Predictors of outpatient mental health service use--the role of foster care placement change

Mental health service use of young people in child welfare services in Quebec, Canada

Background

Youth involved in child welfare have high rates of mental health problems and are known to receive mental health services from multiple settings. Still, gaps remain in our understanding of service use patterns across settings over the course of youth's involvement with child welfare.

Objective

To examine the settings, reasons for contact, persons involved in initiating care, and timing of each mental health service contact for individuals over their involvement with the child welfare system, and to identify factors that predict multi-setting use.

Methods

Data on mental health service contacts were collected retrospectively from charts for youth aged 11-18 (n=226) during their involvement with child welfare services in Montreal, Quebec. Logistic regression analysis was conducted to determine predictors of multi-setting mental health services use (defined as ≥3 settings).

Results

83% of youth had at least one mental health service contact over the course of their child welfare services follow-up, with 45% having multi-setting use. Emergency Departments were the top setting for mental health services. Youth with a higher number of placements and from neighborhoods with greater social and material deprivation were significantly likelier to use ≥3 mental health service settings over the course of their follow-up.

Conclusion

These findings suggest a need for enhanced collaboration between youth-serving sectors to ensure that continuous and appropriate mental health care is being offered to youth followed by child welfare systems. The relationship between placement instability and multi-setting mental health service use calls for specific policies to ensure that young people do not experience multiple discontinuities of care.

Problematic Sexualized Behavior in Children: Essentials for the Pediatric Forensic Nurse

ABSTRACT

Problematic sexual behavior (PSB) in children and adolescents is a significant public health problem. PSB is defined as harmful or developmentally inappropriate behaviors involving sexual organs or regions of the body exhibited by children or adolescents. PSB may be harmful to self or others or be abusive toward another child, adolescent, or adult. Adolescents, typically defined as children 12 years old or older, engaging in PSB can be vulnerable to formal court adjudication as their behaviors may be considered a sexual offense. PSB can result in significant negative consequences for all children and adolescents involved as well as their families. This article will describe sexual behavior in children, normative and problematic, and explore implications for forensic nursing practice.

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.

Home First: Stability and Opportunity in Out-of-Home Care

In this report, the concept of “Home First” is introduced for those children who require long-term, non-kin placements. The term “Home First” connotes a placement engendering stability and continuity; this concept is introduced in conjunction with an evaluation of the historical, theoretical, and empirical evidence surrounding different forms of out-of-home placement, including group-care placements and foster family care. In light of these observations and studies, this report will argue that stability is a major factor, perhaps a necessary if not a sufficient condition, in successful child development. It will argue for the initiation of a new focus on the creation of long-term positive and stable residential placements within the out-of-home care system and show that such placements can and have contributed to the development of healthy, happy, and successful adulthoods. This report offers a bio-psycho-social perspective on child development in out-of-home care. It provides a brief overview of the multiple bio-psycho-social theoretical perspectives that inform us on the necessary role of stability in growth and development and the contribution of instability to dysfunction. This report considers stability in out-of-home care in relation to its associated outcomes and those factors believed to enhance or detract from these outcomes. It reviews the history of substitutive care provision for children and youth and the role of the “stability objective” in that history. Finally, it looks at how child welfare system priorities have influenced stability, and it offers some suggestions for ensuring more stable growth and development in child placement provision.

The Development of Young Peoples' Internalising and Externalising Difficulties Over the First Three-Years in the Public Care System

Although we know there are high rates of mental health difficulties amongst young people in out-of-home care (i.e. social welfare-involved children), there is limited evidence on the longitudinal development of these problems, particularly from when they enter the care system. Using the routinely collected carer-reported strengths and difficulties questionnaire, we explored internalising (emotional and peer) and externalising (conduct and hyperactivity) difficulties for 672 young people across their first 3 years in the UK care system (2-16 yrs, 51% boys, 76% Caucasian). In all cases stable profiles (resilient or chronic) were most common, while changing profiles (recovery or delayed) were less common. Findings showed that entry into the care system is not enough of an intervention to expect natural recovery from mental health difficulties. Number of placements and being separated from siblings were associated with greater difficulties. Implications for child welfare and mental health systems are discussed.

Patterns of healthcare utilization with placement changes for youth in foster care

BACKGROUND

Children in foster care experience poor health and high healthcare use. Child welfare agencies frequently require healthcare visits when children enter foster care; subsequent placement changes also disrupt healthcare. Studies of healthcare use have not accounted for placement changes.

OBJECTIVE

To understand patterns of healthcare use throughout the time a child enters foster care and with placement changes, accounting for mandated visits when children enter foster care or experience a placement change.

PARTICIPANTS AND SETTING

Children 4 and older in foster care between 2012 and 2017 (N = 2787) with linked child welfare administrative data from one county child welfare agency and one Midwest pediatric healthcare system.

METHODS

Negative binomial models predicted healthcare days per month that were planned (e.g., scheduled primary/specialty care), unplanned (e.g., emergency care), or missed.

