Outpatient mental health services for children in foster care: a national perspective

Discrepancies between Foster Care Entry and Mental Health Service Use for Black and Latinx Youth

Black and Latinx youth are more likely to be placed into foster care compared to non-Latinx white youth. Foster care placement can facilitate mental health service use, yet youth from marginalized and oppressed racial and ethnic groups in foster care are still less likely to receive mental health services compared to non-Latinx white youth. This study aims to examine this discrepancy Black and Latinx youth face by testing (a) whether mental health need moderates the relationship between race or ethnicity and foster care placement and (b) whether race or ethnicity moderates the relationship between foster care placement and mental health service use. Data come from the National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal national probability study of youth in contact with the child welfare system. Internalizing need was associated with a decreased likelihood of foster care placement for non-Latinx white youth compared to those with no need; findings showed the opposite for Latinx youth. Race and ethnicity did not significantly moderate the relationship between foster care placement and mental health service use, although predicted probabilities suggest that differences in mental health service use were more pronounced for Black and Latinx youth in in-home and kinship care compared to non-kinship foster care. Results suggest that despite main effects of race and ethnicity on foster care placement and mental health service use, discrepancies across these outcomes are not explained by race and ethnicity alone. Findings highlight the need to comprehensively examine predictors together, rather than separately, when assessing foster care care placement and mental health service use. A multi-pronged approach is outlined for child welfare reform.

Child protective services involvement and exclusionary school discipline

The study examined the impact of child protective services (CPS) contact on out-of-school suspensions for 49,918 Wisconsin students (followed from ages 5-6 to 14-15; [school years 2010-2019; 74% White; 7% Black; 11% Hispanic; 8% other; 49% female]). A quasi-experimental design comparing recent CPS contact to upcoming (future) CPS contact shows that both recent CPS contact without foster care and future CPS contact predict higher odds of suspension compared with no contact. Higher odds of suspension emerged prior to CPS contact and did not substantially increase during or after CPS contact, suggesting that system-induced stress is not a primary driver of behavioral problems leading to suspension. Foster care reduced the odds of suspension among White children and children in special education.

Comprehensive Health Assessment for Children in Out-of-Home Care: An Exploratory Study of Service Needs and Mental Health in a Norwegian Population

A comprehensive model for routine multi-disciplinary health assessment for children in out-of-home care was piloted in a Norwegian region. This paper reports on identified service needs and mental disorders among 196 children (0-17 years) receiving the assessment. Cross-sectional data was extracted from assessment reports. Results show needs across a range of services, with a mean of 2.8 recommended services for children aged 0-6 and 3.3 for children aged 7-17. Mental disorders were identified in 50% of younger children, and 70% of older children. For all children, overall service need was associated with mental disorders, in addition to male gender among younger children. Need for specialized mental health services was associated with mental disorders among younger children and increasing age among older children. The high frequency of service needs and mental disorders illustrate the importance of offering comprehensive health assessments routinely to this high-risk child population and necessitates coordinated service delivery.

Predisposing, Enabling, and Need Factors Associated with Psychotropic Medication and Mental Health Service Use among Children in Out-of-Home Care in the United States: A Scoping Review

This scoping review aimed to identify predisposing, enabling, and need factors associated with the use of mental health services, including psychotropic medications, among children in out-of-home care in the United States. We searched the PsycInfo, SocINDEX, Medline, and Scopus databases, and 22 studies met inclusion criteria and were systematically analyzed. Among the included studies, 7 studies examined predictors associated with taking psychotropic medications, and 16 examined factors associated with using other mental health services. Significant predisposing, enabling, and need factors associated with greater use of mental health services, including psychotropic medications, were identified. The most frequently identified predisposing factors were child race/ethnicity, age, gender, and maltreatment. Important enabling factors were out-of-home placement type and length of care, and need factors included children's mental/behavioral problems. The results provide insight into maximizing factors facilitating children's use of mental health services to address mental health problems of children in out-of-home care. Further, the results imply the importance of the appropriate use of psychotropic medication (e.g., the type and dosage of medications) among children in out-of-home care. The identified factors can inform child welfare agencies and stakeholders on ways to improve access to mental health services and the appropriate use of psychotropic medications among children in out-of-home care in the United States.

Prevalence of Mental Health Diagnoses Among Early Adolescents Before and During Foster Care

OBJECTIVE

This study aimed to characterize the rates and types of diagnosed mental health (MH) disorders among children and adolescents before and during foster care (FC) overall and by race and ethnicity.

METHODS

We used population-based linked administrative data of medical assistance (public insurance) claims records and child protective services data from a cohort of early adolescents who entered FC at 10 to 14 years old. MH diagnoses were coded according to the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9 and ICD-10) and included adjustment disorders, disruptive disorders, attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, mood disorders, attachment disorders, autism, and other disorders.

RESULTS

Before FC entry, 41% of children and adolescents had at least 1 MH diagnosis. Attention-deficit/hyperactivity disorder (25%), mood disorders (18%), and disruptive disorders (15%) were the most common pre-entry diagnoses. Among early adolescents entering FC with no previous diagnosis, 52% were later diagnosed with adjustment disorder (accounting for 73% of all youth with a new diagnosis during FC). White early adolescents had higher rates of diagnosed MH disorders before FC, whereas racial/ethnic minority early adolescents were more likely to receive a MH diagnosis during FC. Black early adolescents were more likely than White and Hispanic early adolescents to be diagnosed with disruptive disorders and less likely to be diagnosed with anxiety or adjustment disorders during FC.

CONCLUSION

Results highlight the high rates of MH needs among early adolescents before entry into FC, whether detected before or during FC. Results also illustrate disparities in pre-entry MH care between racial/ethnic minority and White early adolescents, with minority youth less likely to be receiving services before entry.

