Mental health services for children and caregivers remaining at home after suspected maltreatment

ObjectiveBehavioral problems are common among children remaining at home after suspected maltreatment, but the effectiveness of current mental health services to improve these behavioral problems is unknown. The objective was to determine whether receipt of child and caregiver mental health services was associated with improvements in behavioral problems in maltreated children remaining at home.MethodsWe retrospectively analyzed Second National Survey of Child and Adolescent Well-being data. We included 1117 children ages 2–17 remaining at home after a maltreatment investigation, excluding children with missing outcome, covariate, or survey weight data. We compared mean Child Behavioral Checklist (CBCL) change scores from baseline to 18 months between children who did and did not receive mental health services, before and after adjusting for child, caregiver, and child welfare agency factors using survey-weighted linear regression.ResultsNearly one-quarter (22.6%) of children and 16.0% of caregivers received mental health services. Children receiving services had worse unadjusted baseline and 18-month CBCL scores than children not receiving services (all P < 0.001). Adjusted CBCL change scores revealed behavioral worsening among children receiving services but improvement among children not receiving services (all P < 0.001). However, children had improved behavior, regardless of their own service receipt, if their caregivers received services and reported an absence of depression at 18 months.ConclusionsChildren receiving mental health services had worse behavioral changes than children not receiving services. Caregiver receipt of services was associated with improved child behavior, suggesting that a family-centered approach may be most influential in improving behavioral outcomes among this population.     

A comparison of outcomes for children and youth in foster and residential group care across agencies

Working collaboratively with two state associations and their member (nonprofit) agencies providing out-of-home care to children and youth, University researchers conducted a multi-site project to examine whether there were any differences in individual child-level outcomes between children placed in residential group care and those placed in foster. The study employed a quasi-experimental repeated measures design, with data collected at a minimum of two intervals (at intake and 3-month follow-up) and at subsequent intervals of 6 and 12 months for children remaining in care. Samples for analyses were drawn from 1082 youth in either residential group care (n = 903) or foster care (n = 179), in one of 37 agency sites across two southeastern states, who participated in a broader evaluation project. The average ages of participating youth in residential and foster care were 13.97 (SD = 2.43) and 13.65 (SD = 2.73), respectively. Based on his or her score on the Children's Global Assessment Scale (CGAS) at intake, each participant was also assigned to the low functioning group (n = 526; 53.1%), the borderline group (n = 232; 23.4%), or the high functioning group (n = 232; 23.4%). Analyses confirmed that youth in foster care tended to have higher levels of general functioning at baseline than did youth placed in group care. However, the degree to which youth progressed in care on measures of general functioning and mental and behavioral health problems did not differ based on placement setting; youth in residential group care settings progressed at the same rate as youth in community-based settings, regardless of their level of functioning at intake. The only exception to this pattern was in regard to anxiety; there was an observable, but non-significant trend of youth in foster care reporting decreases in anxiety levels, while those in group care reported increased anxiety.     

Remaining home: Well-being outcomes and co-occurring parental substance use following a maltreatment investigation in middle childhood

PurposeThe purpose of the study is to understand differences in child well-being related to parental substance use among children ages 6–12 who were investigated for maltreatment but not removed from their homes. Children with a substance-using parent in the home are compared to those without a substance-using parent in the home.MethodsLongitudinal data from waves 1 and 3 of the second National Study of Child and Adolescent Well-Being (NSCAW II) are used. NSCAW II is a national sample of families with children and youth aged birth to 17.5 investigated by child protective services (CPS). A subset of the data (analyzed with domain analysis methods) is used for this study (n = 575). Eight well-being outcomes from four domains (cognitive development, physical health, psychological/behavioral development and social/emotional competence) are analyzed.FindingsWe hypothesized that (among children investigated for maltreatment and not removed from home) children whose parents used substances would exhibit lower mean levels of well-being at thirty-six months follow-up compared to those whose parents did not use. Unexpectedly, we found no significant differences in well-being levels between children with parents in the home using substances and those without.ConclusionsChildren with substance-using parents may be able to remain at home over an extended period after investigation, while maintaining well-being levels similar to children at home with parents not using substances. If an effective safety plan can be put in place, this option may provide a path to maintaining safety, permanency and well-being for such children without placement in out-of-home care.     