RESULTS

Planned healthcare days increased as a function of placement changes (Incident Rate Ratio [IRR] =1.69, p < .05) and decreased with placement stability (IRR = 0.92, p < .01). Mandated visits that occurred later in a placement were associated with fewer planned (IRR = 0.81, p < .01) and unplanned (IRR = 0.82, p < .01) healthcare days during that placement.

CONCLUSIONS

Patterns of planned healthcare over the time children are in one placement and move between placements suggest more can be done to ensure youth remain connected to primary and specialty care throughout placements and placement transitions, s that children are seen as clinically appropriate rather than a function of placement disruption. Findings regarding the timing of mandated visits suggest that delays in mandated care may also reflect lower healthcare use overall.

Mental health and use of health care services in opioid-exposed school-aged children compared to foster children

Given the concerns raised regarding the effects of prenatal exposure to methadone and buprenorphine on the developmental outcomes of the children, this study assessed mental health and use of services in a national sample of school-aged children (N = 78) born to women enrolled in opioid maintenance treatment during pregnancy, compared with a group of foster children (N = 140). The majority of the opioid-exposed children lived with their birth parent(s) at the time of assessment (N = 62), while 16 lived in foster homes. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) and the Reactive Attachment Disorder scale. Teachers completed the SDQ. Three kinds of services were included in measuring service use: school-based education services, child mental health services, and hospital-based habilitation services. The main finding of the study is that children prenatally exposed to methadone or buprenorphine living with their family of origin had significantly better mental health status than their foster-placed counterparts and that of the comparison group of foster children. In addition, the exposed children living at home had less child welfare involvement, and only half of them were using any of the three services measured. The odds for using services increased significantly in accordance with increasing mental health problems, independent of group affiliation, indicating a need-based access to services. In line with other studies, we found that the odds for using one or more services was 2.3 times greater for boys than for girls. Our results contribute to a more-nuanced understanding of the developmental outcomes of prenatal exposure to methadone and buprenorphine, and factors associated with increased service use in groups of at-risk children.

Intergenerational transmission of placement in out-of-home care: Mediation and interaction by educational attainment

BACKGROUND

Persons with childhood experiences of out-of-home care (OHC) have elevated risks of having their own children taken into societal care. High educational attainment has been linked to favorable long-term outcomes in a host of previous studies on OHC alumni. This could be indicative of resilience, which may also have protective potential against intergenerational continuity of OHC placements.

OBJECTIVE

The present study examined the processes of mediation and interaction by educational attainment, here conceptualized as having completed upper secondary school, regarding the intergenerational transmission of placement in OHC.

PARTICIPANTS AND SETTING

Longitudinal data came from a Swedish cohort of parents (and their children) born in 1953 (n = 11,338).

METHODS

Associations between parental experience of OHC and their children's placement in OHC were analyzed by means of binary logistic regression. Four-way decomposition was used to explore mediation and interaction by parental educational attainment.

RESULTS

The odds of having at least one child being placed in OHC was more than six-fold (OR = 6.67, 95% CI = 5.28; 8.06) in the OHC group compared to majority population peers. Mediation and/or interaction by educational attainment accounted for a substantial proportion of the overall association (53%). Interaction effects appeared to be more important for the outcome than mediation.

CONCLUSIONS

Having completed upper secondary school seems to reflect processes of resilience with the potential to break the intergenerational transmission of placement in OHC. These findings suggest that the impact of enhanced educational attainment of OHC populations may have potential of extending into the fate of the next generation.

Outcomes in Adulthood After Long-Term Foster Care: A Sibling Approach

When a child is removed from their home and placed in foster care, society takes over the responsibility for that child's well-being and development. Failure to provide a child with a nurturing upbringing may have negative consequences for the child as well as for society. Using Swedish longitudinal registry data for a national cohort sample of siblings, in which some were placed in foster care and others remained in their birth parents' care, this study asks whether long-term foster care ensures improved life chances. Results from multilevel regression analyses of a wide range of educational, social, and health-related outcomes in mature adult age (16 outcome constructs) support a row of previous studies indicating that traditional long-term foster care does not seem to improve maltreated children's life chances.

Factors influencing postpartum blood glucose screening among women with prior gestational diabetes mellitus in a rural community

AIMS

The aims of the present study were: a) to investigate the current state of postpartum glucose screening in rural China; and b) to explore the factors influencing postpartum blood glucose screening among women with prior GDM based on Andersen's behavioural model of health service use.

DESIGN

A multisite, cross-sectional study design, conducted from November 2017 to January 2018.

METHODS

A total of 465 women with prior GDM were included from two county-level hospitals in rural China. The potential influencing factors for postpartum blood glucose screening based on Andersen's behavioural model, including predisposing, enabling, and need factors, were collected by self-reported questionnaires. Chi-square tests and logistic regression were used to explore the influence of these factors on whether screening of blood glucose level after delivery occurred.

RESULTS

The mean age of the women was 31.92 years old (SD 5.16) and the mean time after delivery was 16.73 months (SD 15.07). The postpartum glucose screening proportion was 32.7%. Women who did not have a full-time job (p= .011) (predisposing factor), had not received any treatment for GDM (p= .002), and were not informed about screening plans for diabetes by health professionals (p < .001) (enabling factor) were less likely to engage in postpartum glucose screening. The need factor, high actual risk of developing type 2 diabetes mellitus (T2DM), was not associated with postpartum blood glucose screening (p> .05).