Screening and Assessment of Suicidal Behavior in Transition-Age Youth with Foster Care Involvement

Transition-age youth with foster care involvement (TAY, ages 17-22) are at heightened risk for suicidal behavior. Despite this, mental health screenings are not standardized across child welfare (CW) systems and existing assessment tools are not designed for use with this specific population. As such, TAY are unlikely to be adequately screened for suicide risk and connected with needed services. In this paper, we sought to identify screening and assessment tools that could be effective for use with TAY in CW settings. Using PubMed and PsycINFO, we conducted a search of the current literature to identify some of the most commonly used screening and assessment tools for youth. We then narrowed our focus to those tools that met predefined inclusion criteria indicating appropriateness of use for TAY in CW settings. As a result of this process, we identified one brief screening tool (the ASQ) and four assessments (the SIQ-JR, the C-SSRS, the SHBQ, and the SPS) that demonstrated specific promise for use with TAY. The strengths and limitations of the tools are discussed in detail, as well as the ways that each could be used most effectively in CW settings. We highlight three key points intended to guide social work practice and policy: (1) systematic, routine assessment of mental health and suicide risk across CW settings is critical; (2) the protocol for assessing suicidal behavior in TAY must account for the wide variations in context and service provision; and (3) CW workers administering assessments must be thoughtfully trained on risk identification and the protocol implementation.

Trajectories of mental health services for youth in foster care with attention deficit hyperactivity disorder

Youth in foster care with Attention Deficit Hyperactivity Disorder (ADHD) often have significant needs for mental health services. The degree to which youth taking medication for ADHD use mental health services in relation to sibling co-placement and their level of need over time is unclear. To examine these issues, caregivers (N = 54) provided information on youth mental health service use across an 18-month study period. Results show that siblings living apart had a higher probability of mental health service use. For youth with higher CBCL scores, probability of mental health service use was both high and stable over time. However, youth with lower CBCL scores showed a decrease in probability of mental health service use over time. The sustained commitment to receipt of mental health services among youth with ADHD is something all behavioral health providers who work with foster care involved youth can benefit from, as well as the youth themselves.

Antipsychotics in the California Foster Care System: A 10-Year Analysis

Background: In response to concerns regarding psychotropic medication prescribing, California's foster care system implemented oversight strategies to improve prescribing and monitoring practice, particularly for antipsychotics. The impact of these policies has not been evaluated. Objectives: To examine foster youth psychotropic use data in California and their relationship to national and state policy initiatives. Methods: This study analyzed 2011-2020 data curated by the California Child Welfare Indicators Project. The platform matches Medicaid medication and laboratory claims with individual-level foster youth data to report rates of dispensed psychotropic medications, authorization status, and metabolic screening. Results: In 2011, there were 78,231 California youth in foster care, of which 10,435 (13.3%) received psychotropics and 5570 (7.1%) antipsychotics. In 2020, of 68,386 foster children, 7172 (12.2%) received psychotropics and 2068 (3.0%) antipsychotics. Proper authorizations for psychotropics were obtained for 5581 (77.8%) foster youth in 2020. Of those receiving antipsychotics, 904 (43.7%) underwent metabolic screening. The greatest declines in antipsychotic use occurred between 2013 (6.7%) and 2018 (3.1%). Overall 2011 to 2020 declines were similar for males (8.5% → 3.6%, 58% reduction, p < 0.001) and females (5.5% → 2.4%, 57% reduction, p < 0.001). Regarding age and race, greater declines occurred for children <10 years (2.33% → 0.84%, 64% reduction, p < 0.001) and Latino youth (5.4% → 2.2%, 59% reduction, p < 0.001). Conclusions: Temporal patterns in antipsychotic use suggest an impact of policies and guidelines. While 12.2% of foster youth continue to receive psychotropics, there were reductions in racial/ethnic disparities and declines in antipsychotic use. Lack of adherence to authorization and metabolic screening requirements continue to be concerning.

Reunification for young children of color with substance removals: An intersectional analysis of longitudinal national data

BACKGROUND

The opioid epidemic has resulted in increasing attention to the effect of parental substance use disorders on child welfare system involvement, including foster care utilization. Opioid use disorders are more common among whites than people of color, however.

OBJECTIVE

This study sought to determine number and proportion of children of color with substance removals and whether disparities exist in likelihood of reunification compared to white children.

PARTICIPANTS & SETTING

This study used U.S. Adoption and Foster Care Analysis and Reporting System (AFCARS) data to determine rates of foster care entries and outcomes between 2007-2017 across intersections of child race/ethnicity, age, and substance removal status.

METHODS

Survival analyses were employed to test the primary research questions.

RESULTS

During the 10 year period observed, the number and proportion of white children with substance removals (ages 0-4 and 5+) in foster care increased two- to three-fold compared to children of color with substance removals depending on child age. However, children of color, particularly ages 0-4, faced disadvantages respecting foster care outcomes. Results of the multivariate proportional hazards models revealed that reunification was significantly and substantially more likely for every group compared to young (0-4) children of color with substance removals. Further probing revealed that racial disparities were driven primarily by Black/African American children.

CONCLUSIONS

Children of color with substance removals, particularly Black/African American children, are at higher risk of poor child welfare outcomes compared to their white peers.

A Positive Youth Development Approach to Improving Mental Health Outcomes for Maltreated Children in Foster Care: Replication and Extension of an RCT of the Fostering Healthy Futures Program

Preventing the negative impact of maltreatment on children's mental health requires interventions to be contextually sensitive, grounded in theory and research, and effective in reaching and retaining children and families. This study replicates and extends previous findings of the Fostering Healthy Futures (FHF) program, a 30-week mentoring and skills group intervention for preadolescent maltreated children in foster care. Participants included 426 children recently placed in out-of-home care who were randomized to intervention or control conditions. Outcomes measured 6-10 months postintervention included a multi-informant (child, caregiver, teacher) index of mental health problems as well as measures of posttraumatic stress symptoms, dissociative symptoms, quality of life, and use of mental health services and psychotropic medications. There were high rates of program initiation, retention, and engagement; 95% of those randomized to FHF started the program, 92% completed it, and over 85% of the mentoring visits and skills groups were attended. The FHF program demonstrated significant impact in reducing mental health symptomatology, especially trauma symptoms, and mental health service utilization. These program effects were consistent across almost all subgroups, suggesting that FHF confers benefit for diverse children. Results indicate that positive youth development programming is highly acceptable to children and families and that it can positively impact trauma and its sequelae.

