Health outcomes in young adults from foster care and economically diverse backgrounds

The Dynamic Nature of the Socioeconomic Determinants of Cardiovascular Health: A Narrative Review

Despite decades of social epidemiologic research, health inequities remain pervasive and ubiquitous in Canada and elsewhere. One reason may be our use of socioeconomic measurement, which has often relied on single point-in-time exposures. To explore the extent to which researchers have incorporated dynamic socioeconomic measurement into cardiovascular health outcome evaluations, we performed a narrative review. We estimated the prevalence of socioeconomic longitudinal cardiovascular research studies that identified socioeconomic exposures at 2 or more points in time between the years of 2019 and 2023. We defined cardiovascular outcome studies as those that examined coronary artery disease, myocardial infarction, acute coronary syndrome, stroke, heart failure, cardiac arrhythmias, cardiac death, cardiometabolic factors, transient ischemic attacks, peripheral artery disease, or hypertension. Socioeconomic exposures included individual income, neighbourhood income, intergenerational social mobility, education, occupation, insurance status, and economic security. Seven percent of socioeconomic cardiovascular outcome studies have measured socioeconomic status at 2 or more points in time throughout the follow-up period, hypothesized mechanisms by which dynamic socioeconomic measures affected outcome focused on social mobility, accumulation, and critical period theories. Insights, implications, and future directions are discussed, in which we highlight ways in which postal code data can be better used methodologically as a dynamic socioeconomic measure. Future research must incorporate dynamic socioeconomic measurement to better inform root causes, interventions, and health-system designs if health equity is to be improved.

Drug decriminalization: The importance of policy change for the health and wellbeing of children and youth in Canada

The criminalization of drug use and possession has demonstrable harms on the health of children and youth, with disproportionate effects on Black people, Indigenous people, people from other racially oppressed communities, and people living in poverty. Drug decriminalization, by separating personal possession and use of drugs from the criminal justice system, allows for a health-based approach to drug policy. Paediatricians are well-positioned to advocate for policies within a decriminalization framework to prioritize the physical and mental health of children and youth.

Initial Health Outcomes of a Community-Based Collaboration for Children in Foster Care

Children entering foster care have complex health needs that can persist across the lifespan. Efforts to improve access to primary care services exist; however, few have been tested. This study evaluated the Missoula Foster Child Health Program, a tri-agency, community-based collaboration in Montana, to determine its impact on health outcomes for youth in care. Demographic, health outcome, and child welfare data were collected from 485 children (50 percent male, 50 percent female, aged 0-18). At program admission, children had unmet service needs, lacking a primary care provider (30 percent), a dental provider (58 percent), and required vaccinations (33 percent). Three-quarters of children had at least one health condition, and one-third had a behavioral health concern. Overall, children in the program had significant decreases in physical and behavioral health problems from admission to discharge. Older children and those with fewer placements were more likely to have positive health changes. Data are promising, representing positive health outcomes of a community-based model for children in care.

Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children

OBJECTIVE

This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years.

METHODS

This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex.

RESULTS

Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion.

CONCLUSIONS

This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.

Childhood maltreatment and mental health problems in a 10-year follow-up study of adolescents in youth residential care: A latent transition analysis

Childhood maltreatment and mental health problems are common among young people placed out-of-home. However, evidence on the impact of maltreatment on the course of mental health problems in at-risk populations is sparse. The aim of this longitudinal study is twofold: (a) describe the course of mental health problems and the shift in symptom patterns among adolescents in youth residential care into young adulthood and (b) assess how childhood maltreatment is related to the course of mental health problems. One hundred and sixty-six adolescents in Swiss youth residential care were followed up into young adulthood (36.1% women; MAge-Baseline = 16.1 years; MAge-Follow-Up = 26.4 years). Latent transition analysis was employed to analyze transitions of symptom patterns and their association with maltreatment exposure. We found three latent classes of mental health problems: a "multiproblem"-class (51.8% baseline; 33.7% follow-up), a "low symptom"-class (39.2% baseline; 60.2% follow-up), and an "externalizing"-class (9.0% baseline; 6.0% follow-up). Individuals in the "multiproblem"-class were likely to transition towards less-complex symptom patterns. Higher severity of self-reported childhood maltreatment was associated with more complex and persistent mental health problems. Our study underlines the need for collaboration between residential and psychiatric care systems within and after care placements, with a specialized focus on trauma-informed interventions and care.

