Self-report of health problems and health care use among maltreated and comparison adolescents

The study aims were to compare maltreated and comparison adolescents' health problems and to identify how individual, family and home characteristics and maltreatment status affect adolescents' self-report of health status and health care use. The sample was 224 maltreated adolescents (mean age = 18.3 years) and 128 comparison adolescents (mean age = 18.15 years). Comparison adolescents reported more cold and pain symptoms during the previous 30 days but no differences in other physical health problems, self-assessment of their physical and mental health or health care use compared to maltreated adolescents. Girls were more likely to have had a dental checkup, to have seen a psychological counselor, and to self-identify their physical health as poor compared to boys. Older adolescents were less likely to have had a medical checkup or seen a psychological counselor than younger adolescents. A history of maltreatment was not related to health or health care disparities for adolescents growing up in the same low-income environment as adolescents without a maltreatment report. The environmental context and geographical location in which these adolescents grew up may be the primary driver in their health behaviors and health problems and not the experience of maltreatment.     

The moderating role of length of stay in the relationship between cognitive dysregulation and peer attachment in adolescent boys and girls living in residential care

In Portugal, youth at risk tend to be placed in residential care for long periods of time, during which peers assume a status close to that of family. However, these adolescents often present deficits in emotional regulation, which can compromise the quality of their relationships with peers. Therefore, this study aimed to analyze the relationship between emotional dysregulation experienced by institutionalized adolescents and their own perception of peer attachment, testing whether the length of stay moderates this relationship, for boys and girls independently. Data was collected from a sample of 100 Portuguese adolescents (71 boys; 29 girls), aged 12–18, living in residential care for 43 months average (SD = 43.14). They responded to the Abbreviated Dysregulation Inventory, which measures cognitive, affective and behavioral dysregulation, and the peer version of the Inventory of Parent and Peer Attachment, which measures communication, trust and alienation.Only cognitive dysregulation accounted for the variability of perceived attachment to peers, in the total scale and in communication and trust. When the level of cognitive dysregulation reported by the adolescents is high, there is a positive effect of length of stay in the previous relationships, but only for boys.Results outline how length of placement contributes to youth at risk to reach certain outcomes. They also emphasize the need to develop specific interventions in residential care contexts to address specific characteristics such as gender differences, in order to continuously promote positive interactions with peers in these contexts.     

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.     

Services use by children and parents in multiproblem families

BackgroundMultiproblem families are multi-users of psychosocial and health care services, but little is known about factors associated with their care utilization in the general population. The aim of this study was to assess which factors were associated with the overall and psychosocial care use of two members—i.e., child and parent—of each multiproblem family.MethodsDuring well-child visits or psychosocial care, we identified 354 children and their parents who had problems in several life domains (response 69.1%). We used multivariate stepwise backward logistic regression analyses to identify the factors related to their use of overall and psychosocial care.ResultsA child's overall care use was associated with greater social support from family and friends (odds ratio, OR, 95% confidence interval, CI; OR = 1.05, CI = 1.01–1.08) compared to less perceived social support; and with more psychosocial problems in the child (OR = 1.84, CI = 1.04–3.24). Child's psychosocial care use was more likely among older children (OR = 1.94, CI = 1.20–3.15); greater social support by family and friend (OR = 1.03, CI = 1.00–1.06); more psychosocial problems (OR = 1.75, CI = 1.04–2.97); and when there were more parenting concerns (OR = 1.19, CI = 1.06–1.33). Parental overall and psychosocial care use was more likely when the family experienced a higher number of life events (OR = 1.27, CI = 1.17–1.38, and OR = 1.39, CI = 1.25–1.55).ConclusionsCare use in multiproblem families is related to family factors as well as psychosocial problems. It may be possible to use these family risk factors to identify such families early, whose intensive care use is possibly explained by the relationship with inadequate use of social support.     

Concurrent alcohol and cigarette use among school-going adolescents in Korea

BackgroundConrurrent alcohol and tobacco use may increase the risk for substance abuse in adolescents. The aim of this study was to investigate concurrent alcohol and cigarette use and the co-occurrence risks of each substance in school-going adolescents in Korea.MethodsIn a cross-sectional nationally representative survey in 2016, 65,528 students (Mean age = 15.1 years, SE = 0.02) responded to a questionnaire that included measures of substance use and substance use exposure.ResultsIn all, 13.3% of the students were concurrent lifetime smokers and drinkers (19.3% among boys and 6.7% among girls), 25.5% lifetime alcohol users only (24.2% among boys and 26.9% among girls), 3.0% lifetime smokers only (4.7% among boys and 1.1% among girls) and 58.3% never smoked and never used alcohol (52.2% among boys and 47.8% among girls). All measures of more intensive smoking pattern and smoking exposure and more intensive drinking pattern and drinking exposures, respectively, were associated with consistently increased risk of lifetime alcohol use and lifetime smoking, respectively, compared to lifetime never smokers and abstainers. In multinomial logistic regression, compared to students who neither had used alcohol nor tobacco, concurrent lifetime smokers and drinkers were more likely to be male, mixed or boys school, higher school grade, lower paternal and maternal educational level, perceived lower socio-economic status, ever drug user, perceived stress above average, depressive mood, experience of violence victimization, and living in a rural area or medium sized city.ConclusionPrevention and treatment strategies should better incorporate the comorbidity of cigarette smoking and alcohol use in their intervention programmes.     