Health-Care Utilization Patterns of Maltreated Youth

To examine in detail the health-care utilization patterns of maltreated children, we studied electronic health records (EHRs) of children assigned maltreatment-related codes in a large medical system. We compared youth with maltreatment-related diagnoses (N = 406) with those of well-matched youth (N = 406). Data were based on EHRs during a 4-year period from the University of Minnesota's Clinical Data Repository, which covers eight hospitals and over 40 clinics across Minnesota. A primary care provider (PCP) was assigned to over 80% of youth in both groups. As expected, however, the odds of not having a PCP were twice as high in the maltreated as in the comparison group. Also as expected, maltreated youth had higher rates of emergency department visits. We ruled out differences in age, gender, race, public insurance, duration in the medical system, type of specialty department, and clinic location as potential explanations for these differences. On the other hand, there were no significant differences between maltreated and comparison youth in hospitalizations, preventive visits, or office visits. Contrary to expectations, maltreated youth were not in the medical system for just a brief period of time and were not more likely to cancel or miss appointments. The current study adds to the research literature by providing more detailed information about the nature of health-care services used by children with maltreatment-related diagnoses.

Caseworker assessment of child risk and functioning and their relation to service use in the child welfare system

Children within the child welfare system are more likely to experience emotional and behavioral problems than children not involved with the system. Many states have adopted standardized risk and assessment measures to inform decision-making on appropriate levels of care related to placement or service intensity for children within the system. This study examined the relationship of caseworker ratings of risk across multiple domains to youth functioning and service use for a sample of children open to the child welfare system. The study identified a stratified random sample of youth who were between the ages of five and 21 and open to the child welfare system (n = 184). Stratification was based on current placement (i.e., in-home, foster home, congregate care, and juvenile justice placements). Administrative data was used to access caseworker ratings of risk across child, parent, and family domains using a standardized risk assessment tool. Children's caseworkers (n = 103) completed a standardized measure of child functioning and reported on youth utilization of services across multiple sectors including specialty mental health, school-based, juvenile justice, and medical settings. Regression analyses using variance-corrected estimation for clustered data (by caseworker) revealed higher levels of child risk were associated with poorer child functioning, which, in turn, were associated with higher rates of multi-sector service use. Recommendations and future directions are discussed.

Background, experience of abuse, and mental health among adolescents in out-of-home care: a cross-sectional study of a Swedish high school national sample

PURPOSE

To compare experiences for adverse events, especially sexual abuse, and mental health in a group of high school students in out-of-home care with a representative sample of peers of the same age and similar educational attainment living with their parents.

MATERIALS AND METHODS

A sample of 5839 students in the third year of Swedish high school, corresponding to a response rate of 59.7%, answered a study specific questionnaire. Data from 41 students living in out-of-home care were compared with data from peers not in out-of-home care in a cross-sectional analyze.

RESULTS

Students in out-of-home care had more often an immigrant background and a non-heterosexual orientation, had more often experienced physical and penetrative sexual abuse, and more often sought healthcare for mental problems. Disclosure of sexual abuse was less common, and acts of persuasion or adults' use of their social position was more common among students in out-of-home care.

CONCLUSIONS

Even where the protective factor 'senior educational attainment' is present, risks for abuse and poor mental health are evident for adolescents in out-of-home care. Disclosure of adversity, when it has occurred, ought to be higher among these adolescents with regular contact with social services, but our findings indicate tendencies for the opposite. We therefore suggest routines to be established to screen for adverse life events and mental health actively, along with general and systematic assessments of adversity and mental health during care.

Associations of specific and multiple types of childhood abuse and neglect with personality pathology among adolescents referred for mental health services

The present study investigated the unique association between five types of childhood abuse and neglect and 18 lower-order dimensions of personality pathology, and using latent classes analysis (LCA) explored patterns of childhood abuse or neglect experiences. Further differences across latent classes on personality pathology traits, personality disorder symptom count and a diagnosis of personality disorder were examined. Participants were 178 adolescents and young adults (12-22 years; M = 16.02, 65.7% girls; 83% Axis I/II disorder) from the Netherlands referred for mental health services. Emotional abuse was uniquely associated with 11 personality pathology traits; sexual and physical were associated with three and four traits, respectively. LCA yielded three classes, namely, severe maltreatment (class 1), low-moderate emotional maltreatment and sexual abuse (class 2), and least maltreatment (class 3). After controlling for age, gender, presence of any Axis I disorder, multivariate analysis of covariance indicated that classes with more types of maltreatment experiences and higher severity (classes 1 and 2) endorsed more personality pathology traits, personality disorder symptom counts and a diagnosis of a personality disorder than the least maltreatment class. Findings have theoretical and clinical implications entailing the identification of patterns of maltreatment types and related personality pathology traits among youth.

Services according to mental health needs for youth in foster care? - A multi-informant study

BACKGROUND

Foster children have a high risk of mental disorders. This has contributed to increased international attention to service utilization for youth in foster care. The aim of this study is to examine whether youth in foster care receive services according to need, by using a multi-informant design.

METHOD

Detailed information on the type and frequency of service use during the last 2 years and on youth mental health were collected from foster youths and their carers in Norway (n = 405, aged 11-17 years) through online questionnaires. Mental health was assessed with the Strengths and Difficulties Questionnaire. Statistical analyses were conducted using descriptive statistics and log-binominal regressions.

RESULTS

In total, 48.8% of foster youths showed evidence of mental health problems, and 74.5% of foster families had contact with services. Increased mental health problems and living in non-kin foster care were associated with more service use. Youths with mental health problems had twice the probability of receiving services from the child and adolescent mental health service (CAMHS) and primary health care services compared to youths without problems. However, 57.0% of youths with carer-reported mental health problems did not have contact with CAMHS.