CONCLUSIONS

In rural China, most women with prior GDM were not screened for T2DM after delivery. The women with prior GDM who did not have a full-time job or had not received any prior treatment for GDM should be the target population for health education on postpartum glucose screening.

IMPACT

There is a need for data on postpartum blood glucose testing rates among rural women. Future interventions aimed at increasing postpartum blood glucose screening are needed.

Evaluation of psychiatric liaison-services for adolescents in residential group homes

Objective

Adolescents in residential care are a high-risk population for psychiatric disorders. Due to limited access to outpatient treatment, crises often result in psychiatric hospitalizations. These crises are often accompanied by termination of supportive relationships, which increases the risk for further problems. To minimize hospitalizations and to stabilize the psychological state of these adolescents, we developed and evaluated a home-treatment intervention program based on psychiatric liaison-services and compared it to standard medical care (SMC).

Methods

The intervention was applied in 11 German residential group homes (N = 288, M = 14.1 years, SD = 2.7), while adolescents from 15 institutions (N = 336, M = 13.6 years, SD = 3.0) served as a comparison group (CG) (SMC). The frequency and duration of psychiatric inpatient treatment episodes were documented and caregiver-reported behavioural symptoms were assessed at baseline and at 6 and 12 months postintervention.

Results

In both groups, less than 10% of the adolescents were admitted to psychiatric wards. Compared to SMC, hospitalizations were of shorter duration in the intervention group (IG) (1.30 vs 2.47 days per head within 12 months, p < .001). In both groups, behavioural problems decreased overtime.

Conclusions

Applying a home-treatment intervention program to children in residential care helps to stabilize the developmental course of this high-risk population by shortening psychiatric inpatient treatment.

Measurement Based Care in Child Welfare-Involved Children and Youth: Reliability and Validity of the PSC-17

This study evaluates whether the psychometric properties of the Pediatric Symptoms Checklist-17 (PSC-17), a common behavioral health measure typically used as a dichotomous screening tool for mental health needs, support its use as a continuous measure for tracking behavioral health over time. A total of 6492 foster parents of children and youth aged 5.5-17 completed the PSC-17. Convergent and discriminant validity was assessed by comparing raw PSC-17 subscale scores with associated outcomes (e.g. psychiatric diagnoses). Long-term test-retest reliability was assessed over 6 months. Scores on the PSC-17 demonstrated good convergent and divergent validity. PSC-17 subscale scores were most strongly associated with analogous diagnoses. Test-retest reliability was moderate, as expected for a time window of this length. This study provides moderate support for the psychometric qualities of the PSC-17 when used with children and youth in the child welfare system as a continuous measure of psychosocial functioning over time.

Identifying Psychosocial Problems Among Children and Youth in the Child Welfare System Using the PSC-17: Exploring Convergent and Discriminant Validity with Multiple Informants

Youth who enter foster care are at risk of mental health need, but questions arise as to the validity of their self-reported symptomatology. This study examines the screening validity of the youth-report version of the Pediatric Symptom Checklist-17 (PSC-17) in a child welfare population. Data come from 2389 youth who completed a version of the PSC-17 adapted for youth report, and their biological and foster parents who completed the parent-report version. Youth also completed a shortened version of the Screen for Child Anxiety Related Disorders (SCARED). Convergent and discriminant validity of the PSC-17 was assessed using multi-trait multi-method matrices. The PSC-17's internalizing subscale was strongly correlated, attention subscale was moderately correlated, and externalizing subscale was weakly correlated with the SCARED's anxiety and PTSD subscales. Comparing youth and foster parent scores, the PSC-17 had moderate convergent validity and weak/fair discriminant validity. Comparing youth, foster parent, and biological parent scores, the PSC-17 had moderate convergent validity and weak/fair discriminant validity. The current study provides some support for the validity of the PSC-17 for the population of youth in foster care.

Outcomes in adulthood of adoption after long-term foster care: A sibling study

Prior research has reported a positive impact of adoption on developmental outcomes for children with experience of foster care. To inform decisions about permanent care arrangements, we used Swedish national population registers to create a sibling population consisting of 194 children born 1973–1982 who had been in out-of-home care (OHC) at least 5 years before adolescence but were never adopted (50% boys) and their 177 maternal birth siblings who also had been in OHC at least 5 years before their teens but were adopted before adolescence (52.5% boys). We constructed 14 outcome variables spanning social, educational, and health outcomes in adult age with information from Swedish national registers. Based on multilevel logistic random effects and fixed effects regression models (supplemented with a sensitivity analysis assessing the potential impact of unobserved confounding), results showed that adopted siblings tended to have considerably better outcomes in adult age in educational achievement, income, criminality, disability, and suicidality. Outcomes related to mental health and substance abuse were more similar, but differences pointed in the same direction. Implications for child welfare policy and practice are discussed.

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.

Challenges of health services related to the population displaced by violence in Mexico

OBJECTIVE

To analyze the impacts of the care to the population displaced by violence on the health system and the challenges that this entails.