Aggressive behaviors among Korean children in out-of-home care: The role of placement characteristics

Using data from the Korean Panel Study on Children in Out-of-Home Care, this study examined the impact of placement characteristics on aggressive behaviors among children in out-of-home care by placement type. The sample was divided into three groups based on placement type: institutional care (n = 118), group homes (n = 95), and foster care (n = 212). Results from hierarchical multiple regression analyses indicated that the length of stay in out-of-home care significantly influenced aggressive behaviors amongst children in institutional care, such that increased duration of out-of-home care decreased the level of aggressive behaviors. Perceptions of stigma/discrimination also significantly influenced aggressive behaviors displayed by children in institutional and foster care. Children with a higher perception of stigma/discrimination were more likely to exhibit severe aggressive behaviors than were their counterparts. On the other hand, placement characteristics had no significant influence on aggressive behaviors of children in group homes. The study findings suggest that children's mental health problems and disabilities should be considered during the placement procedure and interventions focusing on decreasing stigmatization should be developed and provided for children in out-of-home care.     

Co-development of internalizing and externalizing behavior problems during early childhood among child welfare-involved children

Using parallel-process latent growth curve modeling, we examine developmental trajectories of internalizing and externalizing behavior problems and identify early risk factors for behavior problems among 329 child welfare-involved children followed from age 2 years to 5 years. Data are drawn from the National Survey of Child and Adolescent Well-Being II. On average, internalizing behavior problems remained stable, while externalizing behavior problems decreased over time. Higher initial levels of internalizing behavior problems were associated with higher initial levels of externalizing behavior problems. Rates of change also had positive cross-domain relationships. Child neglect, exposure to intimate partner violence (IPV), insecure caregiver-child attachment, and caregiver mental health problems were associated with higher initial levels of internalizing and externalizing behavior problems. Exposure to IPV, out-of-home care, and caregiver drug use predicted rates of change in behavior problems. Our findings highlight the importance of comprehensive assessment and treatment for co-occurring internalizing and externalizing behavior problems in young children involved in the child welfare system. Results also indicate the need for identifying and addressing early risk factors to prevent early onset and continued development of behavior problems in high-risk children.     

Effectiveness of brief intervention and case management for children and adolescents with mental health difficulties

ObjectiveTo compare the effectiveness of a Brief Intervention (BI) and Treatment As Usual (TAU) in a sample of children and adolescents seeking mental health treatment from a Child and Youth Mental Health Service (CYMHS). BI comprised up to six sessions of psychological therapy from trainee psychologists, and TAU involves case management incorporating assessment and psychological treatment (e.g., individual, parent, family therapy), plus linkage to other services.MethodA matched subjects design was used to evaluate the BI (n = 79) and TAU (n = 79) treatment conditions. Participants were matched according to age, gender, and baseline symptom scores on the Health of the Nations Outcome Scale for Children and Adolescents (HoNOSCA), which was completed at pre- and post-treatment. The HoNOSCA is a clinician-rated measure of symptoms experienced in the previous two weeks.ResultsBI and TAU both significantly reduced mental health symptoms, with no significant difference between treatments overall, on Externalising or Emotional problems subscales, or on the percentage of most problematic items for participants.ConclusionsBI was as effective as TAU in reducing mental health symptoms in some children and adolescents. BI however is briefer, and could form part of a Stepped Care model for CYMHS. Further research is required to establish the most effective elements of BI in reducing mental health symptoms.     

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.     

The relationship between parent immigration status and concrete support service use among Latinos in child welfare: Findings using the National Survey of Child and Adolescent Well-being (NSCAWII)

The underutilization of concrete services by immigrants is widely documented across several service sectors, yet evidence is lacking on the use of such services among immigrants reported to child welfare for the purposes of reducing maltreatment. It has been suggested that Latino immigrants involved with the child welfare system may face steep challenges to receiving needed services due to issues surrounding legal status, language and cultural barriers. The purpose of this study was to determine whether referral to and receipt of concrete services by Latino families reported to child welfare agencies, was associated with legal immigration status. The sample included children of Latino parents who participated in the second National Survey of Child and Adolescent Well-being (NSCAWII), who remained in the home following a child welfare investigation (n = 561). Over a third (37%) of Latino families were referred for at least one concrete service, yet only 17% received any. Weighted logistic regression models showed that families in which the primary caregiver was undocumented had significantly lower odds (OR = .24) of receiving services once referred. Families who had trouble paying for basic necessities (OR = 7.52), those with active domestic violence in the home (OR = 4.98), and those receiving ongoing child welfare services (OR = 4.52) had increased odds of referral for services by the caseworker. The odds of receiving services increased when the primary caregiver was unemployed (OR = 5.24), when there was domestic violence in the home (OR = 4.59), and with the receipt of child welfare agency services (OR = 8.83). There appears to be an unmet need for concrete services among Latinos investigated by child welfare, as demonstrated in the gap between overall service referral and receipt. A parent's legal status may be one reason for that unmet need, implying that children of undocumented parents are less likely to have basic needs met to mitigate economic stress and reduce maltreatment risk upon contact with child welfare. Policy recommendations and implications for child welfare practice are discussed.     