CONCLUSIONS

Service use among foster youths was associated with service need rather than demographic and placement characteristics. The majority of youths with mental health problems did not receive services from CAMHS. However, many of them were in contact with primary health care services.

Usual Care for Maltreatment-Related Pediatric Posttraumatic Stress Disorder in Germany

Child maltreatment represents a major risk factor for the development of emotional and behavioral problems, especially posttraumatic stress disorder (PTSD). While effective trauma-focused treatments are available, little is known about the usual mental healthcare for abused youths in Germany. The present study compared the utilization of mental healthcare in abused youths who had developed a PTSD (N = 95) with a group presenting other mental disorders (N = 146). Semistructured interviews were used to assess maltreatment histories, current mental health, and healthcare utilization. In addition, potential child factors associated with access to mental healthcare (age and level of functioning) were examined. Results showed that 65 % of both diagnostic groups currently fail to use any mental healthcare service. Of the participants with PTSD, 43 (45 %) had never received any mental healthcare intervention. Investigations on potential barriers are necessary to close the huge gap between clinical services and evidence-based, trauma-focused interventions.

Trajectories of post-traumatic stress and externalizing psychopathology among maltreated foster care youth: A parallel process latent growth curve model

Few longitudinal studies have analyzed how violence exposure (e.g. child maltreatment, witnessing community violence) influence both externalizing and Post-Traumatic Stress (PTS) symptoms among children in foster care. Data from three waves of the National Survey of Child and Adolescent Well-Being (1999-2007) (NSCAW; National Data Archive on Child Abuse and Neglect, 2002) were analyzed to investigate the change trajectories of both externalizing and PTS symptomatology among children with a substantiated report of child maltreatment by Child Protective Services (CPS) between October 1999 and December 2000. This study uses data collected at three time points: baseline and approximately 18 (Wave 3) and 36 (Wave 4) months post-baseline. The Child Behavior Checklist (CBCL) scale measured externalizing symptoms and the Post Traumatic Stress Disorder section of a version of the Trauma Symptom Checklist for Children (TSCC) provided the measure of current trauma-related symptoms or distress. Analyses were conducted using a parallel process growth curve model with a sample of n=280 maltreated youth between the ages of 8 and 15 following home removal. Findings revealed that initial levels of externalizing and PTS symptomatology were both significantly and positively related and co-develop over time. Externalizing symptom severity remained in the borderline range during the first two years in out-of-home care. Both direct and indirect forms of interpersonal violence exposure were associated with initial level of externalizing symptom and PTS symptom severity, respectively. Taken together, our results suggest an underlying process that links early violence exposure to the co-development and cumulative impact of PTS on externalizing behavior above and beyond experiences of maltreatment. We conclude by discussing the key points of intervention that result from a more nuanced understanding of the longitudinal relationship between PTS and externalizing symptoms and the effect of complex trauma on growth in these symptoms over time.

Utilization of Mental Health Services and Mental Health Status Among Children Placed in Out-of-Home Care: A Parallel Process Latent Growth Modeling Approach

This longitudinal study examined the parallel trajectories of mental health service use and mental health status among children placed in Florida out-of-home care. The results of growth curve modeling suggested that children with greater mental health problems initially received more mental health services. Initial child mental health status, however, had no effect on subsequent service provision when all outpatient mental health services were included. When specific types of mental health services, such as basic outpatient, targeted case management, and intensive mental health services were examined, results suggested that children with compromised functioning during the baseline period received more intensive mental health services over time. However, this increased provision of intensive mental health services did not improve mental health status, rather it was significantly associated with progressively worse mental health functioning. These findings underscore the need for regular comprehensive mental health assessments focusing on specific needs of the child.

Youth with Behavioral Health Disorders Aging Out of Foster Care: a Systematic Review and Implications for Policy, Research, and Practice

This systematic review aimed to (1) identify and summarize empirical studies on youth with behavioral health disorders aging out of foster care and (2) address implications for behavioral health policy, research, and practice. We identified previous studies by searching PubMed, PsycINFO, EBSCO, and ISI Citation Indexes and obtaining references from key experts in the child welfare field. A total of 28 full articles published between 1991 and 2014 were reviewed and summarized into the key areas including systems of care, disability type, transition practice area, study methods, study sample, transition outcome measures, study analysis, and study findings. Considering how fast youth who have behavioral health disorders fall through the crack as they exit foster care, one cannot understate the importance of incorporating timely and appropriate transition planning and care coordination for youth who have behavioral health disorders aging out of foster care into the usual case management performed by behavioral health systems and service providers.

Mental Health, Behavioral and Developmental Issues for Youth in Foster Care

Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.

Practice parameter for the assessment and management of youth involved with the child welfare system

This Practice Parameter presents principles for the mental health assessment and management of youth involved with the child welfare system. Important definitions, background, history, epidemiology, mental health care use, and functional outcomes are described. Practical guidance regarding child welfare-related considerations for evaluation and management are discussed.

Trends in psychotropic polypharmacy among youths enrolled in Ohio Medicaid, 2002-2008

OBJECTIVE

This study examined polypharmacy patterns and rates over time among Medicaid-enrolled youths by comparing three enrollment groups (youths in foster care, with a disability, or from a family with low income).

METHODS

Serial cross-sectional trend analyses of Medicaid claims data were conducted for youths age 17 and younger who were continuously enrolled in Ohio Medicaid for a one-year period and prescribed one or more psychotropic medications during fiscal years 2002 (N=26,252) through 2008 (N=50,311). Outcome measures were any polypharmacy (three or more psychotropic medications from any drug class) and multiclass polypharmacy (three or more psychotropic medications from different drug classes).