METHODS

This is a narrative review of the national and international literature in PubMed, SciELO, WHO/PAHO, and Bireme. Inclusion criteria were date of publication (from 2000), relation with the subject, and language (Spanish or English). We found 292 documents, of which 91 met the inclusion criteria.

RESULTS

The main challenges are the intersectoral, participatory, and integral approach (with emphasis on mental health and sexual and reproductive health), ensured accessibility to health services, the need for a reliable registration and information system of the population displaced by violence and its characteristics, and the addressing of the biopsychosocial problems of the different groups, especially women, persons with disabilities or infectious diseases, adolescents, children, ethnic minorities, older adults and the lesbian, gay, bisexual, transsexual, and intersexual population.

CONCLUSIONS

The lack of political will to accept and see the internal displacement by violence and its importance as a humanitarian and public health problem is an obstacle to the adequate and timely care of the population displaced by violence in Mexico.

Understanding Health Risks for Adolescents in Protective Custody

Children in child welfare protective custody (e.g., foster care) are known to have increased health concerns compared to children not in protective custody. The poor health documented for children in protective custody persists well into adulthood; young adults who emancipate from protective custody report poorer health, lower quality of life, and increased health risk behaviors compared to young adults in the general population. This includes increased mental health concerns, substance use, sexually transmitted infections, unintended pregnancy, and HIV diagnosis. Identifying youth in protective custody with mental health concerns, chronic medical conditions, and increased health risk behaviors while they remain in custody would provide the opportunity to target prevention and intervention efforts to curtail poor health outcomes while youth are still connected to health and social services. This study leveraged linked electronic health records and child welfare administrative records for 351 youth ages 15 and older to identify young people in custody who were experiencing mental health conditions, chronic medical conditions, and health risk behaviors (e.g., substance use, sexual risk). Results indicate that 41.6% of youth have a mental health diagnosis, with depression and behavior disorders most common. Additionally, 41.3% of youth experience chronic medical conditions, primarily allergies, obesity, and vision and hearing concerns. Finally, 39.6% of youth use substances and 37.0% engage in risky sexual behaviors. Predictors of health risks were examined. Those findings indicate that women, those with longer lengths of stay and more times in custody, and those in independent living and congregate care settings are at greatest risk for mental health conditions, chronic medical conditions, and health risk behaviors. Results suggest a need to ensure that youth remain connected to health and mental health safety nets, with particular attention needed for adolescents in care for longer and/or those placed in non-family style settings. Understanding who is at risk is critical for developing interventions and policies to target youth who are most vulnerable for increased health concerns that can be implemented while they are in custody and are available to receive services.

Can adoption at an early age protect children at risk from depression in adulthood? A Swedish national cohort study

OBJECTIVE

Our aim was to investigate whether the risk of depression in adulthood in children raised by substitute parents from an early age differ by care arrangements.

METHODS

Register study in Swedish national cohorts born 1972-1981, with three study groups of children raised in adoptive or foster homes with care starting before the age of 2 years and a comparison majority population group. Cox regression estimated HRs of prescribed antidepressive medication and specialised psychiatric care with a diagnosis of depression in adulthood during 2006-2012.

RESULTS

Compared with the general population, long-term foster care carried the highest age-adjusted and sex-adjusted HR for both antidepressive medication, 2.07 (95% CI 1.87 to 2.28), and psychiatric care for depression, 2.85 (95% CI 2.42 to 3.35), in adulthood. Adults raised by adoptive parents were far more similar to the general population with HR of 1.19 (95% CI 1.00 to 1.43) for domestic and 1.13 (95% CI 1.08 to 1.18) for international adoption for antidepressive medication. Adjusting the analysis for school marks and income attenuated these risks more in the long-term foster care group.

CONCLUSION

The study demonstrates the benefits of early adoption when substitute parents are provided for young children, and underlines the importance of improved educational support for children in foster care.

A Theory of Mental Health and Optimal Service Delivery for Homeless Children

Homeless children are a vulnerable group with high risk for developing mental health disorders. The pathways to disorders among homeless children have not been fully elucidated, with significant logistical and measurement issues challenging accurate and thorough assessment of need. The environments of homeless children are uniquely chaotic, marked by frequent moves, family structure changes, household and neighborhood disorder, parenting distress, and lack of continuous services. Despite high rates of service use, mental health outcomes remain poor. This paper reviews the literature on homeless children's mental health, as well as prior theoretical explorations. Finally, the paper proposes a theoretical model that explains elevated rates of mental health problems among homeless children as consequences of harmful stress reactions triggered by chronic household instability along with repeated service disruptions. This model draws upon existing conceptual frameworks of child development, family poverty, health services utilization, and the biology of stress to clarify the role of environmental chaos in the development of child emotional and behavioral problems. Potential strategies to mitigate the risk for mental health disorders among homeless children and future research directions are discussed.