A Review of the Relationship between Socioeconomic Status Change and Health

OBJECTIVES

This review aimed to identify and synthesize the existing literature on the effects of socioeconomic status (SES) changes on health.

METHODS

A review was conducted using Medline, Cochrane library, and CINAHL (Cumulative Index to Nursing and Allied Health Literature). All longitudinal or cross-sectional studies that examined links between changes to SES across different time periods and measured health outcomes were included. Screening was conducted using select inclusion and exclusion criteria in order of title, abstract, and full text. Two independent reviewers assessed the quality of the full text articles using the Downs and Black checklist.

RESULTS

Our literature search led to 2719 peer reviewed articles, 2639 of which were title screened after duplicates were removed. A total of 117 abstracts and 12 full text articles were screened. Overall, findings from 11 articles form the basis of this review. Eight different types of measures of changes to SES were identified. These include education, occupation, economic security, income sufficiency, home ownership, car ownership, health insurance, and marital status. Assessed outcomes included measures related to physical health, cardiovascular disease, mental health, and oral health. A large proportion of studies found that an SES change impacts health. Evidence suggests that those with consistently high SES have the best health outcomes, followed by those who report their SES change from low to high (upward social mobility). Evidence on the relative health effects for those who report their SES change from high to low (downward social mobility) compared to those who report consistently low SES is inconsistent.

CONCLUSION

Current evidence suggests that an SES change has an impact on an individual's health. More research on the effects of SES changes on health outcomes in adulthood is needed and can inform various areas of health research including health resiliency and development. Future studies should focus on individual SES indicators and their effects on health outcomes at multiple points throughout life.

Parent-child separation and cardiometabolic outcomes and risk factors in adulthood: A systematic review

BACKGROUND

Parent-child separation has been associated with negative mental health across childhood and adulthood, yet little is known about the long-term impacts for cardiovascular health. This systematic review synthesized and evaluated the quality of the literature examining the association between exposures to parent-child separation and cardiometabolic outcomes in adulthood.

METHODS

Following a registered protocol, online databases (Pubmed, PsycInfo, and Web of Science) were searched for relevant studies. Studies were included if they (a) defined the exposure before age 18 as institutionalization, foster care placement, parental incarceration, separation due to parents migrating for economic reasons, or asylum and war; and (b) quantified the association between parent-child separation and cardiometabolic events and diagnoses (e.g., coronary heart disease, diabetes) and risk factors (e.g., body mass index, fat distribution, serum-based metabolic markers, inflammatory markers in adulthood (≥ age 18). Studies lacking an unexposed comparison group were excluded. The risk for bias in each study was assessed with a modified Newcastle-Ottawa Scale.

RESULTS

Of the 1938 studies identified, 13 met our inclusion criteria. Two of the four studies examining associations between parent-child separation and cardiometabolic events and diagnoses found positive associations with coronary heart disease and diabetes. Amongst the 13 studies examining associations with any type of adult cardiometabolic risk factors, eight studies reported at least one positive association. Sub-analyses considering separate reasons for parent-child separation provided clearer insights: War evacuation was associated with hypertension and high blood pressure across four studies from the same cohort; out-of home care experiences largely evidenced null results across five different studies, and two studies on parental incarceration suggested positive associations with elevated inflammation, BMI and blood pressure.

CONCLUSIONS

The connections between parent-child separation and adult cardiometabolic outcomes and risk factors are currently inconsistent. The results may depend on the reason for separation, age of assessment, analytic differences and other psychosocial variables that are often unmeasured in this literature.

Mental Disorders Into Adulthood Among Adolescents Placed in Residential Care: A Prospective 10-Year Follow-up Study

Background

Child welfare and juvenile justice placed youths show high levels of psychosocial burden and high rates of mental disorders. It remains unclear how mental disorders develop into adulthood in these populations. The aim was to present the rates of mental disorders in adolescence and adulthood in child welfare and juvenile justice samples and to examine their mental health trajectories from adolescence into adulthood.