RESULTS

Both types of polypharmacy increased across all three eligibility groups. Any polypharmacy increased from 8.8% to 11.5% for low-income youths (adjusted odds ratio [AOR]=1.12, 99% confidence interval [CI]=1.10-1.13), from 18.0% to 24.9% for youths with a disability (AOR=1.11, CI=1.09-1.13), and from 19.8% to 27.3% for youths in foster care (AOR=1.09, CI=1.07-1.11). Combinations associated with positive increases were two or more antipsychotics, two or more stimulants, and antipsychotics with stimulants.

CONCLUSIONS

Polypharmacy increased across all enrollment groups, with the highest absolute rates for youths in foster care. Both the overall prevalence and increases in prescriptions for drug combinations with limited evidence of safety and efficacy, such as the prescription of two or more antipsychotics, underscore the need for targeted quality improvement efforts. System oversight and monitoring of psychotropic medication use appears to be warranted, especially for higher-risk groups, such as youths in foster care and those from low-income households who were prescribed multiple antipsychotics.

Engaging foster parents in treatment: a randomized trial of supplementing trauma-focused cognitive behavioral therapy with evidence-based engagement strategies

The goal of this study was to examine the impact of supplementing Trauma-focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2006) with evidence-based engagement strategies on foster parent and foster youth engagement in treatment, given challenges engaging foster parents in treatment. A randomized controlled trial of TF-CBT standard delivery compared to TF-CBT plus evidence-based engagement strategies was conducted with 47 children and adolescents in foster care and one of their foster parents. Attendance, engagement, and clinical outcomes were assessed 1 month into treatment, end of treatment, and 3 months post-treatment. Youth and foster parents who received TF-CBT plus evidence-based engagement strategies were more likely to be retained in treatment through four sessions and were less likely to drop out of treatment prematurely. The engagement strategies did not appear to have an effect on the number of canceled or no-show sessions or on treatment satisfaction. Clinical outcomes did not differ by study condition, but exploratory analyses suggest that youth had significant improvements with treatment. Strategies that specifically target engagement may hold promise for increasing access to evidence-based treatments and for increasing likelihood of treatment completion.

Should child obesity be an issue for child protective services? A call for more research on this critical public health issue

Given the lasting effects on adolescent and adult health, childhood obesity is a major public health issue. The relatively slow progress toward the prevention and treatment of childhood obesity, however, has prompted leaders in both academic and practice sectors to advocate for what may be considered a radical intervention approach, to conceptualize extreme child obesity as an issue of child maltreatment. Advocates of this approach suggest that this conceptualization affords a new angle for intervention-the involvement of child protective services (CPS) in mandating family-focused lifestyle changes aimed at reducing child overweight and, in the most extreme cases, the removal of the obese child from the home. However, surprisingly little research has been conducted to inform policies or practices consistent with this recommendation, which is already being implemented in some states. This article aims to provide an overview of the challenges to the prevention and treatment of childhood obesity that have motivated the call for CPS involvement in extreme cases and to review the existing research related to this approach. Given that relatively little data are currently available to support or refute the merits of CPS involvement, recommendations for future research that would better inform public policy and decision making regarding this and other intervention strategies are also highlighted.

Improving foster parent engagement: using qualitative methods to guide tailoring of evidence-based engagement strategies

This qualitative study examined applicability and need for tailoring of an evidence-based engagement intervention, combined with Trauma-Focused Cognitive Behavioral Therapy, for foster parents. Qualitative methods were used, including individual interviews with participating foster parents (N = 7), review of interview findings with an independent group of foster parents (N = 5), and review of the combined foster parent findings by child welfare caseworkers (N = 5), an important stakeholder group. The engagement intervention, with its primary focus on perceptual barriers (e.g., past experiences with mental health), was relevant for the foster care population. However, the study identified areas for tailoring to better recognize and address the unique needs and situation of foster parents as substitute caregivers. Perceptually focused engagement interventions may have broad applicability to a range of populations, including foster parents, with the potential for improving caregiver participation in children's mental health services.

Suicidality among preadolescent maltreated children in foster care

This study sought to determine the prevalence of suicidal ideation, plans, and attempts among 515 preadolescent (aged 9-11 years) maltreated children who entered foster care within the prior year. Over a quarter (26.4%) of the children had a history of suicidality according to their own and/or their caregiver's report, 4.1% of whom were imminently suicidal. In bivariate analyses, children at higher risk of suicidality tended to be younger, non-Hispanic, abused, and to have experienced multiple types of maltreatment, more referrals to child welfare, more household transitions, and a longer length of time in foster care. There were no gender differences. Multiple regression analyses found physical abuse and chronicity of maltreatment to be the most robust predictors of suicidality. It is critically important that these high-risk children are screened for suicidality before adolescence and that caregivers and professionals are informed of their risk status so that they may implement mental health treatment, monitoring, and harm reduction measures.

A learning collaborative supporting the implementation of an evidence-informed program, the "4Rs and 2Ss for children with conduct difficulties and their families"

In this qualitative study the authors examine factors associated with the successful implementation and plans for continued use of an evidence-informed intervention, the 4Rs and 2Ss Program for Strengthening Families, in a sample of 29 New York State, Office of Mental Health licensed child mental health clinics. A learning collaborative (LC) approach was used as a vehicle for supporting training and implementation of the program. The PRISM theoretical framework ( Feldstein & Glasgow, 2008 ) was used to guide the data analysis. Data were analyzed using a multi-phase iterative process, identifying influences on implementation at multiple levels: the program (intervention), the external environment, implementation and sustainability infrastructure, and recipient characteristics. Clinics that were more proactive evidenced staff with advanced organizational skills were able to take advantage of the trainings and supports offered by the LC and fared better in their ability to adopt the intervention. The ability to adapt the intervention to the specific constraints of the clinics was a strong influence on continued use following the end of the LC. These preliminary results suggest that the supports provided by the LC are useful in consolidating information about the process of implementing evidence-informed interventions in community mental health settings. The impact of these supports is also based on their interactions with specific clinic contextual factors.

Mental disorders in foster children: a study of prevalence, comorbidity and risk factors

BACKGROUND

The aim of this study is to examine the prevalence of mental disorders in 6- to 12-year-old foster children and assess comorbidity and risk factors.

