Understanding dissociation in relation to child trauma,mental health needs,and intensity of services in child welfare: A possible missing link

Abstract

While there is limited research on the role of dissociation among children and adolescents, emerging evidence links child trauma history, dissociation, risk behaviors, and other negative outcomes among youth. This study examined dissociation in relation to mental health needs and intensity of services among a large sample of youth in Illinois child welfare, upon entry into care and in residential treatment settings. The Child and Adolescent Needs and Strengths (CANS), a comprehensive, trauma-informed assessment strategy and information integration/planning tool was the primary measure. This study included two overall samples of child welfare-involved youth, ages 3–18: at entry into care (N?=?27,737) and in residential treatment (N?=?5,758). Findings indicated that rates of clinically significant dissociation were generally highest among younger youth (under age 14) and among youth with more cumulative and severe trauma. Dissociative youth were significantly more likely to exhibit several risk behaviors (e.g., fire setting and self-harm) and mental health symptoms (e.g., psychosis and somatization). Those youth with significant dissociation at entry into care were more likely to be psychiatrically hospitalized, placed into residential treatment, with greater likelihood of placement disruptions within the 2 years following entry into care. Implications of these findings are discussed in terms of the value of identifying and assessing dissociation and other trauma-related symptoms that may be less recognized but can be linked to high-risk behaviors and other negative outcomes within child welfare and across child-serving systems. Understanding dissociation may be an important component of training, service/treatment planning, and clinical care within child-serving systems.     

Baseline Characteristics of Dependent Youth Who Have Been Commercially Sexually Exploited: Findings From a Specialized Treatment Program

ABSTRACT

Commercial sexual exploitation of children has emerged as a critical issue within child welfare, but little is currently known about this population or effective treatment approaches to address their unique needs. Children in foster care and runaways are reported to be vulnerable to exploitation because they frequently have unmet needs for family relationships, and they have had inadequate supervision and histories of trauma of which traffickers take advantage. The current article presents data on the demographic characteristics, trauma history, mental and behavioral health needs, physical health needs, and strengths collected on a sample of 87 commercially sexually exploited youth. These youth were served in a specialized treatment program in Miami-Dade County, Florida, for exploited youth involved with the child welfare system. Findings revealed that the youth in this study have high rates of previous sexual abuse (86% of the youth) and other traumatic experiences prior to their exploitation. Youth also exhibited considerable mental and behavioral health needs. Given that few programs emphasize the unique needs of children who have been sexually exploited, recommendations are offered for providing a continuum of specialized housing and treatment services to meet the needs of sexually exploited youth, based on the authors’ experiences working with this population.     

Risk factors for mental health diagnoses among children adopted from the public child welfare system

Children awaiting adoption through the child welfare system often have “special needs,” or characteristics that make securing an adoptive home for them challenging. A subset of these youth experiences significant psychiatric symptomatology, which may pose a problem for the stability of the adoptive placement. Clinicians and policymakers require information about precursors to mental health difficulties in order to plan effectively for the placement of these children.This study examines potential child and biological family risk factors for the presence of a DSM-IV mental health diagnosis among 368 children placed for adoption by a special needs adoption program between February 1997 and April 2005 using logistic regression within the Generalized Estimating Equations (GEE) framework. A significant proportion of the children and biological parents in our study experienced serious adversity prior to adoptive placement. Older age at adoptive placement, white race, male gender, having more than one placement, and a history of sexual abuse are significant predictors of the presence of a mental health diagnosis in the logistic regression model. Biological parent incarceration is significantly associated with the absence of a mental health diagnosis.Adoptive placement is a key transition for youth who have often experienced significant loss and trauma prior to placement. Support of the adoptive family and youth can be critical to ensuring placement stability and may be especially salient for youth with documented mental health diagnoses and corresponding behavioral problems, which put children at increased risk for placement disruption. More work is needed to understand the interplay of risk and protective factors for mental health difficulties among youth adopted from the child welfare system, including how these are affected by child welfare policies, informal procedures, and resources to produce varying outcomes for children in peril.     

Relationship of risk assessment to placement characteristics in a statewide child welfare population

Risk assessments allow child and youth services to identify children who are at risk for maltreatment (e.g., abuse, neglect) and help determine the restrictiveness of placements or need for services among youth entering a child welfare system. Despite the use of instruments by many agencies within the U.S. to determine the appropriate placements for youth, research has shown that placement decisions are often influenced by factors such as gender, age, and severity of social–emotional and behavior problems. This study examined ratings of risk across multiple domains using a structured assessment tool used by caseworkers in the Rhode Island child welfare system. The relationship between ratings of risk and placement restrictiveness was also examined. Risk levels varied across placement settings. Multivariate analyses revealed that lower caseworker ratings of parent risk and higher ratings of youth risk were associated with more restrictive placements for youth. Implications for the child welfare system are discussed.     

