomes for Older Abused Children are somewhat better than for Children with Complex Needs, they represent a vulnerable population of youth in out-of-home care who have a very low chance of being adopted. Overall, this study suggests that service provision by itself may not improve permanency outcomes for children unless both prevention and intervention efforts address co-occurring family needs and are tailored to specific characteristics of the children being served.     

Children placed in out-of-home care: risk factors for involvement with the juvenile justice system

In previous research, child maltreatment has been associated with several negative outcomes, including delinquency. This study uses administrative data to examine risk factors, including the severity and chronicity of maltreatment, for juvenile justice involvement among children, ages 7 to 17, who were placed in out-of-home care in Florida (N = 13,212). The results of multivariate Cox regression analysis indicated that among specific types of maltreatment, sexual abuse was associated with the risk of faster placement only in a detention center. Additionally, findings from this study suggest that maltreatment chronicity but not maltreatment severity increases the chances of earlier involvement with the juvenile justice system among children who were placed in an out-of-home care. Implications of these findings are discussed.     

Exploring the Climate for Overweight and Obese Students in a Student Health Setting

Attitudes and beliefs of health care providers, in conjunction with a nonthreatening physical environment, are important components in establishing a constructive and supportive climate for care of overweight and obese students. Objective: The authors explored providers' attitudes about obesity and assessed the physical environment in a student health clinic to identify areas that may be detrimental to the care of overweight and obese students. Participants: Eighteen direct care providers participated in the project. Methods: The authors conducted focus groups with direct care providers and assessed their experiences and perceived challenges in working with overweight and obese students. The authors also conducted a walk-through assessment of the physical environment. Results: Direct care providers expressed discomfort in deciding how and when to discuss weight with students. The authors found that elements of the physical environment could present barriers to care for overweight and obese students. Conclusions: The authors make recommendations for improving the health care climate for overweight and obese students.     

Health care policies for children in out-of-home care

Placement in out-of-home care is one intervention used to protect children from abuse and neglect. While children are in such care, it is the child welfare agency's responsibility to ensure that their health needs are met. The study reported here examined health care policies and services for children in 46 state child welfare agencies. Virtually all states had some sort of written policies regarding health care for children in out-of-home care. Half, however, reported having no information management system to record health care data, and only six of the 23 had computerized systems. Most states fell short of meeting the standards set by the Child Welfare League of America for the health care of children in out-of-home care.     

Measuring contract agency performance with administrative data

This article uses administrative data to analyze the relative performance of contract agencies-those organizations under contract with a city child welfare agency to provide out-of-home care services to children placed in the custody of the public agency-by examining how long it took children placed in out-of-home care to return home to their families. The objective was to determine whether credible empirical evidence could show a relationship between length of stay and the agency providing care. Agency level reunification rates are widely distributed around the mean, indicating that contract agency performance differs and that "agency effects" leave an independent imprint on a child's out-of-home care experience.     

Specialized foster care and group home care: Similarities and differences in the characteristics of children in care

Until recently, foster children who presented special medical or behavioral problems were largely served in group care environments. Specialized (or “treatment”) foster care has recently been developed to serve some of these challenging children. Although growing evidence points to the special needs of children in foster care, much is still unknown about how children placed in various out-of-home care settings differ from one another. The growth of specialized foster care as an alternative placement to group care, calls for examination of how children in these settings compare on demographic, educational, health, and behavioral characteristics. A cross-sectional mailed survey was distributed to all group care and specialized foster care agencies in a large state to address topics related to children's characteristics. Comparisons point to two groups of very difficult children, with unique mental health and health needs.     

A Response to <Emphasis Type="BoldItalic">No One Ever Asked Us</Emphasis>: A Review of Children’s Experiences in Out-of-Home Care

Recent research on children in out-of-home care has highlighted their demographic characteristics, their physical and mental health status, and case outcomes, yet the body of literature examining children’s perspectives on care is relatively limited. This review provides an overview of almost two dozen studies examining children’s experiences of care. Findings from studies involving interviews with current and former foster youth are reviewed in relation to four child welfare goals: (1) protecting children from harm; (2) fostering children’s well-being; (3) supporting children’s families; and (4) promoting permanence. Implications for improved child welfare practice are offered.     

Supporting families: Outcomes of placement in voluntary out-of-home care for children and young people with disabilities and their families

Parents caring for children and young people with disabilities typically have extensive additional demands on their time and resources. This added pressure can significantly impact well-being and mental health. In extreme circumstances, parents may seek an out-of-home placement for their child. Previous research has looked into factors that influence decisions for families to place their child into out-of-home care but little is known about outcomes for these young people and their families. The Supporting Families study aimed to explore the impact of a voluntary out-of-home placement on young people with disabilities, and consequences for their families. Fourteen parents/carers, twenty six case managers, six accommodation services' managers, and four young people with disabilities participated in face-to-face and telephone interviews and focus groups. Participants reported a range of outcomes for young people in care. Positive outcomes included increased levels of respect for themselves and others, an improvement in independent living skills, and reductions in challenging behaviours. Negative outcomes centred on their experiences of grief, loss and rejection, as well as behavioural problems. Positive and negative outcomes were also found for families. For many parents/carers there was a reduction in perceived stress and caring load, as well as improved mental health and wellbeing for them and the child's siblings. However, parents/carers often experienced ongoing feelings of guilt, grief and loss. The study adds to knowledge about outcomes of being in voluntary out-of-home care for this small but vulnerable group of young people in care and their families.     

Problematic Eating and Food-related Behaviours and Excessive Weight Gain: Why Children in Out-of-home Care Are at Risk

Emerging evidence suggests that abuse and neglect in childhood may play a role in subsequent development of obesity. One population group particularly at risk is children and young people living in out-of-home care (OOHC). Given this population is already a vulnerable group, identifying potential mechanisms by which childhood abuse and neglect increases risk for obesity is essential. A possible explanation is that problematic eating and food-related behaviours (i.e., emotional eating, compulsive eating, overeating, binge eating, stealing or hoarding food) might mediate the association between adverse childhood experiences and obesity. Hence, the overall goal of this paper was to provide a narrative review of eating and food-related difficulties for children in care and their possible association with unhealthy and excessive weight gain. This review revealed a shortage of existing empirical papers and signalled particular need for further examination of the mediating effects of problematic eating.     

Evolve Therapeutic Services: A 5-year outcome study of children and young people in out-of-home care with complex and extreme behavioural and mental health problems

BackgroundLittle evaluation research has been conducted on the effectiveness of services and intervention provided to children in out-of-home care. This study evaluated an innovative Queensland, Australia program employing a collaborative wrap-round model of care in combination with a flexible intervention approach, individually tailored to children and young people in out-of-home care presenting with complex and extreme behavioural and mental health problems.MethodThe sample consisted of 664 children and young people. Two clinician-rated measures, the CGAS and HoNOSCA, were used to assess young people's functioning via a pre-post-treatment design.ResultsResults revealed significant improvements across a range of problems areas: general functioning and adjustment; disruptive, antisocial and aggressive behaviour; overactivity, poor attention and concentration; non-accidental self-injury; problems with scholastic and language skills; non-organic somatic symptoms; emotional symptoms; peer and family relationships; self-care and independence; and school attendance.ConclusionFindings provide good evidence for the effectiveness of the therapeutic intervention program. Implications for future research are explored.