METHODS

Information on mental health was collected from foster parents and from teachers using Developmental and Well-Being Assessment (DAWBA) Web-based diagnostic interview. Child welfare services provided information about care conditions prior to placement and about the child's placement history.

RESULTS

Diagnostic information was obtained about 279 (70.5%) of 396 eligible foster children. In total, 50.9% of the children met the criteria for one or more DSM-IV disorders. The most common disorders were grouped into 3 main diagnostic groups: Emotional disorders (24.0%), ADHD (19.0%), and Behavioural disorders (21.5%). The comorbidity rates among these 3 main groups were high: 30.4% had disorders in 2 of these 3 diagnostic groups, and 13.0% had disorders in all 3 groups. In addition, Reactive attachment disorder (RAD) was diagnosed in 19.4% of the children, of whom 58.5% had comorbid disorders in the main diagnostic groups. Exposure to violence, serious neglect, and the number of prior placements increased the risk for mental disorders.

CONCLUSIONS

Foster children in Norway have a high prevalence of mental disorders, compared to the general child population in Norway and to other societies. The finding that 1 in 2 foster children presented with a mental disorder with high rates of comorbidity highlight the need for skilled assessment and qualified service provision for foster children and families.

Immediate Effects of a School Readiness Intervention for Children in Foster Care

RESEARCH FINDINGS

School readiness is a strong predictor of adjustment in elementary school and beyond. Children in foster care are at particular risk for academic and social difficulties in school. Limitations in self-regulatory skills and caregiver involvement among these children might contribute to a lack of school readiness. This study presents the immediate effects on school readiness of a targeted, short-term intervention designed to improve children's early literacy, prosocial, and self-regulatory skills during the summer before kindergarten entry: Kids in Transition to School (KITS). Using a randomized controlled trial design, 192 children in foster care were assigned to either an intervention or services as usual comparison condition. Multimethod, multiagent assessments were conducted immediately prior to and following the completion of the intervention. The results from structural equation modeling indicated that the intervention had significant, positive effects on early literacy and self-regulatory skills.

PRACTICE

An efficacious, short-term, readily scalable, theoretically-based intervention targeted at specific vulnerabilities for children in foster care may help to improve their school readiness and eventual school adjustment.

Rationale for a New Direction in Foster Youth Substance Use Disorder Prevention

BACKGROUND

Of the 463,000 children residing in United States foster care, 29,000 annually exit the system because they have "aged out," are thus dropped from supportive services, and become responsible for their own housing, finances, and health needs. Given histories of maltreatment, housing instability, and parental substance use, youth preparing to exit care are at substantial risk of developing substance use disorders. Unfortunately, access to services is often limited, both before and after exit from care.

METHODS

With the goal of developing a relevant substance use intervention for these youth, focus groups were conducted with foster care staff, administrators, and parents to assess the feasibility of potential approaches.

RESULTS

Participants identified several population-specific barriers to delivering adapted intervention models developed for normative populations. They expressed concerns about foster youth developing, then quickly ending, relationships with interventionists, as well as admitting to substance use, given foster care program sanctions for such behavior. Group members stressed the importance of tailoring interventions, using creative, motivational procedures.

CONCLUSIONS

Foster youth seem to encounter unique barriers to receiving adequate care. In light of these results, a novel, engaging approach to overcoming these barriers is also presented.

Early school engagement and late elementary outcomes for maltreated children in foster care

Children with a history of maltreatment and placement into foster care face elevated risks of poor psychosocial outcomes including school failure, substance use, externalizing, and deviant peer association. For children in the general population, school engagement appears to be a promotive factor in preventing negative outcomes. In this study, differences in 3 dimensions of school engagement (behavioral, affective, and cognitive) in early elementary school were explored in maltreated children in foster care (n = 93) and a community comparison group of low-socioeconomic status, nonmaltreated children (n = 54). It was also hypothesized that these 3 dimensions of school engagement would mediate the association between being maltreated and in foster care and several outcomes in late elementary school (Grades 3-5): academic competence, endorsement of substance use, externalizing behaviors, and deviant peer association. Measures were multimethod and multi-informant. Results showed that the children in foster care had lower affective and cognitive school engagement than children in the community comparison group. Structural equation modeling revealed that both affective and cognitive school engagement mediated the association between group status and academic competence in late elementary school. Cognitive engagement also mediated the association between group status and engagement in risk behaviors. The identification of dimensions of early school engagement that predict later outcomes suggests potential points of intervention to change trajectories of academic and behavioral adjustment for maltreated children in foster care.

Mental Health and Substance Use Disorders among Foster Youth Transitioning to Adulthood: Past Research and Future Directions

At a time when there is increasing attention being given to systematically integrating the well-being of children with the goals of safety and permanence in child welfare, little is known about the psychosocial functioning of foster youth transitioning to adulthood from substitute care. This article systematically reviews 17 peer-reviewed articles and/or research reports to identify lifetime and past year prevalence rates of mental health disorders and service utilization. At ages 17 or 18, foster youth are 2 to 4 times more likely to suffer from lifetime and/or past year mental health disorders compared to transition aged youth in the general population. Findings show that mental health service use declines at ages when the prevalence rate of mental health disorders is peaking. The findings of this review suggest the need to focus future efforts in three main areas: 1) Setting a common research agenda for the study of mental health and service use; 2) Routine screening and empirically supported treatments; and 3) Integration and planning between child and adult mental health service systems.

Mental health service use by youths in contact with child welfare: racial disparities by problem type

OBJECTIVE

This study examined racial disparities in mental health service use by problem type (internalizing versus externalizing) for youths in contact with the child welfare system.

METHODS

Participants included 1,693 non-Hispanic white, African-American, and Hispanic youths (ages four to 14) from the National Survey of Child and Adolescent Well-Being, a national probability study of youths who were the subject of investigations of maltreatment by child welfare agencies. Mental health need, assessed at baseline, was considered present if the youth had internalizing or externalizing scores in the clinical range on either the Child Behavior Checklist or the Youth Self-Report. Out patient mental health service use in the subsequent year was assessed prospectively.