Methods

Seventy adolescents in shared residential care, placed by child welfare (n = 52, mean age = 15 years) or juvenile justice (n = 18, mean age = 17 years) authorities, were followed up into adulthood (child welfare: mean age = 25 years; juvenile justice: mean age = 27 years). Mental disorders were assessed based on the International Classification of Diseases 10th Revision diagnoses at baseline and at follow-up. Epidemiological information on mental disorders was presented for each group. Bivariate correlations and structural equation modeling for the relationship of mental disorders were performed.

Results

In the total sample, prevalence rates of 73% and 86% for any mental disorder were found in adolescence (child welfare: 70%; juvenile justice: 83%) and adulthood (child welfare: 83%; juvenile justice: 94%) respectively. General psychopathology was found to be stable from adolescence into adulthood in both samples.

Conclusions

Our findings showed high prevalence rates and a high stability of general psychopathology into adulthood among child welfare and juvenile justice adolescents in Swiss residential care. Therefore, continuity of mental health care and well-prepared transitions into adulthood for such individuals is highly warranted.

Multivariate Analysis of the Predicted Probability of Smoking Behavior of Foster Care Minors: Results of a Study from Romania

Background: There are a multitude of factors that influence smoking status, and minors from the social protection system are a vulnerable category in terms of smoking. Methods: The objective of this research was to assess the degree of smoking dependence and to identify potential predictors of smoking status in foster care teenagers. Smoker status was confirmed by dosing CO in the exhaled air, and the degree of dependence was assessed using the Fagerström score. We performed a multivariate logistic regression analysis. Results: From the 275 foster care minors, 22.5% were current smokers. Exhaled CO was not influenced by general demographic factors, was associated with the frequency of smoking, and was positively correlated with the estimated number of cigarettes consumed daily and with the Fagerström score. The calculated probability of being a smoker was less than 20.4% in 75% of nonsmokers, whereas 75% of actual smokers had a predicted probability higher than 30.3%. Conclusions: In addition to age, gender, social environment, previous exposure to secondhand smoking, and residential type of foster care system, the expressed opinions regarding the health effects of tobacco use were associated with smoking in foster care teenagers.

Mental disorders among adults formerly in out-of-home care: a systematic review and meta-analysis of longitudinal studies

While children and adolescents placed in child welfare or juvenile justice out-of-home care show higher prevalence rates of mental disorders compared to the general population, it remains unclear whether this pattern persists into adulthood. A quantitative synthesis of existing studies is lacking. The aim of this meta-analysis was to estimate the prevalence rates for mental disorders among adults with a foster or residential child welfare or juvenile justice care history, comparing them where possible to rates among the general population. PubMed, PsycInfo, EMBASE, and Web of Science were systematically searched for epidemiological studies published up to 28 October 2020. Nineteen studies, totaling 604,257 participants, met our inclusion criteria. Random-effects models were used for prevalence rates and odds ratios (OR) of mental disorders, and study quality was rated. A prevalence rate of 30% [95% CI (23.36, 37.36)] for any mental disorder in adults with a child welfare care history was found (3-17% for specific disorders). A prevalence rate of 45% [95% CI (42.38, 47.38)] for any mental disorder was found in adults with a juvenile justice care history (6-66% for specific disorders). For out-of-home placement history, adult mental disorders were significantly higher than in the general population (OR = 1.33-2.76). Studies differed in terms of methodology and the disorder groups considered, so heterogeneity between effect sizes ranged from low to high. Our findings suggest that the high risk that mental health issues will persist in adults with an out-of-home placement history needs to be taken seriously in the transition from adolescence to adulthood. The care systems involved need to collaborate and to be aware of these risks.

Association of public care in childhood with social, criminal, cognitive, and health outcomes in middle-age: five decades of follow-up of members of the 1958 birth cohort study

BACKGROUND

Children who have been exposed to public (out-of-home) care experience a range of negative outcomes by late adolescence and early adulthood. The longer-term impact of childhood care is, however, uncertain.

AIM

To examine if there is a prospective association between childhood public care and adverse life outcomes in middle-age.

METHODS

We used data from the UK 1958 birth cohort study of 18 558 individuals. Parents reported offspring care status at age 7, 11 and 16. An array of social, criminal, cognitive, and health outcomes was self-reported by cohort members at age 42 (71% response proportion in eligible sample) and a cognitive test battery was administered at age 50 (62% response).