Characteristics of children in residential treatment in New York State

This study addresses three questions about the population of children and families served in the highest level of care in the child welfare system in New York State residential treatment centers (RTCs): (1) How prevalent are emotional and behavioral problems in the youth entering RTCs? (2) Has the proportion of youth with such problems increased compared to 10 years ago? (3) Are there identifiable subgroups of youth entering RTCs? One-fourth of RTC admissions in fiscal year 2001 were randomly selected from a representative sample of 16 RTCs. The study completed a standardized data collection instrument based on a review of agency records, and included information that was known at the time each child was admitted. The results show significant increases compared to t10 years earlier in the proportion of youth with mental health problems and juvenile justice backgrounds. The findings suggest that youth who traditionally have been served by other systems of care are now being served in the child welfare system. The increased treatment needs of these youth and the heterogeneity of the RTC population have important implications for policies, programs, and practice.     

Who am I? Who do you think I am? Stability of racial/ethnic self-identification among youth in foster care and concordance with agency categorization

While it has been well documented that racial and ethnic disparities exist for children of color in child welfare, the accuracy of the race and ethnicity information collected by agencies has not been examined, nor has the concordance of this information with youth self-report. This article addresses a major gap in the literature by examining 1) the racial and ethnic self-identification of youth in foster care, and the rate of agreement with child welfare and school categorizations; 2) the level of concordance between different agencies (school and child welfare); and 3) the stability of racial and ethnic self-identification among youth in foster care over time. Results reveal that almost 1 in 5 youth change their racial identification over a one-year period, high rates of discordance exist between the youth self-report of Native American, Hispanic and multiracial youth and how agencies categorize them, and a greater tendency for the child welfare system to classify a youth as White, as compared to school and youth themselves. Information from the study could be used to guide agencies towards a more youth-centered and flexible approach in regard to identifying, reporting and affirming youth's evolving racial and ethnic identity.     

Screening for trauma exposure, and posttraumatic stress disorder and depression symptoms among mothers receiving child welfare preventive services

The role of parental trauma exposure and related mental health symptoms as risk factors for child maltreatment for parents involved with the child welfare (CW) system has received limited attention. In particular, little is known about the extent to which mothers receiving CW services to prevent maltreatment have experienced trauma and suffered trauma-related psychopathology. This study examined screening data collected from 127 mothers receiving CW preventive services. There were high levels of trauma exposure among screened mothers and their young children. Among mothers, 91.6% experienced at least one traumatic event (M = 2.60) and 92.2% reported their children had been exposed to one or more traumas (M = 4.85). Mothers reported high levels of trauma-related symptoms: 54.3% met probable criteria for posttraumatic stress disorder (PTSD) or depression (61.7%). Nearly half (48.8%) met criteria for co-morbid PTSD and depression. The large majority of the clients with trauma-related disorders were not receiving mental health services. Latina women had significantly more severe PTSD symptoms than African American women. Case planners reported that the screening process was useful and feasible. These findings underscore the feasibility and importance of trauma screening among parents receiving CW preventive services.     

“No One Acknowledged My Loss and Hurt”: Non-death Loss,Grief, and Trauma in Foster Care

How do youth in foster care experience non-death loss? Drawing upon the theories of ambiguous loss, symbolic loss, and disenfranchised grief, this applied theoretical article integrates research findings to address how youth experience loss, grief, and trauma in foster care. Youth’s reports illustrate experiences of non-death loss, the impact of non-death loss on psychological and emotional well-being, and how non-death losses are disenfranchised and enfranchised within the foster care system. Recommendations are made that child welfare agencies consider how their practices and policies can be enhanced to meet the needs of grieving youth in foster care.     

Barriers and facilitators for access to mental health services by traumatized youth

Polytrauma is a highly prevalent public health problem in the U.S. with even higher rates in urban areas. Children with polytrauma often end up in multiple child-serving systems (e.g., mental health, child welfare, education, juvenile justice) with needs that are both complex and severe. Providers within these child-serving systems have potential to serve as gatekeepers to trauma services by linking youth with trauma-informed treatments and supports that promote recovery. The purpose of our study was to assess the perspective of providers who participated in a nine-month, trauma-informed care (TIC) training intervention on 1) their capacity to make referrals to trauma-specific services following the training, and 2) factors external to the training intervention that supported or hindered their ability to link traumatized youth with services. A subset of sixteen participants from the TIC training completed individual interviews. These participants were predominantly female, African American, and based in the social services sector. The constant comparative method was used to derive three thematic domains related to participant perceptions regarding youth referrals: 1) Organizational and provider capacity to provide trauma treatment or to make referrals to trauma-specific services, 2) Barriers to youth accessing trauma services, and 3) Suggestions for improving coordination of care and referrals. Our study highlights the influence of contextual factors on whether a TIC training can improve the capacity of agencies and individual providers to support traumatized youth in accessing appropriate services. The development of a structure that formally connects youth-serving agencies and providers with specialists trained in addressing traumatized youth is recommended.     