RESULTS

Children who were removed from the home and those investigated for abuse (versus neglect) were more likely to receive services in the year after the child welfare investigation. Overall, African-American youths were less likely than non-Hispanic white youths to receive mental health services. However, race-ethnicity moderated the association between externalizing need and service use such that African Americans were more likely to receive services when externalizing need was present (26% versus 4%) compared with non-Hispanic white youths (30% versus 14%). Race and ethnicity did not moderate the association between youth internalizing need and service use, but internalizing need was associated with increased probability of service use only for non-Hispanic white youths.

CONCLUSIONS

Examinations of overall racial disparities in service use may obscure important problem specific disparities. Additional research is needed to identify factors that lead to disparities and to develop strategies for reducing them.

An Examination of Exposure to Traumatic Events and Symptoms and Strengths for Children Served in a Behavioral Health System of Care

The present study examined how exposure to traumatic events impacts children with severe emotional disturbance who are being served in a school-based system of care. Multilevel growth curve models were used to examine the relationships between a child's history of traumatic events (physical abuse, sexual abuse, or domestic violence) and behavioral and emotional strengths, internalizing problem behaviors, or externalizing problem behaviors over 18 months. Results indicate that children receiving services (N = 134) exhibited increased emotional and behavioral strengths and decreased internalizing and externalizing problem behaviors from enrollment to 18 months follow-up. Children with a history of traumatic events improved more slowly than children without such a history on both strengths and internalizing problem behaviors, even after controlling for dosage of services received and other characteristics previously found to predict outcomes. Gender was also related to improvement in internalizing symptoms. Results highlight the continued need to assess the impact of exposure to traumatic events for children served in a system of care.

Behavior problems, foster home integration, and evidence-based behavioral interventions: What predicts adoption of foster children?

OBJECTIVES

Adoption is particularly important for foster children with special mental health needs who are unable to return home, as adoption increases parental support often critically needed by youth with mental health issues. Unfortunately, significant behavior problems frequently inhibit foster parents from adopting, and little is known about factors that predict adoption when a child has behavior problems. Previous research suggests that foster parent behavioral training could potentially increase rates of successful adoptions for pre-school-aged foster children with behavior problems (Fisher, Kim, & Pears, 2009), but this has not been previously tested in older samples. In older children, effective treatment of behavior problems might also increase adoption by reducing the interference of behavior problems and strengthening the child's foster home integration. This pilot study focused on this question by testing associations between behavior problems, foster home integration, an evidence-based foster parent intervention, and adoption likelihood.

METHODS

This study used an intent-to-treat design to compare foster home integration and adoption likelihood for 31 foster children with histories of abuse and neglect whose foster parents received a foster behavioral parenting intervention (see Chamberlain, 2003) or usual services. Random effect regression analyses were used to estimate outcomes across four time points.

RESULTS

As expected, externalizing behavior problems had a negative effect on both integration and adoption, and foster home integration had an independent positive effect on adoption. Internalizing behavior problems (e.g., depression/anxiety) were not related to adoption or integration. However, the intervention did not have a direct effect on either foster home integration or adoption despite its positive effect on behavior problems.

CONCLUSIONS

Results from this preliminary study provide further evidence of the negative effect of externalizing behavior problems on adoption. Its findings also suggest that foster home integration is an important dimension of foster home adaptation that appears particularly relevant to chances for adoption. While behavior problems appear to weaken foster home integration, integration is also an independent predictor of adoption likelihood. If these results are replicated in a larger study, consideration of foster home integration in case planning and future intervention studies focused on increasing permanency could potentially improve outcomes for foster children with behavior problems.

Child welfare caseworkers as service brokers for youth in foster care: findings from project focus

Youth in the foster care system have substantially higher rates of mental health needs compared to the general population, yet they rarely receive targeted, evidence-based practices (EBPs). Increasingly emerging in the literature on mental health services is the importance of "brokers" or "gateway providers" of services. For youth in foster care, child welfare caseworkers often play this role. This study examines caseworker-level outcomes of Project Focus, a caseworker training and consultation model designed to improve emotional and behavioral outcomes for youth in foster care through increased linkages with EBPs. Project Focus was tested through a small, randomized trial involving four child welfare offices. Caseworkers in the Project Focus intervention group demonstrated an increased awareness of EBPs and a trend toward increased ability to identify appropriate EBP referrals for particular mental health problems but did not have significantly different rates of actual referral to EBPs. Dose of consultation was associated with general awareness of EBPs. Implications for practice and outcomes for youth are discussed.

Mental health services expenditures among children placed in out-of-home care

This study examined Florida Medicaid mental health expenditures for children in out-of-home care. Child welfare and Medicaid administrative databases were analyzed using two-part models to identify characteristics associated with expenditures. Mental health expenditures were higher for older children, boys, children who were abused or lost their caregivers, or with a longer length of stay in out-of-home care. In contrast, African American children were less likely to have positive expenditures than White children, but among youth with positive expenditures, African Americans had higher expenditures. In addition, among youth with positive expenditures, substance use and affective disorders were associated with higher expenditures.

Predicting resilience in sexually abused adolescents

This research examined factors that predicted resilience in sexually abused adolescents. Using Bronfenbrenner's Process-Person-Context-Time (PPCT) ecological model, this study considered the proximal and distal factors that would contribute to adolescents' reactions to sexual victimization. This correlational study used hierarchical regression analysis (n=237) with cross-sectional data from the National Survey of Child and Adolescent Well-Being Wave I (NSCAW, Dowd et al., 2002). This study found that school engagement, caregiver social support, hope and expectancy, caregiver education and SES predicted resilience. In line with the PPCT model, findings suggest that placing a greater emphasis on the contextual environment could improve support for adolescent resilience. Augmenting interventions that focus on individual change with those that address environmental factors may increase the benefits to adolescents affected by sexual abuse.

