Disrupted family reunification: Mental health, race, and state-level factors

The children's mental health landscape is rapidly changing, and youth with mental health conditions (MHCs) are overrepresented in the child welfare system. Mental health is the largest unmet health need in child welfare, so MHCs may affect the likelihood of system reentry. Concerns regarding mental health contribute to calls for expanded supports, yet systems contact can also generate risk of continued child welfare involvement via surveillance. Still, we know little about how expanded supports at the state-level shape child welfare outcomes. Using the Adoption and Foster Care Analysis Reporting System (AFCARS), we examine the association between MHCs and system reentry within 36 months among youth who reunified with their families in 2016 (N = 41,860). We further examine whether this association varies across states and White, Black, and Latinx racial and ethnic groups via two- and three-way interactions. Results from multilevel models show that, net of individual and state-level factors, MHCs are associated with higher odds of reentry. This relationship is stronger for youth in states that expanded Medicaid by 2016 and with higher Medicaid/CHIP child participation rates. The results also show evidence of the moderating role of state-level factors, specifically student-to-school counselor ratio, diverging across racial and ethnic groups. Our results suggest a need for systems of care to better support youth mental health and counteract potential surveillance.

Foster Care and Health in Medicaid-Enrolled Children Experiencing Parental Opioid Use Disorder

Importance

The burden of the US opioid crisis has fallen heavily on children, a vulnerable population increasingly exposed to parental opioid use disorder (POUD) in utero or during childhood. A paucity of studies have investigated foster care involvement among those experiencing parental opioid use during childhood and the associated health and health care outcomes.

Objective

To examine the health and health care outcomes of children experiencing POUD with and without foster care involvement.

Design, Setting, and Participants

This population-based cohort study used nationwide Medicaid claims data from January 1, 2014, to December 31, 2020. Participants included Medicaid-enrolled children experiencing parental opioid use-related disorder during ages 4 to 18 years. Data were analyzed between January 2023 and February 2024.

Exposure

Person-years with (exposed) and without (nonexposed) foster care involvement, identified using Medicaid eligibility, procedure, and diagnostic codes.

Main Outcomes and Measures

The main outcomes included physical and mental health conditions, developmental disorders, substance use, and health care utilization. The Pearson χ2 test, the t test, and linear regression were used to compare outcomes in person-years with (exposed) and without (nonexposed) foster care involvement. An event study design was used to examine health care utilization patterns before and after foster care involvement.

Results

In a longitudinal sample of 8 939 666 person-years from 1 985 180 Medicaid-enrolled children, 49% of children were females and 51% were males. Their mean (SD) age was 10 (4.2) years. The prevalence of foster care involvement was 3% (276 456 person-years), increasing from 1.5% in 2014 to 4.7% in 2020. Compared with those without foster care involvement (8 663 210 person-years), foster care involvement was associated with a higher prevalence of developmental delays (12% vs 7%), depression (10% vs 4%), trauma and stress (35% vs 7%), and substance use-related disorders (4% vs 1%; P < .001 for all). Foster children had higher rates of health care utilization across a wide array of preventive services, including well-child visits (64% vs 44%) and immunizations (41% vs 31%; P < .001 for all). Health care utilization increased sharply in the first year entering foster care but decreased as children exited care.

Conclusions and Relevance

In this cohort study of Medicaid-enrolled children experiencing parental opioid use-related disorder, foster care involvement increased significantly between 2014 and 2020. Involvement was associated with increased rates of adverse health outcomes and health care utilization. These findings underscore the importance of policies that support children and families affected by opioid use disorder, as well as the systems that serve them.

Child protective services involvement and exclusionary school discipline

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

Reunification trajectories in Quebec: Acknowledging chronic family challenges to support stability

BACKGROUND

While family reunification following out-of-home placement is a goal of child protection policy, complex family needs may not be met at the point that child protection systems reunify families. Permanency legislation creating maximum placement timeframes prompts questions regarding what families need to be supported in stably reunifying following a child's removal from the home.

OBJECTIVE

We aim to identify clinical risk factors salient for initial placements and placements following a child reunifying with their family to inform successful reunification and improve children's stability.

PARTICIPANTS AND SETTING

The study includes a representative sample of children in Quebec with a child protection investigation in 2008 (N = 3051) followed for nine years.

METHODS

Cross-sectional clinical data from the Quebec Incidence Study (QIS) on Evaluated Child Protection Reports (2008) were linked with longitudinal administrative data from 16 provincial child protection agencies. Canadian Census data (2006) were used to create a factorial index measure for poverty. Chi-square automatic interaction detector (CHAID) decision tree analysis was used to compare risk factors salient for initial placements (n = 1120) with post-reunification placements (n = 455).