Sexual and reproductive health policies for foster youth in California: A qualitative study of child welfare professionals' experiences and perceptions of policies

Child welfare professionals and foster parents increasingly suggest the importance of establishing clear and consistent policies and procedures to address the sexual and reproductive health of youth in foster care. The present study examines the content and context of such policies across 18 California counties through a search of publically available county policy documents, and surveys and expert interviews with child welfare professionals (N = 22). A policy framework for agenda setting and policymaking was used to guide the data collection and analysis process. Child welfare professionals were aware of multiple sources of information, support and services for foster youths' sexual and reproductive health, though few practiced in counties with formal policies that outline the resources and support that youth should receive. Participants demonstrated widespread recognition that issues of youth sexual and reproductive health were significant; posing challenges to youth, foster parents and child welfare staff. Identified policy solutions included: 1) training for social workers and foster parents; 2) collaborative partnerships with public health nurses and community providers; 3) data tracking and monitoring of outcomes to assess youth needs and evaluate the impact of programs and policies; and 4) involvement by advocacy organizations in defining problems and advocating for improved services and support for youth in care. Social workers largely perceived that support from child welfare administrators and policy leaders is necessary to prioritize this issue and initiate policy formation. Additional research is needed to further examine the impact of policy mandates on social workers, foster parents and youth in foster care.     

A Glimpse Within: An Exploratory Study of Child Welfare Agencies’ Practices With LGBTQ Youth

This article presents findings from a national survey of agency members of the Child Welfare League of America (CWLA) with respect to organizational culture and service delivery for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth. Sixty-seven study participants provided quantitative and qualitative data via an Internet questionnaire. Overall, agencies fall short of fully subscribing to recommendations made by the CWLA. They could improve their support for providing an inclusive environment, creating supportive policies, and selecting childcare providers regardless of sexual orientation/gender identity. In addition, agencies varied with respect to the relative emphasis that services geared specifically for LGBTQ should occur. Although some progress has been made, much work remains for child welfare agencies to fully address the needs of LGBTQ youth.     

Mental health and behavioral problems of youth in the child welfare system: residential treatment centers compared to therapeutic foster care in the Odyssey Project population

This is the first multisite, prospective study of behavioral and mental health disorders of youth in residential treatment centers (RTC) and therapeutic foster care (TFC), and the first study to compare the two. This study addressed two questions in a sample of 22 agencies in 13 states: (1) how prevalent were emotional and behavioral disorders in the youth admitted to RTCs and TFC?, and (2) were the youth in RTCs significantly more likely to be disturbed than youth served in TFCs? Data were drawn from the Time 1 phase of the longitudinal national "Odyssey Project" developed by the Child Welfare League of America (1995). Measures included an extensive child and family characteristics form (CFC) and the Child Behavior Checklist (CBCL). The results revealed extremely high levels of behavioral and mental health disorders in the sample as a whole, well above the norms for a non-child welfare population. The prevalence of disorder in the RTC population was substantially greater than in the TFC population.     

Fathers matter: involving and engaging fathers in the child welfare system process

Research suggests that children with involved and engaged fathers tend to have more positive outcomes relative to physical, cognitive, and social emotional health. Of children who become involved in the child welfare system, involving multiple parents in the case (e.g. mother and father) often results in a greater chance of a child returning home, fewer placement episodes, and reduced trauma that may be caused by separation anxiety. With the rise of single parenting homes (which are mostly maternal) in the United States, child welfare agencies are examining the efficacy of engaging multiple caregivers (esp. fathers) in the child welfare process. Research suggests that in order to involve fathers in child welfare processes, practices and policies must be intentional in implementing systems and protocols that encourage involvement of all parents regardless of relationship status of the parents. However, few child welfare agencies are required to inquire about fathers or involve fathers in the child’s case. The purpose of this paper is to highlight efforts of the Connecticut Comprehensive Outcome Review (CCOR) process and discuss challenges and lessons learned from interviews and listening forums/focus groups that included social workers and fathers who are involved in the child welfare system in the state of Connecticut. Recommendations and considerations on engaging and involving fathers are discussed.     

Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network

Many children in the child welfare system (CWS) have histories of recurrent interpersonal trauma perpetrated by caregivers early in life often referred to as complex trauma. Children in the CWS also experience a diverse range of reactions across multiple areas of functioning that are associated with such exposure. Nevertheless, few CWSs routinely screen for trauma exposure and associated symptoms beyond an initial assessment of the precipitating event. This study examines trauma histories, including complex trauma exposure (physical abuse, sexual abuse, emotional abuse, neglect, domestic violence), posttraumatic stress, and behavioral and emotional problems of 2,251 youth (age 0 to 21; M = 9.5, SD = 4.3) in foster care who were referred to a National Child Traumatic Stress Network site for treatment. High prevalence rates of complex trauma exposure were observed: 70.4% of the sample reported at least two of the traumas that constitute complex trauma; 11.7% of the sample reported all 5 types. Compared to youth with other types of trauma, those with complex trauma histories had significantly higher rates of internalizing problems, posttraumatic stress, and clinical diagnoses, and differed on some demographic variables. Implications for child welfare practice and future research are discussed.     

Improving Permanency: Caseworker Perspectives of Older Youth in Another Planned Permanent Living Arrangement

Researchers conducted focus groups with 52 child welfare caseworkers across five county child welfare agencies to understand their approach to working with and views about outcomes for youth in Another Permanent Planned Living Arrangement (APPLA). Analysis of the focus groups yielded five themes, including (a) youth and family factors contributing to APPLA as a case designation, (b) caseload intensity relative to this specific population, (c) perceptions of organizational support, (d) lack of focus on legal permanency, and (e) overemphasis on independent living services. The range of viewpoints from these child welfare professionals spoke to the complexities of addressing the needs for older youth in care and to identifying strategies to improve permanency outcomes for this population. The implications for practices that account for individual, organizational, and systemic factors impacting legal permanency for older youth are discussed.     

Exploring the self-care practices of child welfare workers: A research brief

Child welfare workers experience higher rates of vicarious trauma, workplace stress, and compassion fatigue, when compared to other social service workers. Increasingly, social service agencies, in general, and child welfare agencies, specifically, recognize the importance of self-care in assuaging these problematic employee outcomes. However, research that explicitly examines the self-care practices of child welfare workers in nominal. This study brief explores the self-care practices of child welfare workers (N = 222) in one southeastern state. Results reveal that child welfare workers only engage in self-care at moderate levels. Additionally, data suggests that variables such as health status, current financial status, and relationship status significantly impact personal and professional self-care practices, respectively. After a terse review of relevant literature, this brief will explicate findings associated with this study, and identify salient discussion points and implications for child welfare training, practice, and research.     

The role of interagency collaboration in facilitating receipt of behavioral health services for youth involved with child welfare and juvenile justice

Unmet need for behavioral health care is a serious problem for crossover youth, or those simultaneously involved with the child welfare and juvenile justice systems. Although a large percentage of crossover youth are serious emotionally disturbed, relatively few receive necessary behavioral health services. Few studies have examined the role of interagency collaboration in facilitating behavioral health service access for crossover youth. This study examined associations for three dimensions of collaboration between local child welfare and juvenile justice agencies - jurisdiction, shared information systems, and overall connectivity - and youths' odds of receiving behavioral health services. Data were drawn from the National Survey of Child and Adolescent Well-Being, a national survey of families engaged with the child welfare system. Having a single agency accountable for youth care increased youth odds of receiving outpatient and inpatient behavioral health services. Inter-agency sharing of administrative data increased youth odds of inpatient behavioral health service receipt. Clarifying agency accountability and linking databases across sectors may improve service access for youth involved with both the child welfare and juvenile justice systems.     

Foster care transition services for youth with disabilities: findings from a survey of county service providers

This study explores the transition services available for youth with disabilities in foster care and the collaboration among foster care transition programs with other types of providers. Findings from this survey of independent living coordinators working for child welfare agencies indicate that while youth with disabilities are being served through transition programs and these programs collaborate with other government agencies, there are few services targeted directly toward their needs, little collaboration with community-based agencies, and a need for more information sharing.     

Young People Transitioning from Out-of-home Care in Victoria: Strengthening Support Services for Dual Clients of Child Protection and Youth Justice

Abstract

A significant proportion of young people leaving out-of-home care make their transition to independence via the youth justice system, exposing them to further risks and reducing their likelihood of full social and economic engagement in mainstream society. This article presents the initial findings of a research project based on a partnership between Monash University and seven nongovernment child and youth welfare agencies in Victoria, Australia. Seventy-seven key stakeholders participated in interviews and focus groups with a view to identifying practices and policies that could reduce the over-representation of young people leaving out-of-home care in the youth justice system. Factors that contributed to offending included varied responses by the child protection and youth justice systems, limited utility of leaving care plans, and the availability of a range of preventative and diversionary programs. The findings point to a need for more formalised interagency collaboration, and intensification of the interventions and supports offered both in custodial settings and post discharge from custody or care.