Food neglect and maltreatment re-report

This study examines the time to re-report following the close of a maltreatment investigation for cases involving food neglect. Data on families of children 0 to 17 involved in Child Protective Services (CPS) investigations from a merger of the 2010 cohort of the National Survey of Child and Adolescent Well-Being (NSCAW II) and the National Child Abuse and Neglect Data System (NCANDS) were used (n = 3580). More than half of the families had a history of CPS involvement, a third received CPS services, and one-in-ten families had their child place in out-of-home care following an investigation. After controlling for other types of maltreatment allegations and multiple covariates, families investigated for food neglect had a greater chance of being re-reported for a subsequent CPS investigations in a shorter length of time than families without an allegation of food neglect. While only a small percentage of families had a food neglect allegation, problems adequately feeding a child - whether due to severe poverty, inattentiveness, or abusive negligence - placed a family at a higher risk of a future CPS investigation.     

Societal factors impacting child welfare: Re-validating the Perceptions of Child Welfare Scale

ObjectiveThis research examines the psychometric properties of the Perceptions of Child Welfare Scale (PCWS) by seeking to understand the differences between workers' perceptions of how society views them based upon job title by revalidating the PCWS with a sample of administrators and clinicians.MethodsConfirmatory factor analysis was utilized to analyze data on 165 administrators and 153 clinical child welfare workers.ResultsThe final model consisted of three latent variables with ten indicators related to stigma, value, and respect ([X²] = 167.6, [p] = 0.00; [RMSEA] = 0.07; 90% [CI]: 0.06–0.09; [CFI] = 0.95; [TLI] = 0.95).DiscussionThe factors found in the previous study were confirmed using an entirely different sample of child welfare workers. The factors value, stigma, and respect were confirmed across the sample based upon whether the workers were administrators or clinicians. This provides reassurance that measuring how workers perceive they are viewed by those outside the child welfare system does not vary based upon job title.     

Medical complexity and placement outcomes for children in foster care

ObjectiveMedical complexity threatens placement stability and permanency outcomes for children in foster care (FC). This study aimed to characterize for US children in FC: 1) medical complexity, using number of diagnosed types of disability as a proxy; 2) demographic and removal characteristics based on level of complexity; and 3) whether increasing levels of complexity were associated with foster care placement outcomes.MethodsThe analysis included children in FC, ages 0–21 whose disability status was clinically assessed and documented (n = 538,695). Using data from the FY 2014 Adoption and Foster Care Analysis and Reporting System, medical complexity was categorized (0–4 +) based on 5 disability types: emotional, hearing/vision, intellectual, physical, and other. Bivariate analyses (χ² tests, Kruskall-Wallis) compared the distribution of demographic and removal characteristics among complexity groups. Multiple logistic regression evaluated relationships between medical complexity and placement outcomes, including length of stay in FC, placement stability, and permanency.ResultsTwenty-three percent of the sample had 1 disability type, 7% had 2, 3% had 3, 1% had 4 +, and 67% had no disability. Children with increasing complexity were more likely to be older, older on FC entry, male, Black, non-Hispanic, placed in a group home or institution, have abuse, neglect, and/or child disability/behavior as reason for removal, and have poor placement outcomes.ConclusionChildren in FC with greater medical complexity are at risk for undesirable placement outcomes. By recognizing and addressing the unique needs of this vulnerable population, pediatric providers and child welfare staff may identify strategies to improve placement outcomes.     