RESULTS

For the placement sample (n = 1120), significant factors were: attachment issues, caregiver drug use, child's suicidal thoughts, child's self-harming behavior, and academic difficulties. Of the children who reunified with their families (n = 847), over half (n = 455; 54%) returned to out-of-home placements. Certain factors remained significant for placement after reunification: academic difficulties, attachment issues, and caregiver drug use. The CHAID model fit estimates suggest 70.9% (SE = 0.008) accuracy predicting out-of-home placement following child protection investigation and 58.2% (SE = 0.017) accuracy predicting re-placement following family reunification.

CONCLUSIONS

Complex needs among families most likely to experience reunification breakdown indicate potential service gaps. When legislated placement timeframes prompt quick resolution of family challenges, these analyses can contribute to policy discussions regarding clinical family challenges that impact stability.

Developmental Service Referrals and Utilization Among Young Children in Protective Custody

Children in foster care are at high risk for developmental delay. In this retrospective cohort study of young children presenting to a foster care clinic, 77% were not receiving developmental services and 75% failed developmental screening. Of those potentially eligible, 60% were not referred for developmental services.

Adverse Childhood Experiences and Rate of Memory Decline From Mid to Later Life: Evidence From the English Longitudinal Study of Ageing

Evidence on the role of early-life adversity in later-life memory decline is conflicting. We investigated the relationships between adverse childhood experiences (ACEs) and memory performance and rate of decline over a 10-year follow-up among middle-aged and older adults in England. Data were from biennial interviews with 5,223 participants aged 54 years or older in the population-representative English Longitudinal Study of Ageing from 2006/2007 to 2016/2017. We examined self-reports of 9 ACEs prior to age 16 years that related to abuse, household dysfunction, and separation from family. Memory was assessed at each time point as immediate and delayed recall of 10 words. Using linear mixed-effects models with person-specific random intercepts and slopes and adjusted for baseline age, participants' baseline age squared, sex, ethnicity, and childhood socioeconomic factors, we observed that most individual and cumulative ACE exposures had null to weakly negative associations with memory function and rate of decline over the 10-year follow-up. Having lived in residential or foster care was associated with lower baseline memory (adjusted β = -0.124 standard deviation units; 95% confidence interval: -0.273, -0.025) but not memory decline. Our findings suggest potential long-term impacts of residential or foster care on memory and highlight the need for accurate and detailed exposure measures when studying ACEs in relation to later-life cognitive outcomes.

Exploring placement stability for children in out-of-home care in England: a sequence analysis of longitudinal administrative data

BACKGROUND

To monitor stability of care, the proportion of children in England who have experienced three or more placements in the preceding 12-month period is published in government statistics. However, these annual snapshots cannot capture the complexity and heterogeneity of children's longitudinal care histories.

OBJECTIVE

To describe the stability of care histories from birth to age 18 for children in England using a national administrative social care dataset, the Children Looked After return (CLA).

PARTICIPANTS AND SETTING

We analyzed CLA data for a large, representative sample of children born between 1992 and 1994 (N = 16,000).

METHODS

Using sequence analysis methods, we identified distinct patterns of stability, based on the number, duration, and timing of care placements throughout childhood.

RESULTS

Although care histories were varied, six distinct patterns of stability were evident including; adolescent 1^st entries (17.6%), long-term complex care (13.1%) and early intervention (6.9%). Overall, most children (58.4%) had a care history that we classified as shorter term care with an average of 276 days and 2.48 placements in care throughout childhood. Few children (4.0%) had a care history that could be described as long-term stable care.

CONCLUSIONS

Longitudinal analyses of administrative data can refine our understanding of how out-of-home care is used as a social care intervention. Sequence analysis is a particularly useful tool for exploring heterogeneous and complex care histories. Considering out-of-home care histories from a life course perspective over the entire childhood period could enable service providers to better understand and address the needs of looked after children.

Predictors of remaining in foster care after age 18 years old

BACKGROUND

The Fostering Connections to Success and Increasing Adoptions Act of 2008 created the option for U.S. states to extend the foster care age limit up to the 21 st birthday. The law provides foster youth extra protections while they transition to adulthood.

OBJECTIVE

To inform states' efforts to better design and implement extended foster care (EFC), we examine the impact of the policy change on length of EFC stay and factors associated with youth's time in EFC.

PARTICIPANTS AND SETTING

We use two samples of foster youth in California that extended the foster care age limit to 21 in 2012: 37,827 youths who turned 18 between the years 2008 and 2014 and 711 youths who participated in an interview-based panel study.