Factors influencing the development of psychiatric disorders in the victims of sexual abuse: A study on Turkish children

The purpose of this study is to test empirically whether there are sex differences in childhood sexual abuse characteristics and psychiatric disorders, and there is an association with sexual abuse characteristics and psychiatric disorders caused by abuse. Files of 482 cases referred to the Child Surveillance Center due to sexual abuse between September 2012 and September 2014, for whom legal reports were prepared, were investigated retrospectively. Of the abused children, 82.2% (n = 396) were girls and 17.8% (n = 86) were boys. The mean age of girls was 14.1 ± 2.9 years, while that of boys was 11.6 ± 3.8 years. The most common type of abuse was sexual touching in girls, while it was anal penetration in boys. The rate of being diagnosed with at least one psychiatric disorder was found to be 68.9% (n = 273) in girls, while it was 38.4% (n = 33) in boys. When the abuser was from the family or someone close to the victim, when the numbers of abuse incidents and abusers were greater than one, and in cases of force and violence, the rate of being diagnosed with a psychiatric disorder was found to be higher. With greater duration of time passing after the abuse, in those who became pregnant due to abuse, and in those who did not tell their parents about the incident, the rate of psychiatric diagnosis was significantly higher. In addition, it was found that when there were more than one abused people in the same event, the rate of psychiatric diagnosis was lower. Among all these variables, independent variables affecting the development of psychiatric disorders in victims were gender, number of abuse, presence of force and physical violence, and presence of more than one abuse victim in the same event. Because of high rates of psychiatric disorders in children exposed to sexual abuse, it is crucial to evaluate these children in a careful and closely manner by clinicians.     

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.     

A randomized controlled trial of the effectiveness of the youth crime prevention program ‘New Perspectives’ (NP): Post-treatment changes and moderator effects

ObjectivesNew Perspectives (NP) aims to prevent that youth at onset of a criminal career will develop a more persistent criminal behavior pattern. The study aim was to examine whether NP was effective relative to care as usual in preventing and reducing (persistent) delinquency. Moreover, we examined improvements in secondary outcomes (e.g., peer and parent relationships and cognitive distortions) and other outcomes (e.g., substance use and self-esteem).MethodsAt-risk youth (N = 101) aged 12 to 19 years were randomly assigned to the intervention group (NP, n = 47) or control group (‘care as usual’, n = 54). The effects of the NP intensive phase (3 months after program start) and aftercare phase (6 months after program start) were analyzed.ResultsNP and care as usual did not differ on any of the outcome measures at both post-test occasions. The effects of NP were the same for boys and girls, different age groups, and ethnic groups.ConclusionsThe overall null-effects are discussed, including implications for further research, policy, and practice.     

The role of religion in mediating the transition to residential care

PurposeThe move from independent domicile to residential care can be a traumatic experience for the elderly. This study investigated the mediatory role of the individual's religious and spiritual beliefs on coping with this transition.Design and methodsA self-report survey design was used, and questionnaires were administered to 50 individuals who had entered residential care within the previous 12 months.ResultsThe analyses showed that scores on a life satisfaction scale were significantly and positively correlated with those from a spirituality measure (p = .033), from a faith in nature and humanity scale (p = .001), and from an instrument to measure the use of religion as a coping measure (p = .004). Contrary to the hypotheses, there were no such significant relationships with measures of either organised or non-organised religion. The relationships between variables were further explored through a path analysis.ImplicationsThe findings pointed to the benefits of a more personal and subjective belief system than a formal one. We concluded that it is important for all those who work with the elderly to acknowledge and recognise the role that religious and spiritual beliefs may have as a coping mechanism during stressful times.     