RESULTS

A total of 420 (3.8%) of 11 160 people in the analytical sample experienced childhood public care by age 16. Net of confounding factors, experience of public care (vs none) was linked to 11 of the 28 non-mutually exclusive endpoints captured in middle-age, with the most consistent effects apparent for psychosocial characteristics: 4/7 sociodemographic (eg, odds ratio; 95% confidence interval for homelessness: 2.1; 1.4 to 3.1); 2/2 antisocial (eg, use of illicit drug: 2.0; 1.2 to 3.5); 2/3 psychological (eg, mental distress: 1.6; 1.2 to 2.1); 1/3 health behaviours (eg, current cigarette smoker: 1.7; 1.3 to 2.2); 2/8 somatic health (physical disability: 2.7; 1.9 to 3.8); and 0/5 cognitive function (eg, beta coefficient; 95% confidence interval for immediate word recall: -0.1; -0.3 to 0.1) endpoints.

CONCLUSIONS

The present study suggests that selected associations apparent between childhood care and outcomes in adolescence and early adulthood are also evident in middle-age.

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review

Purpose: Black women in the United States face poor outcomes across reproductive health measures-from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

Do Aftercare Services Take Young People's Health Behaviour into Consideration? A Retrospective Document Analysis from Finland

BACKGROUND

Health disparities among children and young people predict health disparities in adulthood and cause a long-term detrimental impact on a person's quality of life as well as increased costs to society.

PURPOSE

The purpose of the study was to describe the health behaviour of Finnish young people (n = 600) who had left aftercare services by the end of April 2015 based on their electronic patient records.

DESIGN AND METHODS

A retrospective document analysis. Data were collected from the register by a structured worksheet designed for this study and analysed using descriptive statistical methods.

RESULTS

The entries made in the aftercare participants' records concerning their weight, sleep and rest, smoking and sexual health were insufficient. The documents contained clearly more detailed reports of their substance use. Women were affected more than men by lifestyles other than substance abuse endangering their health. An increase in the number of out-of-home care placements produces a spike in risky behaviour.

CONCLUSIONS

The young people in aftercare are in an unequal position compared to the mainstream population in the area of health promotion. Their risky behaviour is not identified or taken into consideration.

PRACTICE IMPLICATIONS

Aftercare and the related multiprofessional collaboration must be developed to prevent risks related to the young persons` health and to take these comprehensively into account.

The Impact of Health Care Education on Utilization Among Adolescents Preparing for Emancipation From Foster Care

PURPOSE

As teens in foster care prepare for emancipation, health care navigation is often overlooked, as caseworkers address other social needs. This study examined the impact of health care education materials designed for foster youth, called ICare2CHECK. It was hypothesized that ICare2CHECK would increase nonurgent ambulatory health care use and decrease emergency/urgent care use.

METHODS

Adolescents (N = 151; aged 16-22 years) were enrolled in ICare2CHECK and received health education materials at their baseline study visit. Surveys were repeated every 3 months to assess health care utilization. After 12 months of enrollment, health care data for all eligible youth and matched comparison youth (N = 151) over the previous 24 months were extracted from the electronic health record (N = 302). Electronic health record data were coded as counts of completed nonurgent ambulatory care encounters (i.e., primary and preventative care and specialty care), completed urgent or emergency encounters (i.e., urgent and emergency department visits and hospitalizations), completed foster care clinic visits, and total completed visits.

RESULTS

Health care use significantly decreased over time for both enrolled and comparison youth. Females, youth engaging in health risk behaviors, and those with a mental health or chronic condition diagnosis used significantly more health care. Receipt of educational materials was associated with a smaller decline in health care use and nonurgent ambulatory care use, controlling for covariates. Self-reported use of educational materials was associated with increased utilization in the enrolled condition.

CONCLUSIONS

Results suggest that ICare2CHECK is associated with increased engagement in health care generally and nonurgent ambulatory care specifically (e.g., outpatient primary and specialty care).

Childhood Adversity and Associated Psychosocial Function in Adolescents with Complex Trauma

Background

Childhood adversity is linked to a number of adult health and psychosocial outcomes; however, it is not clear how to best assess and model childhood adversity reported by adolescents with known maltreatment exposure.