Mental Health Interventions for Children in Foster Care: A Systematic Review

Children in foster care have high rates of adverse childhood experiences and are at risk for mental health problems. These problems can be difficult to ameliorate, creating a need for rigorous intervention research. Previous research suggests that intervening with children in foster care can be challenging for several reasons, including the severity and complexity of their mental health problems, and challenges engaging this often transitory population in mental health services. The goal of this article was to systematically review the intervention research that has been conducted with children in foster care, and to identify future research directions. This review was conducted on mental health interventions for children, ages 0 to 12, in foster care, using ERIC, CINAHL, PsycINFO, PubMed, ProQuest's Dissertation and Theses Database, Social Services Abstracts, and Social Work Abstracts. It was restricted to interventions that are at least "possibly efficacious" (i.e., supported by evidence from at least one randomized controlled trial). Studies were evaluated for risk of bias. Ten interventions were identified, with diverse outcomes, including mental health and physiological. Six interventions were developed for children in foster care. Interventions not developed for children in foster care were typically adapted to the foster context. Most interventions have yet to be rigorously evaluated in community-based settings with children in foster care. Little research has been conducted on child and family engagement within these interventions, and there is a need for more research on moderators of intervention outcomes and subgroups that benefit most from these interventions. In addition, there is not consensus regarding how to adapt interventions to this population. Future research should focus on developing and testing more interventions with this population, rigorously evaluating their effectiveness in community-based settings, determining necessary adaptations, and identifying which interventions work best for whom.

Foster care placement change: The role of family dynamics and household composition

Sibling co-placement and kinship care have each been shown to protect against the occurrence of placement change for youth in substitute care. However, little is known about the effects of different combinations of sibling placement and relative caregiver status on placement change. Nor does the field fully understand how family dynamics may differ in these households. Utilizing data from the Supporting Siblings in Foster Care study, this paper examines family dynamics across four typologies of living composition, and tests the effects of living composition membership on the odds of experiencing a placement change over an 18-month period of time. Findings suggest that across living composition typologies, children who were placed separately from their siblings in non-relative care were more likely to be older, have more extensive placement histories, and experience more placement changes both prior to and during the study than were children in other living composition groups. Family living composition was found to influence the occurrence of placement change. Specifically, children co-placed in kinship care were least likely to experience movement; however, sibling co-placement in non-relative care was also protective. Results reveal the need to conduct additional research into the experiences of children in different family living arrangements, and tailor case management services and supports to children in substitute care accordingly. Implications and future directions are discussed.

Promoting Birth Parents' Relationships with their Toddlers upon Reunification: Results from Promoting First Relationships® Home Visiting Program

Birth parents, once reunified with their child after a foster care placement, are in need of in-home support services to prevent reoccurrence of maltreatment and reentry into foster care, establish a strong relationship with their child, and enhance child well-being. Few studies have addressed the efficacy of home visiting services for reunified birth parents of toddlers. This study reports on the findings from a randomized control trial of a 10-week home visiting program, Promoting First Relationships^® (Kelly, Sandoval, Zuckerman, & Buehlman, 2008), for a subsample of 43 reunified birth parents that were part of the larger trial. We describe how the elements of the intervention align with the needs of parents and children in child welfare. Although the sample size was small and most of the estimates of intervention effects were not statistically significant, the effect sizes and the pattern of results suggest that the intervention may have improved both observed parenting sensitivity and observed child behaviors as well as decreased parent report of child behavior problems. Implications are that providing in-home services soon after a reunification may be efficacious in strengthening birth parents' capacity to respond sensitively to their children as well as improving child social and emotional outcomes and well-being.

Behavioral health services following implementation of screening in Massachusetts Medicaid children

OBJECTIVES

To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children.

METHODS

After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services.

RESULTS

Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06).

CONCLUSIONS

Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

Effects of a structural intervention and implementation on physical activity among youth in residential children's homes

This study reports the effects of a structural intervention, ENRICH (Environmental Interventions in Children's Homes) which targeted the physical and social environment within residential children's homes (RCHs) to increase physical activity (PA) among residents (n=799). Participating RCHs (n=29) were randomized to Early (n=17) or Delayed (n=12) groups from 2004 to 2006 and 2006 to 2008, respectively. Children's PA was measured at three time periods (2004, 2006, 2008). Intent-to-treat analysis revealed no intervention impact on PA. Subsequent analyses used process evaluation data to group organizations into high and low PA-promoting RCHs to compare PA level, controlling for assignment to condition. Organizations with high PA-promoting environments were found to have more active youth. Utility of a comprehensive implementation monitoring plan and the need for formative assessment of organizational capacity is discussed.

The Caregiver as Gatekeeper for Accessing Health Care for Children in Foster Care: A Qualitative Study of Kinship and Unrelated Caregivers

The objective of this qualitative study was to examine issues that unrelated and kinship foster caregivers in Los Angeles, CA, have in seeking help and accessing and using health care for children in foster care. There were four themes identified for all caregivers: (1) "Doing Our Best" (caregivers advocated persistently and creatively for health care); (2) "Support from Others Helped" (caregivers relied on caseworkers, organizations, and their social network); (3) "Child has Complicated, Serious, Chronic Health Problems" (caregivers had difficulty securing specialty services and with Medicaid insurance to meet health care needs); and (4) "Caregiver Competence in Meeting Health Needs" (caregivers noted their ability to attend health appointments and understand instructions). An additional theme of "Differences between Unrelated and Kinship Foster Caregivers" highlighted more difficulties among kinship caregivers in finding and using primary health care services and more financial stress, whereas unrelated caregivers were less satisfied with child welfare caseworker help. Despite wide-ranging stressors and serious frustrations with the child welfare and health care systems, caregivers emerged as powerful drivers of health care for foster children. National adoption of a medical home model would ameliorate some of the access barriers identified by foster caregivers in this study.