Use and quality of mental health services for Haitian youth

OBJECTIVE

To describe the mental health service use of Haitian, African-American, and non-Latino White youth in a community mental health setting. Groups are compared on adherence to treatment guidelines for attention-deficit/hyperactivity disorder (ADHD) and depressive disorders.

DESIGN

Retrospective review of outpatient mental health charts (n = 252) from five community sites in an urban area of the Northeastern United States. We recorded the total number and treatment type of sessions during the first six months of treatment. Guideline-adherent treatments were compared and predicted after controlling for clinical need.

RESULTS

Most Haitian and African-American youth stopped treatment by six months, with the majority attending less than eight sessions. One third of Haitian and African-American patients attended just one session. Haitian patients who presented with less severe symptoms and dysfunction were more likely to have single-session treatments. Guideline-adherent treatment for ADHD and depression was less likely for Haitians. Older patients were more likely to receive adequate depression treatment. Haitian youth were relatively underinsured, had more family separations documented, and received Adjustment Disorder diagnoses more often.

CONCLUSIONS

Haitian youth use outpatient mental health services in similar proportion to African-American youth and at lower rates than White youth. Guideline-adherent treatment for ADHD and depression is limited by low retention in care for Black youth. Low insurance coverage is likely an important contributor to reduced use of services, especially for Haitians. These findings are discussed in the context of providing culturally sensitive mental health care to diverse communities.

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) 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.

Trauma in early childhood: Empirical evidence and clinical implications

Children in the birth to 5 age range are disproportionately exposed to traumatic events relative to older children, but they are underrepresented in the trauma research literature as well as in the development and implementation of effective clinical treatments and in public policy initiatives to protect maltreated children. Children from ethnic minority groups and those living in poverty are particularly affected. This paper discusses the urgent need to address the needs of traumatized young children and their families through systematic research, clinical, and public policy initiatives, with specific attention to underserved groups. The paper reviews research findings on early childhood maltreatment and trauma, including the role of parental functioning, the intergenerational transmission of trauma and psychopathology, and protective contextual factors in young children's response to trauma exposure. We describe the therapeutic usefulness of a simultaneous treatment focus on current traumatic experiences and on the intergenerational transmission of relational patterns from parent to child. We conclude with a discussion of the implications of current knowledge about trauma exposure for clinical practice and public policy and with recommendations for future research.

Mixed method designs in implementation research

This paper describes the application of mixed method designs in implementation research in 22 mental health services research studies published in peer-reviewed journals over the last 5 years. Our analyses revealed 7 different structural arrangements of qualitative and quantitative methods, 5 different functions of mixed methods, and 3 different ways of linking quantitative and qualitative data together. Complexity of design was associated with number of aims or objectives, study context, and phase of implementation examined. The findings provide suggestions for the use of mixed method designs in implementation research.

Advancing prediction of foster placement disruption using Brief Behavioral Screening

OBJECTIVE

Behavioral difficulties increase the risk that children will experience negative placement disruptions while in foster care. Chamberlain et al. (2006) found that the Parent Daily Report (PDR), a brief measure of parent-reported child behaviors, was a strong predictor of negative placement changes over 1 year among children receiving "usual case work" services. This paper sought to replicate and extend original findings regarding the PDR among 359 foster parents participating in a group parent-training intervention.

METHODS

Foster parents of children experiencing a recent foster placement, and taking part in the KEEP parenting program, were included in analyses. Foster parents completed 16 weekly PDR calls about the behavior of a foster child in their care during the KEEP intervention and about their stress related to the child's behaviors. Multiple strategies, including latent class analysis of weekly PDR counts and continuous moving averages of PDR counts over shorter time frames, were used to test improvements in prediction of negative placement changes.

RESULTS

Consistent with prior findings, children with elevated PDR ratings and children living with non-relative foster parents had significantly higher levels of negative placement disruptions. Prediction improved with decision rules relying upon increased amounts of weekly PDR information, although good prediction was achieved with 3-5 weeks of PDR information. Parent-reported stress associated with behavior did not improve prediction.

CONCLUSIONS

This study confirmed the potential utility of the PDR as a predictor of negative placement changes and illustrates how longitudinal PDR information may aid in improving such prediction. Potential applications of the PDR for improving the timing, type, and quantity of services offered to help foster parents prevent placement disruptions are discussed.

A national study of the impact of outpatient mental health services for children in long-term foster care

Despite the tremendous mental health need evidenced by children in foster care and high rates of use of mental health services among children in foster care, little is known about the impact of outpatient mental health services on the behavioral health of this population. This study utilizes data from the National Survey of Child and Adolescent Well-being (NSCAW), the first nationally representative study of child welfare in the United States. A subsample of 439 children who have experienced long-term foster care were included in this study. These data were used to estimate the impact of outpatient mental health services on the externalizing and internalizing behavior problems of children in long-term foster care. A propensity score matching model was employed to produce a robust estimate of the treatment effect. Results indicate that children who have experienced long-term foster care do not benefit from the receipt of outpatient mental health services. Study results are discussed in the context of earlier research on the quality of mental health services for children in foster care.

Concordance of mental health impairment and service utilization among children in care

This paper describes caregiver-reported patterns of mental health service use for 347 pre-adolescent children in foster and kinship care in New South Wales (NSW), Australia. Children's mean time in care and mean time with their present caregivers were 4.3 and 3.3 years respectively. Forty-four percent of children received individual therapy or counselling, 45% received interventions in the form of clinical guidance for their caregivers, and 31% received both forms of service. Among children scoring in the clinical range on any CBCL sub-scale (N = 191), equivalent rates of mental health service use were 60%, 55% and 41% respectively. Although not directly comparable, these findings describe a higher rate of service use than that reported for children in care elsewhere. While children with more complex and severe difficulties had higher rates of service use, there was no evidence of variable access for treatment of different types of disorder. Predictors of service use are reported and contrasted with previous findings. The paper considers several features of the NSW child welfare, health and education systems that may account for the relatively high rate of service use.