Objective

This study sought to identify an empirically-supported measurement model of childhood adversity for adolescents in child protective custody and associations among childhood adversity and adolescent outcomes.

Methods

Self-report survey data assessed childhood adversity and adolescent outcomes, including psychological wellbeing, quality of life, and substance use, in 151 adolescents ages 16 to 22 in protective custody with a documented maltreatment history.

Results

Findings suggest that, among youth with complex trauma histories, it is important to distinguish among risk related to unexpected tragedy (e.g., natural disaster, parental divorce), family instability (e.g., parental substance abuse or mental health concerns), and family violence (e.g., physical or sexual abuse). Family violence was associated with poorer psychological wellbeing and quality of life, while family instability was associated with cigarette and marijuana use.

Conclusions

Among adolescents with complex trauma histories, childhood adversity assessments reflect multiple domains of adversity, each of which are differentially related to adolescent risks. Properly assessing childhood adversity in adolescents with complex trauma histories may help target interventions for specific risks (e.g., substance use) based on which types of childhood adversity youth have been exposed to.

Socioeconomic Characteristics of Neighborhoods where Youth in Out-of-Home Care Reside

In the U.S., little is known about the neighborhoods where youth in out-of-home care live prior to emancipation. This study describes the socioeconomic characteristics of such neighborhoods. Addresses for 229 youth aged 16-20 years and residing in out-of-home care in a single Midwest county were used. Addresses were geocoded and linked to U.S. Census' data at the census tract level. Neighborhoods, or tracts, with youth in out-of-home care were significantly more disadvantaged across five area-based socioeconomic indicators. Findings suggest that youth in out-of-home care live in neighborhoods with disproportionately high rates of socioeconomic disadvantage.

The role of adverse childhood experiences and mental health care use in psychological dysfunction of male multi-problem young adults

Adverse childhood experiences (ACEs) are associated with severe problems later in life. This study examines how eleven types of ACEs and mental health care use history are related to current psychological dysfunction among multi-problem young adults. A sample of 643 multi-problem young adult men (age 18-27) gave informed consent for us to collect retrospective regional psychiatric case register data and filled out questionnaires. ACEs were highly prevalent (mean 3.6, SD 2.0). Logistic regression analysis showed that compared with participants who experienced other ACEs, participants who experienced psychological problems in their family and grew up in a single-parent family were more likely to have used mental health care, and physically abused participants were less likely to have used mental health care. Linear regression analyses showed a dose-response relationship between ACEs and internalizing and externalizing problems. Linear regression analyses on the single ACE items showed that emotional abuse and emotional neglect were positively related to internalizing problems. Emotional and physical abuse and police contact of family members were positively related to externalizing problems. While multi-problem young adults experienced many ACEs, only a few ACEs were related to mental health care use in childhood and adolescence. Long-term negative effects of ACEs on psychological functioning were demonstrated; specifically, emotional abuse and emotional neglect showed detrimental consequences. Since emotional abuse and emotional neglect are not easily identified and often chronic, child health professionals should be sensitive to such problems.

Mental and Physical Health Profiles of Maltreated Youth

To examine both mental and physical health profiles of children diagnosed as maltreated in the community, we studied diagnoses in the electronic health records (EHRs) of youth assigned maltreatment-related diagnoses (N = 406) and well-matched youth without a maltreatment-related diagnosis (N = 406) during a four-year period in a large healthcare system that covers eight hospitals and over 40 clinics. Data extracted automatically from the EHRs was supplemented by manual chart review. The odds of the maltreated group being assigned a code for mental illness was 2.69 times higher than the odds for the comparison group, with large differences in mood and anxiety disorders and suicidality. The odds of having an injury or poisoning diagnosis were 3.45 times higher in maltreated than in comparison youth. Maltreated youth were also less likely to have been immunized. Nevertheless, contrary to our hypothesis, maltreated youth had significantly lower rates of diagnoses across almost all major physical disease categories assessed and did not differ from comparison youth in terms of body mass index (BMI). Furthermore, maltreated youth were assigned fewer diagnoses than comparison youth whether they came in for at least one preventive visit or not. Findings suggest a need for health care professionals to be prepared to address the high rates of mental disorders in maltreated youth, to be more vigilant about possible physical disorders in this population, and to take greater advantage of opportunities to immunize these youth.