Emerging adulthood and leaving foster care: settings associated with mental health

The present study examined the role of contextual support on mental health during the transition to adulthood within a vulnerable group, adolescents leaving foster care because of their age. Participants were 265 19- to 23-year-olds who retrospectively reported on 3 main contexts of emerging adulthood: housing security, educational achievement, and employment attainment in the first 2 years after leaving foster care. Mental health measured self-reported emotional distress, substance abuse, and deviancy at the time of interview. Growth Mixture Modeling empirically identified 3 latent trajectory classes. Stable-Engaged (41%) experienced secure housing and increasing connections to education and employment over time. Stable-Disengaged (30%) maintained housing but reported decreasing rates of education and small increases in employment. Instable-Disengaged (29%) experienced chronic housing instability, declined connection to education, and failed to attain employment. Stable-Engaged and Stable-Disengaged classes reported better mental health compared to the Instable-Disengaged class, indicating the importance of housing in transitioning to adulthood.

Validating office-based screening for psychosocial strengths and difficulties among youths in foster care

OBJECTIVES

To assess the effectiveness of social-emotional screening in the primary care setting for youths in foster care.

METHODS

The setting was a primary care practice for all youth in home-based foster care in 1 county. Subjects were youths, aged 11 to 17 years, and their foster parents; both completed a Strengths and Difficulties Questionnaire at well-child visits. The Strengths and Difficulties Questionnaire is a previously validated 25-item tool that has 5 domains: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems; and prosocial behaviors and an overall total difficulties score. We first compared youth versus parent Strengths and Difficulties Questionnaire scores and then assessed the accuracy of these Strengths and Difficulties Questionnaire scores by comparing them in a subsample of youths (n = 50) with results of home-based structured clinical interviews using the Children's Interview for Psychiatric Syndromes.

RESULTS

Of 138 subjects with both youth and parent reports, 78% had prosocial behaviors (strengths), and 70% had 1 or more social-emotional problems. Parents reported significantly more conduct problems (38% vs 16%; P < .0001) and total difficulties (30% vs 16%; P = .002) than did youth. The Strengths and Difficulties Questionnaire had better agreement with the Children's Interview for Psychiatric Syndromes (n = 50) for any Strengths and Difficulties Questionnaire-identified problem for combined youth and foster-parent reports (93%), compared with youth report alone (54%) or parent report alone (71%).

CONCLUSIONS

Although most youths in foster care have social-emotional problems, most have strengths as well. Youth and foster-parent perspectives on these problems differ. Systematic social-emotional screening in primary care that includes both youth and parent reports can identify youths who may benefit from services.

Pediatric health assessments of young children in child welfare by placement type

OBJECTIVES

To describe health-related problems across placement types (unrelated foster, kin foster, in-home with birth parent); to examine the association of placement and demographic/child welfare variables (child gender, age, race/ethnicity; caregiver language; type of maltreatment, and length of time receiving services from child welfare) with health-related problems.

METHODS

This study utilized a retrospective medical chart review of children less than 6 years old (n=449) seen at an outpatient child welfare pediatric clinic. Logistic regression modeling was used to estimate odds of having a weight, medical, or provisional developmental delay problem by placement and demographic/child welfare characteristics.

RESULTS

Almost 13% of children in the sample were obese (≥95% age-gender specific percentile) and more than a quarter were overweight/obese (≥85%) while only 7% were underweight (≤5%). Most children (78%) had a physical health diagnosis and 25% were provisionally identified with a developmental delay. No differences between weight diagnoses, type of medical diagnoses, and provisional developmental delay by placement type were found, although children with 3 or more medical diagnoses were more likely to be with kin (p<.05). Children 2 years old or older were more likely to be overweight/obese than children under 2 years old (p<.05) and Hispanic children were more likely to be overweight/obese than non-Hispanic children (p<.01). Length of stay in child welfare was positively related with a medical diagnosis or provisional developmental delay (p<.01).

CONCLUSIONS

Results argue for careful assessment of weight, medical, and developmental problems in children active to child welfare, whether residing in their home of origin, with kin, or with unrelated foster parents. The increasing problem of obesity among young children in child welfare warrants further investigation and intervention.

PRACTICE IMPLICATIONS

The comprehensive health examination and enhanced health maintenance schedule for children in foster care should be extended to children who remain at home with child welfare services as child welfare involvement rather than placement is related to health-related problems.

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.

Do Maltreated Children who Remain at Home Function Better than Those who Are Placed?