To be or not to be a rights holder: Direct and indirect effects of perceived rights on psychological adjustment through group identification in care

This study explores how young people in residential care perceive their rights and the relationship with their adjustment, through the role of group identification. Data from a non-random sample of young people (N = 356; aged 11–18 years) in Portuguese residential settings was analysed and a set of mediation effects was found. Findings revealed a set of mediation effects on the relationship between Participation and Protection and Positive Self and between Respectful system practices and behaviours and Emotional Distress, Anger Control and Antisocial Behaviour. Higher scores of these rights perceptions were associated with lower psychological problems, through the indirect effect of group identification (i.e., the sense of belonging to the group in residential care). These findings are discussed based on social and developmental insights together with empirical evidence on residential care. These results provided important practical implications in residential care, namely, assuring the young people's participation, the promotion of professional practices based on the respect for young people and their families, non-discriminatory behaviours and equal opportunities.     

Program records as a source for program implementation assessment and youth outcomes predictors during residential care

This study used point card information from a residential program to generate treatment fidelity metrics and determine if the metrics predicted youth outcomes after six months in care. Youth outcomes included staff (n = 52) and youth (n = 143) ratings, youth conduct records kept by the residential program's teaching-family homes and school records. Treatment fidelity metrics included the program components: (a) percentage of positive interactions, (b) number of privileges earned, and (c) a skills taught to interactions ratio. The percentage of positive interactions averaged 90% per youth; 76% of the point cards indicated that privileges were earned; and a variety of life skills were typically taught to the youth (skills ratio = .61). The data from the treatment fidelity metrics supported that the program was implemented consistent with program expectations. The range of implementation quality for each measured component was then used to predict youth outcomes. Increased percent of positive interactions predicted significantly decreased externalizing behaviors as reported by staff (β = − 0.31, p < .001) and youth (β = − 0.30, p < .001), and significantly fewer incidents of non-compliance (Exp(b) = 0.93, p < .001) and school problems (Exp(b) = 0.91, p < .001) as indicated on the program records. The skills ratio indicated similar trends across outcomes, although non-significant at the p < .01 level. Permanent products may be helpful to develop program treatment fidelity metrics, which may be useful for monitoring implementation and may be associated with improved youth outcomes.     

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.     

A cross-lagged model of the relationship between violent video game exposure and moral disengagement in middle school and high school students

Previous studies have proved that violent video game exposure might have an association with moral disengagement; however, the directionality of this correlation remains unclear. Therefore, we examined the reciprocal effects between violent video game exposure and moral disengagement in a longitudinal study. The sample included 1393 adolescents (48.7% boys) in the seventh (middle school students, n = 694, M_age = 13.15 years) and tenth (high school students, n = 699, M_age = 15.93 years) grades at six Chinese secondary schools. The results showed that high school students' levels of moral disengagement were higher than those of middle school students, and violent video game exposure was positively associated with moral disengagement. The cross-lagged panel model suggested that violent video game exposure predicted moral disengagement (six months later) in all participants, with a slightly stronger effect in middle school students. The finding also indicated differences in the development of perspective regarding the association between violent video game exposure and moral disengagement, which observed a predictive effect for middle school students but a lagged effect for high school students. Thus, different preventions and interventions should be distinguished for middle school and high school students.     

Risky sexual behavior and substance use among adolescents: A meta-analysis

This study presents the results of a meta-analysis of the association between substance use and risky sexual behavior among adolescents. 87 studies fit the inclusion criteria, containing a total of 104 independent effect sizes that incorporated more than 120,000 participants. The overall effect size for the relationship between substance use and risky sexual behavior was in the small to moderate range (r = .22, CI = .18, .26). Further analyses indicated that the effect sizes did not substantially vary across the type of substance use, but did substantially vary across the type of risky sexual behavior being assessed. Specifically, mean effect sizes were the smallest for studies examining unprotected sex (r = .15, CI = .10, .20), followed by studies examining number of sexual partners (r = .25, CI = .21, .30), those examining composite measures of risky sexual behavior (r = .38, CI = .27, .48), and those examining sex with an intravenous drug user (r = .53, CI = .45, .60). Furthermore, our results revealed that the relationship between drug use and risky sexual behavior is moderated by several variables, including sex, ethnicity, sexuality, age, sample type, and level of measurement. Implications and future directions are discussed.     

Concurrent reductions in psychotropic medication,assault, and physical restraint in two residential treatment programs for youth

Over the past decade, the level of clinical needs of youth in residential treatment has increased significantly. Youth in out-of-home settings typically experience higher levels of psychotropic medication use than their peers living at home, even when controlling for the severity of clinical issues. The purpose of the current study was to examine the effects of an approach to clinically reassess psychotropic medication utilization for youth residing in residential treatment settings while also observing the impact on the youth's need for physical containment. Medication changes were based on a data-informed process, using input from a multi-disciplinary treatment team. Data for 531 youth who were consecutively admitted to one of two non-affiliated intensive residential treatment programs, one in the Midwest and one in New England, was analyzed. Over half of these youth (n = 292, 55%) had their medications reduced during their stay and only 14% (n = 76) were prescribed more medication at discharge than they had been taking at admission. The remainder either saw no change during their stay (n = 104, 20%) or were never on medication at any time (n = 59, 11%). From admission to discharge there was a 62% decrease in the number of assaultive incidents as well as a 72% decrease in the use of physical restraints. These results support the view that residential treatment can provide a treatment milieu that allows for thoughtful reassessment of the clinical basis for behavioral disorders in children that can achieve the dual goals of medication reduction and behavioral stabilization.     