Adverse Childhood Experiences and Young Adult Health Outcomes Among Youth Aging Out of Foster Care

OBJECTIVE

Former youth in foster care (YFC) are at greater risk of chronic health conditions than their peers. Although research in general population samples has shown a dose-response relationship between adverse childhood experiences (ACEs) and adult health outcomes, few studies have conducted similar analyses in highly stress-exposed populations such as YFC. In this study we used person-centered latent class analysis methods to examine the relationship between different profiles of ACE exposures and divergent health trajectories among this high-risk population.

METHODS

Data are from longitudinal research that followed transition-age YFC from age 17 to 26 (N = 732). Using 3 subgroups previously identified by their ACEs histories-complex, environmental, and lower adversity groups-we applied group mean statistics to test for differences between the groups for physical and sexual health outcomes in young adulthood.

RESULTS

In contrast to previous research that showed that the environmental group was at the highest risk of criminalbehavior outcomes, for most of the physical and sexual health risk outcomes evaluated in this study, the complex adversity group had the highest risk.

CONCLUSIONS

This study shows that there are subgroups of YFC, which each have a distinct profile of risk in young adulthood, with the complex group being at highest risk of the physical and sexual health risk outcomes evaluated. Findings strongly suggest the need for targeted strategies to promote screening for ACEs and chronic health conditions, linkage to adult health care, and continuity of care for adolescents and young adults in foster care to offset these trajectories.

Improving Child Welfare Outcomes: Balancing Investments in Prevention and Treatment

To provide objective analyses about the effects of prevention and treatment programs on child welfare outcomes, RAND researchers built a quantitative model that simulated how children enter and flow through the nation's child welfare system. They then used the model to project how different policy options (preventive services, family preservation treatment efforts, kinship care treatment efforts, and a policy package that combined preventive services and kinship care) would affect a child's pathway through the system, costs, and outcomes in early adulthood. This study is the first attempt to integrate maltreatment risk, detection, pathways through the system, and consequences in a comprehensive quantitative model that can be used to simulate the impact of policy changes. This research suggests that expanding both prevention and treatment is needed to achieve the desired policy objectives: Combining options that intervene at different points in the system and increasing both prevention and treatment generates stronger effects than would any single option. The simulation model identifies ways to increase both targeted prevention and treatment while achieving multiple objectives: reducing maltreatment and the number of children entering the system, improving a child's experience moving through the system, and improving outcomes in young adulthood. These objectives can all be met while also reducing total child welfare system costs. A policy package combining expanded prevention and kinship supports pays for itself: There is a net cost reduction in the range of 3 to 7 percent of total spending (or approximately $5.2 billion to $10.5 billion saved against the current baseline of $155.9 billion) for a cohort of children born over a five-year period.

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.

Child Protection Service interference in childhood and the relation with mental health problems and delinquency in young adulthood: a latent class analysis study

BACKGROUND

Most multi-problem young adults (18-27 years old) have been exposed to childhood maltreatment and/or have been involved in juvenile delinquency and, therefore, could have had Child Protection Service (CPS) interference during childhood. The extent to which their childhood problems persist and evolve into young adulthood may differ substantially among cases. This might indicate heterogeneous profiles of CPS risk factors. These profiles may identify combinations of closely interrelated childhood problems which may warrant specific approaches for problem recognition and intervention in clinical practice. The aim of this study was to retrospectively identify distinct statistical classes based on CPS data of multi-problem young adults in The Netherlands and to explore whether these classes were related to current psychological dysfunctioning and delinquent behaviour.

METHODS

Age at first CPS interference, numbers and types of investigations, age at first offence, mention of child maltreatment, and family supervision order measures (Dutch: ondertoezichtstelling; OTS) were extracted from the CPS records of 390 multi-problem young adult males aged 18-27 (mean age 21.7). A latent class analysis (LCA) was conducted and one-way analyses of variance and post-hoc t-tests examined whether LCA class membership was related to current self-reported psychological dysfunctioning and delinquent behaviour.