The majority of children in the child welfare system remain with their maltreating parents, yet little is known about their level of functioning and whether they are in need of mental health intervention. The purpose of this study was to evaluate the mental health functioning of an ethnically diverse sample of 302 maltreated children and 151 non maltreated children ages 9-12 to see if there were differences between those who remained at home, those placed in kin care, non-relative foster care or a comparison group of children who were not maltreated. Children were evaluated on multiple measures of mental health functioning, both self report and caregiver report. Results showed that the maltreated children did not differ by placement type but did score significantly higher than the comparison children on many measures. There were substantial numbers of maltreated children scoring in the clinical range of measures in all placement types with over 60% of those remaining with birth parents being seen as functioning at a level that indicated a need for mental health intervention. While fewer comparison children had scores indicating a need for mental health care, the numbers were higher than noted in national studies. Implications of the findings are presented.

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.

Mental Health Services for Children and Youth in the Child Welfare System: A Focus on Caregivers as Gatekeepers

Caregivers serve as gatekeepers for children while in the child welfare system, but few studies have focused on the caregiver and the factors that influence the use of mental health services for the children under their care. The purpose of this study was to examine the child's mental health need, the caregiver's level of stress, depression, and social support, and the utilization of mental health services by children using the three most common types of caregivers in the child welfare system (i.e., birth parent, relative caregiver, and foster parent). Data comes from the Patterns of Care (POC) study of five public sectors of care. The present study examined parents/caregivers and youth from the child welfare sector. Findings suggest that while birth parents were more likely to endorse more risk factors for themselves, and the children under their care had a higher level of mental health need, they were the least likely to utilize mental health services for the children under their care. Implications for the child welfare and mental health systems are discussed.

Rates of psychotropic medication use over time among youth in child welfare/child protective services

OBJECTIVE

The aim of this study was to examine rates of psychotropic medication use over time among a national probability sample of youths involved with child welfare/child protective services (CW/CPS) in the National Survey of Child and Adolescent Well-Being (NSCAW).

METHODS

Growth mixture modeling was used to classify 2,521 youths into groups based on individual medication use trajectories. Determinants associated with groupings were examined using logistic regression.

RESULTS

Overall, 22% of youths used medications over 3 years. Three groups were identified: (1) Low medication use (85%, n = 2,057), where medication was used rarely or never; (2) increasing medication use, where medication was commonly started after investigation (4%, n = 148); and (3) high medication use, where medication use was endorsed over multiple study waves (12%, n = 316). On multivariate modeling, physical abuse predicted membership in the increasing-use group (reference group, low use); Caucasian (versus African American) and need predicted membership in the high-use group (reference group, low use). Male gender was associated with membership in both the increasing-use and high-use groups (reference group, low use). Age and abuse type (physical abuse, neglect) demonstrated complex relationships with group membership.

CONCLUSIONS

Psychotropic medication use trajectories for children in child welfare vary and are best understood when disaggregated into distinct subpopulations.

Meeting Children's Mental and Physical Health Needs in Child Welfare: The Importance of Caregivers

Caregivers in the child welfare system are an important element in ensuring that mental and pediatric health services for their children are utilized appropriately. The high prevalence of mental and physical health problems of children in the child welfare system along with the inadequate utilization of health services make the role of caregivers essential for improving health outcomes. This article explores the barriers to meeting the health needs of this vulnerable population of children and how different types of caregivers (unrelated foster, kinship foster, and birth parents) utilize mental and pediatric health services. Child welfare caseworkers need to increase their communication with caregivers, assess adherence to health care recommendations, and help alleviate barriers to care.

Behavior problems and placement change in a national child welfare sample: a prospective study

OBJECTIVE

There is ongoing debate regarding the impact of youth behavior problems on placement change in child welfare compared to the impact of placement change on behavior problems. Existing studies provide support for both perspectives. The purpose of this study was to prospectively examine the relations of behavior problems and placement change in a nationally representative sample of youths in the National Survey of Child and Adolescent Well-Being.

METHOD

The sample consisted of 500 youths in the child welfare system with out-of-home placements over the course of the National Survey of Child and Adolescent Well-Being study. We used a prospective cross-lag design and path analysis to examine reciprocal effects of behavior problems and placement change, testing an overall model and models examining effects of age and gender.

RESULTS

In the overall model, out of a total of eight path coefficients, behavior problems significantly predicted placement changes for three paths and placement change predicted behavior problems for one path. Internalizing and externalizing behavior problems at baseline predicted placement change between baseline and 18 months. Behavior problems at an older age and externalizing behavior at 18 months appear to confer an increased risk of placement change. Of note, among female subjects, placement changes later in the study predicted subsequent internalizing and externalizing behavior problems.

CONCLUSIONS

In keeping with recommendations from a number of professional bodies, we suggest that initial and ongoing screening for internalizing and externalizing behavior problems be instituted as part of standard practice for youths entering or transitioning in the child welfare system.

Impact of kinship care on behavioral well-being for children in out-of-home care

OBJECTIVE

To examine the influence of kinship care on behavioral problems after 18 and 36 months in out-of-home care. Growth in placement of children with kin has occurred despite conflicting evidence regarding its benefits compared with foster care.

DESIGN

Prospective cohort study.

SETTING

National Survey of Child and Adolescent Well-Being, October 1999 to March 2004.

PARTICIPANTS

One thousand three hundred nine children entering out-of-home care following a maltreatment report.