Factors associated with treatment attrition for Medicaid-enrolled youth with serious emotional disturbances

Premature discontinuation from treatment is a significant problem that undermines the delivery of effective mental health services and increases the risk for relapse and poor outcomes. However, factors associated with treatment attrition in children and adolescents are not well understood. This retrospective longitudinal cohort study examines factors associated with attrition for Medicaid-enrolled youth, aged 5 to 17 with “new episodes” of ICD-9-CM diagnosed serious emotional disturbance (N = 43,122). Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Multilevel modeling was used to assess the association between individual and contextual-level variables and attrition. Of the 43,122 youth in the study sample, 4056 (9.4%) discontinued treatment. The odds of treatment attrition were significantly higher for youth who were male (OR = 1.16, p < 0.001), black compared to white (OR = 1.19, p < 0.001), had a co-occurring substance abuse disorder (OR = 1.35, p = 0.01), and lived in a county with a larger percentage of minorities (OR = 1.02, p = 0.01). In contrast, youth diagnosed with bipolar and depressive disorders compared to ADHD (OR = 0.78, p < 0.001 and OR = 0.87, p = 0.01, respectively), with comorbid psychiatric (OR = 0.74, p < 0.001) and medical disorders (OR = 0.82, p < 0.001), and a prior history of two or more psychotropic medications compared to no medications (OR = 0.76, p < 0.001) had lower odds of attrition. Residence in a county with a larger number of pediatricians and psychologists also reduced the odds of attrition (OR = 0.97, p = 0.05 and OR = 0.99, p = 0.03 respectively). Overall, this study suggests that a combination of individual factors, demographic and clinical, and contextual factors impact attrition in children's mental health outpatient treatment.     

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.     

Development of an innovative process evaluation approach for the Families Improving Together (FIT) for weight loss trial in African American adolescents

This study demonstrates how a multi-theoretical, multilevel process evaluation was used to assess implementation of the Families Improving Together (FIT) for weight loss intervention. FIT is a randomized controlled trial evaluating a culturally tailored, motivational plus family-based program on weight loss in African American adolescents and their parents. Social Cognitive, Self Determination, Family Systems theories and cultural tailoring principles guided the conceptualization of essential elements across individual/family, facilitator, and group levels. Data collection included an observational rating tool, attendance records, and a validated psychosocial measure.ResultsAttendance records (0 = absent, 1 = present, criteria = ≥70%) indicated that 71.5% of families attended each session. The survey (1 = false, 6 = true, criteria = ≥4.5) indicated that participants perceived a positive group climate (M = 5.16, SD = 0.69). A trained evaluator reported that facilitator dose delivered (0 = no, 1 = yes, criteria = ≥75%) was high (99.6%), and fidelity (1 = none to 4 = all, criteria = ≥3) was adequate at facilitator (M = 3.63, SD = 0.41) and group levels (M = 3.35, SD = 0.49). Five cultural topics were raised by participants related to eating (n = 3) and physical activity (n = 2) behaviors and were integrated as part of the final curriculum.DiscussionResults identify areas for program improvement related to delivery of multi-theoretical and cultural tailoring elements. Findings may inform future strategies for implementing effective weight loss programs for ethnic minority families.     

Significance of action plans in the development of occupational well-being in the schools of Finland and Estonia

This article is part of a long term project “Promoting the Occupational Well-Being of School Staff—Action Research Project in Finland and Estonia, 2009–2014.” The purpose of this article is to describe the significance of action plans in the promotion of the occupational well-being of primary and upper secondary school staff in Finland and Estonia from 2010 to the turn of the year 2011–2012. An electronic open questionnaire was sent to occupational well-being groups in Finland (N = 18) and in Estonia (N = 39). In Finland, the questionnaire was responded to by 16 (n = 16) occupational well-being groups, and in Estonia, by 38 (n = 38) groups. The qualitative data were analyzed using the inductive-deductive method and content analysis. The obtained results indicate that the schools had named goals for action plans in all aspects of the promotion of occupational well-being in schools (worker and work, working conditions, professional competence, working community) and that these goals were mainly realized in the schools in a systematic way. Schools felt that the action plan for occupational well-being helped them to set goals for occupational well-being and that the planned actions were realized in a more systematic way than before.