RESULTS

Four latent classes were identified: (1) late CPS/penal investigation group (44.9%), (2) early CPS/multiple investigation group (30.8%), (3) late CPS interference without investigation group (14.6%), and (4) early CPS/family investigation group (9.7%). The early CPS/family investigation group reported the highest mean anxiousness/depression and substance use scores in young adulthood. No differences were found between class membership and current delinquent behaviour.

CONCLUSIONS

This study extends the concept that distinct pathways are present in multi-problem young adults who underwent CPS interference in their youth. Insight into the distinct combinations of CPS risk factors in the identified subgroups may guide interventions to tailor their treatment to the specific needs of these children. Specifically, treatment of internalizing problems in children with an early onset of severe family problems and for which CPS interference is carried out should receive priority from both policy makers and clinical practice.

Cost Effectiveness of a School Readiness Intervention for Foster Children

OBJECTIVE

Many young children in foster care suffer from emotional and behavior problems due to neglect and abuse. These problems can lead to difficulties in school, and functioning in school is linked to long-term health and development. Early intervention to reduce emotional and behavioral issues can help children successfully transition to school, which can improve long-term outcomes. However, communities need information on relative costs and benefits associated with programs to make informed choices. The objective of this study was to assess cost effectiveness, over 12 months, of the Kids in Transition to School (KITS) intervention compared to usual services available to children in a foster care control group (FCC).

METHOD

Randomized controlled trial of 192 children in foster care entering kindergarten who were randomized to KITS (n = 102) or FCC (n = 90). KITS includes school readiness groups and parent training over 4 months. Main outcomes were days free from internalizing symptoms (IFD), days free from externalizing behavior (EFD), intervention costs, public agency costs, and incremental cost effectiveness.

RESULTS

KITS significantly increased IFD and EFD compared to FCC. Average total cost of the intervention was $932 per family. The intervention did not significantly impact usual services. Average incremental cost effectiveness was $64 per IFD and $63 per EFD.

CONCLUSIONS

The cost of KITS is comparable to, or less than, similar programs, and the intervention is likely to provide significant emotional and behavioral benefits and improvements in school readiness for young children in foster care.

ADVERSE CHILDHOOD EXPERIENCES AMONG YOUTH AGING OUT OF FOSTER CARE: A LATENT CLASS ANALYSIS

Research has demonstrated that youth who age out, or emancipate, from foster care face deleterious outcomes across a variety of domains in early adulthood. This article builds on this knowledge base by investigating the role of adverse childhood experience accumulation and composition on these outcomes. A latent class analysis was performed to identify three subgroups: Complex Adversity, Environmental Adversity, and Lower Adversity. Differences are found amongst the classes in terms of young adult outcomes in terms of socio-economic outcomes, psychosocial problems, and criminal behaviors. The results indicate that not only does the accumulation of adversity matter, but so does the composition of the adversity. These results have implications for policymakers, the numerous service providers and systems that interact with foster youth, and for future research.

Qualitative Evaluation of Historical and Relational Factors Influencing Pregnancy and Sexually Transmitted Infection Risks in Foster Youth

PURPOSE

To explore how attitudes, norms, behaviors, responses to early life experiences, and protective factors influence pregnancy and sexually transmitted infection risks from the perspectives of current and former foster youth to inform the development of prevention strategies.

METHODS

We conducted semi-structured individual qualitative interviews with a diverse sample of 22 current/former foster youth aged 15-21 years (63% female; average age = 18.6 years). We then used Theoretical Thematic Analysis to systematically analyze the data for key themes related to sexual health in four categories: 1) norms and attitudes, 2) responses to early life experiences, 3) protective factors, and 4) youth-driven intervention ideas.

RESULTS

Participants reported a range of sexual experience levels, varied sexual orientations, and also reported varied life experiences prior to and during foster care. We detected several norms and attitudes that likely contribute to risks of early pregnancies and sexually transmitted infections. These included that one can tell by looking whether a partner is trustworthy or has a sexually transmitted infection, that condoms aren't necessary with long-term or infrequent partners or if birth control is used, and that teen pregnancy is an inevitable event. With respect to responses to early life experiences, youth frequently described difficulties dealing with strong emotions in the context of romantic and/or sexual relationships; many attributed these difficulties to early experiences with biological family members or in foster care. Participants linked emotion regulation difficulties with struggles in trust appraisal, effective communication, and impulsive behaviors. Youth also described a variety of protective factors that they felt helped them prevent sexual risk behaviors or improved their lives in other respects. Finally, participants endorsed factors likely to improve intervention acceptability and efficacy, including an open, non-judgmental group-based environment, involvement of peer mentors, and inclusion of caregiver and caseworker training components.