METHODS

Leveraging California's child welfare administrative data and California Youth Transitions to Adulthood Study's (CalYOUTH) survey data, we investigated predictors of months youths remained in EFC with linear regression and Cox proportional hazard regression.

RESULTS

Almost half of youth eligible for EFC remained in care until their 21 st birthday. These cohorts stayed in foster care up to 16 months longer (p < .001) than previous cohorts without an EFC option. Multiple individual factors were associated with youths' length of stay in EFC. However, a youth's county of placement made a greater difference on their time in EFC-up to 16 months (p < .05).

CONCLUSIONS

Our findings underscore the importance that placement location has on how long youth remain in EFC, and expands our understanding of how county and state context shape EFC participation.

The Effect of CASA on Child Welfare Permanency Outcomes

The present study is the largest and most rigorous study to date on the effects of being appointed a Court Appointed Special Advocate (CASA) on permanency outcomes of children in foster care. The intent-to-treat study accounts for selection bias by applying inverse probability weighting to logistic and sequential logistic regressions in a large sample of children in foster care in the state of Texas (N = 31,754). Overall, children appointed a CASA have significantly lower odds than children without a CASA of achieving permanency. They have lower odds of being reunified, greater odds of being adopted (if not reunified), and lower odds of being placed in permanent kin guardianship (if not reunified or adopted) than children who are not appointed CASA. This study makes an additional contribution by looking beyond the aggregate effect of CASA on permanency by examining the effect of CASA for different age groups and different types of first placement after removal.

Association of Child Placement in Out-of-Home Care With Trajectories of Hospitalization Because of Suicide Attempts From Early to Late Adulthood

Importance

Children placed in out-of-home care (OHC) have higher rates of suicidal behaviors, including suicide attempts, compared with those who grow up in their family of origin. Several studies have shown that this elevated risk persists into young adulthood. Yet, our knowledge about any longer-term associations of OHC with suicide attempts is limited.

Objective

To examine how childhood experiences of placement in OHC are associated with trajectories of hospitalization because of suicide attempts (HSA) from early into late adulthood.

Design, Setting, and Participants

This prospective birth cohort study that was conducted in Stockholm, Sweden, and analyzed in March 2020 included 14 559 individuals born in 1953 who were living in the greater metropolitan of Stockholm in November 1963 and followed through registers up until December 2016.

Exposures

Childhood experiences of OHC based on information from the Social Register (age 0-19 years).

Main Outcomes and Measures

Hospitalization because of suicide attempts based on in-patient care data from the National Patient Register. Group-based trajectory modeling was used to cluster individuals according to their probabilities of HSA across adulthood (age 20-63 years).

Results

In this cohort of 14 559 individuals (7146 women [49.1%]), 1320 individuals (9.1%) had childhood experiences of OHC, whereas 525 individuals ( 3.6%) had HSA. A Cox regression analysis showed a substantially higher risk of HSA among those with childhood experiences of OHC (hazard ratio, 3.58; 95% CI, 2.93-4.36) and after adjusting for a range of adverse childhood living conditions (hazard ratio, 2.51; 95% CI, 2.00-3.15). Those with at least 1 HSA were grouped into 4 trajectories: (1) peak in middle adulthood (66 [12.6%]), (2) stable low across adulthood (167 [31.8%]), (3) peak in early adulthood (210 [40.0%]), and (4) peak in emerging adulthood (82 [15.6%]). A multinomial regression analysis suggested that those with experiences of OHC had higher risks of following any of these trajectories (trajectory 1: relative risk ratio [RRR], 2.91; 95% CI, 1.61-5.26; trajectory 2: RRR, 3.18; 95% CI, 2.21-4.59; trajectory 3: RRR, 4.32; 95% CI, 3.18-5.86; trajectory 4: RRR, 3.26; 95% CI, 1.94-5.46). The estimates were reduced after adjusting for adverse childhood living conditions.

Conclusions and Relevance

The findings suggest that the elevated risk of suicide attempts among former child welfare clients does not cease after young adulthood, indicating the necessity for clinical attention to childhood experiences of OHC as a risk marker for suicidal behavior across the life span.

The Cumulative Prevalence of Termination of Parental Rights for U.S. Children, 2000-2016

Recent research has used synthetic cohort life tables to show that having a Child Protective Services investigation, experiencing confirmed maltreatment, and being placed in foster care are more common for American children than would be expected based on daily or annual rates for these events. In this article, we extend this literature by using synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System to generate the first cumulative prevalence estimates of termination of parental rights. The results provide support for four conclusions. First, according to the 2016 estimate, 1 in 100 U.S. children will experience the termination of parental rights by age 18. Second, the risk of experiencing this event is highest in the first few years of life. Third, risks are highest for Native American and African American children. Nearly 3.0% of Native American children and around 1.5% of African American children will ever experience this event. Finally, there is dramatic variation across states in the risk of experiencing this event and in racial/ethnic inequality in this risk. Taken together, these findings suggest that parental rights termination, which involves the permanent loss of access to children for parents, is far more common than often thought.