MAIN EXPOSURE

Kinship vs general foster care.

MAIN OUTCOME MEASURES

Predicted probabilities of behavioral problems derived from Child Behavior Checklist scores.

RESULTS

Fifty percent of children started in kinship care and 17% of children who started in foster care later moved to kinship care. Children in kinship care were at lower risk at baseline and less likely to have unstable placements than children in foster care. Controlling for a child's baseline risk, placement stability, and attempted reunification to birth family, the estimate of behavioral problems at 36 months was 32% (95% confidence interval, 25%-38%) if children in the cohort were assigned to early kinship care and 46% (95% confidence interval, 41%-52%) if children were assigned to foster care only (P = .003). Children who moved to kinship care after a significant time in foster care were more likely to have behavioral problems than children in kinship care from the outset.

CONCLUSIONS

Children placed into kinship care had fewer behavioral problems 3 years after placement than children who were placed into foster care. This finding supports efforts to maximize placement of children with willing and available kin when they enter out-of-home care.

Prevention of behavior problems for children in foster care: outcomes and mediation effects

Parent training for foster parents is mandated by federal law and supported by state statues in nearly all states; however, little is known about the efficacy of that training, and recent reviews underscore that the most widely used curricula in the child welfare system (CWS) have virtually no empirical support (Grimm, Youth Law News, April-June:3-29, 2003). On the other hand, numerous theoretically based, developmentally sensitive parent training interventions have been found to be effective in experimental clinical and prevention intervention trials (e.g., Kazdin and Wassell, Journal of the American Academy of Child and Adolescent Psychiatry, 39:414-420, 2000; McMahon and Forehand, Helping the noncompliant child, Guilford Press, New York, USA, 2003; Patterson and Forgatch, Parents and adolescents: I. Living together, Castalia Publishing, Eugene, OR, USA, 1987; Webster-Stratton et al., Journal of Clinical Child Pyschology Psychiatry, 42:943-952, 2001). One of these, Multidimensional Treatment Foster Care (MTFC; Chamberlain, Treating chronic juvenile offenders: Advances made through the Oregon Multidimensional Treatment Foster Care model, American Psychological Association, Washington, DC, USA, 2003), has been used with foster parents of youth referred from juvenile justice. The effectiveness of a universal intervention, KEEP (Keeping Foster Parents Trained and Supported) based on MTFC (but less intensive) was tested in a universal randomized trial with 700 foster and kinship parents in the San Diego County CWS. The goal of the intervention was to reduce child problem behaviors through strengthening foster parents' skills. The trial was designed to examine effects on both child behavior and parenting practices, allowing for specific assessment of the extent to which improvements in child behavior were mediated by the parenting practices targeted in the intervention. Child behavior problems were reduced significantly more in the intervention condition than in the control condition, and specific parenting practices were found to mediate these reductions, especially for high-risk children in foster families reporting more than six behavior problems per day at baseline.

Longitudinal patterns of health insurance coverage among a national sample of children in the child welfare system

OBJECTIVES

We sought to describe health insurance coverage over time among a national sample of children who came into contact with child welfare or child protective services agencies.

METHODS

We used data from 4 waves of the National Survey of Child and Adolescent Well-Being to examine insurance coverage among 2501 youths. Longitudinal insurance trajectories were identified using latent class analyses, a technique used to classify individuals into groupings of observed variables, and survey-weighted logistic regression was used to identify variables associated with class membership.

RESULTS

We identified 2 latent insurance classes--1 contained children who gained health insurance, and the other contained children who stably maintained coverage over time. History of sexual abuse, and race/ethnicity other than White, Black, and Hispanic, were associated with membership in the "gainer" class. Foster care placement and poorer health status were associated with membership in the "maintainer" class. Caregiver characteristics were not associated with class membership.

CONCLUSIONS

The majority of children in child welfare had stable health insurance coverage over time. Given this vulnerable population's dependence upon Medicaid, protection of existing entitlements to Medicaid is essential to preserve their stable insurance coverage.

Cascading implementation of a foster and kinship parent intervention

Most foster parents in the United States are required to participate in training, yet no empirical support exists for the training's effectiveness. During the past two decades, high-quality clinical trials have documented that parent management training (PMT) programs produce positive outcomes for children and families in clinical and school settings; yet, these advances have not transferred to foster/kinship parents. Here, we describe a randomized control trial testing the effectiveness of a PMT-based treatment with 700 foster/kinship parents in San Diego County. The collaborative processes to engage stakeholders, the strategies for involving parents, and the results of two levels of developer involvement in training and supervision on child behavioral outcomes are also described.

Administrative barriers to the adoption of high-quality mental health services for children in foster care: a national study

While the need to provide appropriate mental health services to children in foster care is well recognized, there is little information on administrative barriers to assuring that such services are provided. This article presents results from a national survey of mental health agencies to profile their awareness of currently available practice standards, the roles these standards play in guiding practice of mental health agencies, common reimbursement strategies in use for mental health services, and collaborations between mental health and child welfare agencies that enhance children's access to appropriate mental health care. Implications and recommendations for mental health policymakers are discussed.