CONCLUSIONS

Trauma-informed, tailored intervention strategies which address key norms and attitudes and provide broad-based assertiveness and emotion regulation skills are likely to be the most effective strategies to reduce risks of teen pregnancies and sexually transmitted infections among teens in foster care. Group-based interventions that involve peer mentors and caregiver and caseworker components may be especially acceptable and effective for teens in foster and/or kinship care.

Maltreatment histories of aging out foster youth: A comparison of official investigated reports and self-reports of maltreatment prior to and during out-of-home care

This study compared official investigated reports of child maltreatment with retrospective self-reports prior to and during out-of-home care for a sample of foster youth who reached the age of majority in out-of-home care in Illinois. Using matched administrative and self-reported data for 474 youth who completed a baseline interview in the Midwest Evaluation of Adult Functioning of Former Foster Youth (i.e. the Midwest study) at ages 17-18, and 386 youth who completed a follow up interview at age 19, this study finds that official reports and self-reports of maltreatment prior to and during out-of-home care differ significantly. Findings from this study add insight into measurement discrepancies, and help to inform understanding of the extent of maltreatment experienced by this sub-sample of young people exiting out-of-home care in adulthood. Study findings have implications for independent living policy and practice in child welfare.

Medical foster care: what happens when children with medical complexity cannot be cared for by their families?

Medical interventions for life-threatening pediatric conditions often oblige ongoing and complex medical care for survivors. For some children with medical complexity, their caretaking needs outstrip their parents' resources and abilities. When this occurs, the medical foster care system can provide the necessary health care and supervision to permit these children to live outside of hospitals. However, foster children with medical complexity experience extremes of social and medical risk, confounding their prognosis and quality of life beyond that of similar children living with biologic parents. Medical foster parents report inadequate training and preparation, perpetuating these health risks. Further, critical decisions that weigh the benefits and burdens of medical interventions for these children must accommodate complicated relationships involving foster families, caseworkers, biologic families, legal consultants, and clinicians. These variables can delay and undermine coordinated and comprehensive care. To rectify these issues, medical homes and written care plans can promote collaboration between providers, families, and agencies. Pediatricians should receive specialized training to meet the unique needs of this population. National policy and research agendas could target medical and social interventions to reduce the need for medical foster care for children with medical complexity, and to improve its quality for those children who do.

Children in nonparental care: health and social risks

Approximately 2.3 million children in the United States live separately from both parents; 70-90% of those children live with a relative. Compared with children living with one or both parents, children in nonparental care are in poorer health, are at heightened risk for experiencing disruptions and instability in caregiving, and are vulnerable to other social antecedents of child health (e.g., neglect, poverty, maltreatment). Given the significant impact of adversity in childhood on health across the lifespan, which is increased among children in nonparental care, it is informative to consider the health risks of children living in nonparental care specifically. Research examining the contributions of poverty, instability, child maltreatment, and living in nonparental care, including meta-analyses of existing studies, are warranted. Longitudinal studies describing pathways into and out of nonparental care and the course of health throughout those experiences are also needed. Despite these identified gaps, there is sufficient evidence to indicate that attention to household structure is not only relevant but also essential for the clinical care of children and may aid in identifying youth at risk for developing poor health across the lifespan.

Physical Health Problems and Barriers to Optimal Health Care Among Children in Foster Care

Children and adolescents in foster care placement represent a unique population with special health care needs, often resulting from pre-placement early adversity and neglected, unaddressed health care needs. High rates of all health problems, including acute and/or chronic physical, mental, and developmental issues prevail. Disparities in health status and access to health care are observed. This article summarizes the physical health problems of children in foster care, who are predisposed to poor health outcomes when complex care needs are unaddressed. Despite recognition of the significant burden of health care need among this unique population, barriers to effective and optimal health care delivery remain. Legislative solutions to overcome obstacles to health care delivery for children in foster care are discussed.