Predictors of placement disruptions in foster care

BACKGROUND

Many children who are removed from a dangerous or neglectful home and placed in state custody subsequently experience additional disruptions while in custody, which can compound the effects of ongoing stress and instability. As such, placement stability has been identified as a critical objective and a key indicator of success for children residing in substitutive care.

OBJECTIVE

To examine the utility of child protective services data in identifying predictors of placement disruption.

PARTICIPANTS AND SETTING

The current study examined data from youth in Tennessee state custody who had been assessed using the Child and Adolescent Needs and Strengths (CANS) assessment within 30-days of their first, out-of-home placement. The sample included 8,853 youth ages 5-19 years old (M = 13.1; SD = 4.0; 44.8 % female).

METHODS

Demographics, placement information, and the CANS assessment were collected by the Tennessee Department of Children's Services for all child welfare episodes for children as part of the system's usual standard of care. Bivariate correlation and linear regression models were conducted.

RESULTS

Multiple risk indices from the CANS appeared to significantly increase risk of placement disruption, including child internalizing and externalizing symptoms, school difficulties, youth affect dysregulation, and child age.

CONCLUSIONS

The current findings suggest that data collected as part of standard practice by child welfare workers such as the CANS is both feasible and has utility for identifying sources of risk for placement disruptions and to inform possible targets of intervention to enhance placement stability.

Unintentional child injury in child welfare placements

BACKGROUND

Child welfare professionals are charged with protecting children from non-accidental caregiving behaviors resulting in intentional injuries as well as environmental risks and parenting behaviors resulting in unintentional injuries. Yet little is known about unintentional injury prevalence and risk factors by child welfare placement type.

OBJECTIVE

To examine factors related to unintentional child injury requiring medical attention, including child welfare placement type, child behavioral problems, caregiver characteristics, and neighborhood factors.

METHODS

Data from the second and third wave of the 2010 National Survey of Child and Adolescent Well-Being (NSCAW II) were used. Stable child welfare placements between waves 2 and 3 included investigated biological, reunified, adopted, licensed and unlicensed kin, and nonkin foster homes. Logistic regression analysis modeled injury as a function of placement type while controlling for other covariates. Interaction effects between placement and child behavioral scores were also modeled.

RESULTS

Children with more behavioral problems were at greater odds of an injury (OR = 1.05, p < .01) compared to children with fewer behavioral problems. However, interaction models showed that children with more behavioral problems were at decreased odds of injury if living with unlicensed kin (OR = .91, p < .05), licensed kin (OR = .92, p < .001), or foster care (OR = .92, p < .001) compared to biological homes.

CONCLUSION

The absence of a behavioral problem was associated with higher risk of injury for children placed in foster care. More research is needed to better understand injury type, prevalence and specific risk factors.

Early Childbirth Among Foster Youth: A Latent Class Analysis to Determine Subgroups at Increased Risk

CONTEXT

Research has documented elevated rates of early childbirth among adolescents who have spent time in foster care, and a better understanding is needed of the characteristics of vulnerable individuals and the circumstances of their time in care.

METHODS

California birth records for 1999-2010 were probabilistically linked to state child welfare service records spanning the same date range to identify females aged 12-19 who had spent time in foster care and had had a first birth before age 20. Latent class analysis was used to identify subgroups based on age at most recent entry into care, length of this stay and three indicators of placement instability. The probability of a first birth being related to class membership was assessed as a distal outcome, and differences across classes were assessed using chi-square tests.

RESULTS

Four distinct classes of foster youth were identified: Later Entry/High Instability (20% of individuals), Later Entry/Low Instability (43%), Earlier Entry/High Instability (12%) and Earlier Entry/Low Instability (25%). The probability of a first childbirth ranged from 31% (class 1) to 15% (class 4); classes 2 and 3 experienced moderate risk (23% and 24%, respectively). Two groups were further characterized by high rates of reentry into care, with 56% of class 1 and 41% of class 3 individuals experiencing more than one episode in care.

CONCLUSIONS

Identifiable subgroups of female foster youth are at heightened risk of early childbirth and may benefit from early intervention, enhanced support and access to reliable, ongoing sexual and reproductive health care.