Cost effectiveness of a school readiness intervention for foster children

ObjectiveMany young children in foster care suffer from emotional and behavior problems due to neglect and abuse. These problems can lead to difficulties in school, and functioning in school is linked to long-term health and development. Early intervention to reduce emotional and behavioral issues can help children successfully transition to school, which can improve long-term outcomes. However, communities need information on relative costs and benefits associated with programs to make informed choices. The objective of this study was to assess cost effectiveness, over 12 months, of the Kids in Transition to School (KITS) intervention compared to usual services available to children in a foster care control group (FCC).MethodRandomized controlled trial of 192 children in foster care entering kindergarten who were randomized to KITS (n = 102) or FCC (n = 90). KITS includes school readiness groups and parent training over 4 months. Main outcomes were days free from internalizing symptoms (IFD), days free from externalizing behavior (EFD), intervention costs, public agency costs, and incremental cost effectiveness.ResultsKITS significantly increased IFD and EFD compared to FCC. Average total cost of the intervention was $932 per family. The intervention did not significantly impact usual services. Average incremental cost effectiveness was $64 per IFD and $63 per EFD.ConclusionsThe cost of KITS is comparable to, or less than, similar programs, and the intervention is likely to provide significant emotional and behavioral benefit and improvement in school readiness for young children in foster care.     

Expanding the conceptualization of re-entry: The inter-play between child welfare and juvenile services

Re-entry in child welfare is traditionally viewed as a child exiting to permanency and then reentering the child welfare system. Using this approach is effective for understanding child welfare practice from a single-system lens, but gives an incomplete picture of how children may move between related child serving systems. The present study expands the definition of re-entry by examining re-entry for 2259 children who either return to the child welfare system or move into the juvenile justice system after reunification from foster care. When measuring a broader concept of re-entry (into either system) the rate of re-entry went from 18% to 25% - a 33% increase. Regression analyses further suggested that many of the risk and protective factors associated with standard child welfare reentry were also predictive of multisystem re-entry such as having previous child welfare experience (OR = 1.79, p < 0.000), and child behavior as a factor at removal (OR = 1.75, p < 0.000). Findings of this study support the need to continue increasing the conceptualization of re-entry to be more inclusive of related systems as well as continuing to focus research efforts on understanding effective practices within child serving systems so that re-entry into either system is mitigated.     

Internalizing and externalizing behavioral problems of American Indian children in the child welfare system

Children involved in the child welfare system display elevated or clinically significant behavioral problems. However, there is a dearth of literature on the behavioral problems of American Indian children following child welfare involvement. Grounded in Patterson's Family Adjustment and Adaptation Response theory, this study fills that gap. Baseline, 18-month, and 36-month follow-up data from the National Survey of Child and Adolescent Well-being were utilized. The sample (n = 3498) consisted of American Indian, African American, and Caucasian children ages 2–16 at baseline (M = 8.13 years old, SD = 3.85) and 51.7% were female. Nearest neighbor propensity score matching analyses were used to estimate the effect of race on clinically significant internalizing and externalizing behavioral problems. Findings suggest that although externalizing behavioral problems do not differ based on race after controlling for other important factors, internalizing behavioral problems do differ. American Indian children are more likely to display clinically significant internalizing behavioral problems.     

Quality improvement learning collaborative to examine foster care guidelines

Learning collaboratives (LC) are an important method of implementing quality improvement by serving as laboratories to translate research into practice and sharing knowledge. We created a Foster Care Learning Collaborative (FCLC) of 11 foster care health sites to share best practices on providing health services for children in foster care. Using a collaborative approach involving monthly conference calls, we invited each health site to present specific health care delivery issues for the purpose of developing collaborative quality improvement projects regarding the delivery of healthcare to children placed into foster care. For health sites providing primary care (n = 8 of 11 sites), we examined adherence to two American Academy of Pediatrics (AAP) guidelines for children entering foster care: a) the initial health screen, and b) the comprehensive medical evaluations. At least four distinct types of health care models that provide either direct primary care or administrative oversight for children in foster care were identified: 1) medical home sites (n = 3); 2) foster care evaluation/intake sites (n = 2); 3) specialized primary care sites (n = 1); and, 4) state administrative programs (n = 2). Data from the six direct primary care sites (n = 586 children) and two state administrative models (n = 3855 children) was collected. The time-frame for the initial health screen was adjusted to 7 days after entry and adherence (31%) was comparable among primary care sites. Adherence to AAP guidelines regarding completion of a comprehensive medical evaluation within 30 days of intake varied among medical homes (30%–86%), intake models (23%–33%), specialized primary care site (43%), and state models (43%–73%). No site was fully compliant with the AAP guideline for universal comprehensive medical evaluation within 30 days, and there is variation within and among care models. A foster care learning collaborative identified significant variability in adherence to a commonly accepted guideline for timely access to healthcare for children placed into foster care. The LC c model offers the opportunity to evaluate best practices, identify barriers to care, and provide objective feedback for improvement.     

Recent changes in the child welfare system: One state's experience

Nationwide over the past 5 years there has been a substantial reduction in the number of children involved with the child welfare system entering out-of-home care as well as a reduction in the lengths of stay among those who do enter the system. This article compares national data on children entering out-of-home care and the length of stay with data from Florida over a 7-year period (2005–2011). Findings are shared on the strategies and services that stakeholders in one state reported as contributing to preventing out-of-home placements and reducing lengths of stay in residential settings. Federal policies such as IV-E Waivers that support this reduction also are discussed. The article concludes with policy and research recommendations regarding how to sustain this reduction while ensuring that child safety and well-being are preserved.     

Exploratory analysis of child protection mediation permanency placement outcomes

Using a merged data set constructed from empirical data obtained from Child Protective Services (CPS) and a nonprofit agency tasked with conducting an evaluation of a child protection mediation pilot project in the state in which this study was conducted, this study (N = 311) explores how various child and family factors in child protection mediation cases affect placement outcomes for children in care. Results of the multinomial logistic regression (MLR) analyses found that children for whom parent/caregiver substance abuse and/or mental illness was an issue were less likely to be reunified with their parents than remain in care. Those children who experienced a higher number of placements and those who were male were less likely to be placed with relatives. Children whose parents experienced mental health issues were less likely to be placed with a relative. With regard to the permanency outcome of adoption, the findings showed that as the age of the child at time of removal increased, children were less likely to be adopted than remain in care. Additionally, African American children in the sample were less likely to be adopted.     

Unmet legal and social advocacy needs of children with sickle cell disease: Implications for health care payer costs

Previous studies of advocacy needs faced by children and families have not differentiated needs that require attorney involvement (“legal advocacy needs”) from needs best addressed by social workers or lay advocates (“social advocacy needs”). Studies have also not examined the relationship between either type of need and health care costs. We developed a novel, replicable process to differentiate between legal advocacy needs and social advocacy needs. We then collected cross-sectional data from a sample of 52 children with sickle cell disease who were at least 1 year of age, a population with high advocacy needs and high health care costs. Mean annual health care costs to payers for children whose families had a least one legal advocacy need were $16,314, compared to $5552 for children in families with no legal advocacy needs (P = 0.007). After adjusting for covariates, the presence of a legal advocacy need was associated with $12,040 more in health care costs to payers (P = 0.02). Whether interventions to prevent and resolve legal advocacy needs can reduce health care costs by addressing the social determinants of health warrants future study.     

From foster care to juvenile justice: Exploring characteristics of youth in three cities

Children placed in foster care are at risk for becoming involved with the juvenile justice system. This study documents the rates at which children involved with foster care enter the juvenile justice system (crossover or dually involved), and the factors associated with this risk. We utilize multiple birth cohorts and prospective, longitudinal data from birth to maturity separately in three major American cities. Analyses consider integrated administrative records from multiple birth cohorts representing populations in Cook County (Chicago; N = 26,003), Cuyahoga County (Cleveland; N = 10,284), and New York City (N = 13,065). Crossover rates ranged from 7 to 24%. African American males, and children who experienced congregate care were at highest risk for juvenile justice involvement. Older age at first foster care placement signaled progressively greater risk, as did more foster care spells for those first placed as infants. We discuss findings in terms of developmental theory, and as actionable intelligence to inform prevention, practice, and policy.     

Effects of kinship care on behavioral problems by child age: A propensity score analysis

When a child must be removed from the family home, placement with a relative is often sought because kinship care is the least restrictive and most family-like out-of-home placement. Although kinship care has become a preferred option in most U.S. child welfare systems, this preference is often based on “soft evidence” rather than rigorous evaluation of the risks and benefits of kinship care. Therefore, an evaluation of the impact of kinship care on child behavioral problems is needed to guide child welfare practice and policy. In addition, given that children of different ages and in different developmental stages are likely to have varying placement experiences, the evaluation of kinship care should explore the effect of kinship care on child behavioral problems across age groups. To fill these knowledge gaps, we compare the behavioral problems of 584 children in kinship care with those of 470 children in non-kinship care. Moreover, we examine the impact of kinship care on behavioral problems in 2 age groups: younger children (0 to 5 years) and older children (6 to 17.5 years). The analysis uses data from Waves 1 and 2 of the National Survey of Child and Adolescent Wellbeing, and applies propensity score methods to account for selection bias. Results show that older children in kinship care had significant lower levels of externalizing, internalizing, and total behavior problems. However, for younger children, the effects of kinship care on child behavioral problems did not reach statistical significance. The implications for practice, research and policy are discussed.