Mapping the evidence about what works to safely reduce the entry of children and young people into statutory care: a systematic scoping review protocol

INTRODUCTION

The increasing number of children and young people entering statutory care in the UK is a significant social, health and educational priority. Development of effective approaches to safely reduce this number remains a complex but critical issue. Despite a proliferation in interventions, evidence summaries are limited. The present protocol outlines a scoping review of research evidence to identify what works in safely reducing the number of children and young people (aged ≤18 years) entering statutory social care. The mapping of evidence gaps, clusters and uncertainties will inform the research programme of the newly funded Department for Education's What Works Centre for Children's Social Care.

METHODS AND ANALYSIS

The review uses Arksey and O'Malley's scoping review methodology. Electronic database and website searches will identify studies targeting reduction of care entry, reduction of care re-entry and increase in post-care reunification. Supplementary searching techniques will include international expert consultation. Abstracts and full-text studies will be independently screened by two reviewers. Ten per cent of data abstraction will be independently conducted by two reviewers, with the remainder being extracted and then verified by a second reviewer. Descriptive numerical summaries and a thematic qualitative synthesis will be generated. Evidence will be synthesised according to primary outcome, intervention point (mapped across socioecological domains) and the realist EMMIE categorisation of evidence type (Effectiveness; Mechanisms of change; Moderators; Implementation; Economic evaluation).

ETHICS AND DISSEMINATION

Outputs will be a conceptual evidence map, a descriptive table quantitatively summarising evidence and a qualitative narrative summary. Results will be disseminated through a peer-reviewed publication, conference presentations, the What Works Centre website, and knowledge translation events with policy-makers and practitioners. Findings will inform the primary research programme of the What Works Centre for Children's Social Care and the subsequent suite of systematic reviews to be conducted by the Centre in this substantive area.

Child welfare characteristics in a sample of youth involved in commercial sex: An exploratory study

BACKGROUND

Homeless, runaway, and youth exiting foster care are vulnerable to sexual exploitation, but little research has parsed the societal, community, and individual factors that contribute to their risk.

OBJECTIVES

(1) To estimate child welfare characteristics in a sample of homeless young people who engaged in commercial sex (CS); and (2) To compare young people who were sex trafficked (ST) to those who engaged in some other form of CS.

PARTICIPANTS AND SETTING

This study includes 98 homeless young people in Philadelphia, PA, Phoenix, AZ, and Washington, DC, who were interviewed for a larger study of ST and endorsed engagement in CS.

METHODS

We used a non-probability, purposive, maximum variation sampling procedure. Interviews were recorded and responses were simultaneously noted on a standardized interview form. Data were analyzed through means, frequencies, and bivariate tests of association.

RESULTS

Average age of the full sample of 98 homeless young people was 20.9 years; 48% were female and 50% were Black/African American. Forty-six percent of the full sample was sex trafficked. The full sample and the victims of ST differed significantly in three child welfare characteristics, with the ST group more likely to have been maltreated as children, more likely to have had family involvement with the child welfare system (CWS), and more likely to report higher rates of living someplace other than with their biological parents as children.

CONCLUSIONS

ST victims differ from those who engaged in other forms of CS in histories of maltreatment, involvement with the CWS, and exposure to residential instability while growing up.

Children and youth in out-of-home care: What can predict an initial change in placement?

BACKGROUND

A significant proportion of children placed in out of-home care experience placement disruptions in the United States. Placement instability has deleterious effects on children's well-being.

OBJECTIVES

(a) To measure the time-to-initial placement change in different types of settings, including non-relative foster homes, kinship care, residential treatment centers (RTC), group homes and other types of settings; and (b) To identify predictors of the initial placement change.

PARTICIPANTS AND SETTING

Data were obtained from the State Automated Child Welfare Information System operated by the child welfare agency in a Mid-Atlantic state. The sample included 4177 children who entered into the foster care and were followed over three years.

METHOD

Descriptive, bivariate, and survival Cox regression models were conducted.

RESULTS

More than half (53%) of the children had experienced placement change within 3 years. The mean length for an initial change in placement was longer for children in RTC and kinship care compared to children in foster and group homes, and other placements (χ2 = 322.31, p < 0.001). Several factors significantly increased the likelihood of an initial change, including: older children (p < 0.001, HR = 1.01), children with behavioral problems (p < 0.001, HR = 1.26), parental substance abuse (p < 0.05, HR = 1.12), and cases in which the parents voluntarily gave up their parental rights (p < 0.05, HR = 1.12). The type of placement also increased the risk for placement change.

CONCLUSIONS

Providing early interventions and services to these children and their families is essential to increase placement stability.

Child protective services decision-making: The role of children's race and county factors

The current study investigates the role of race and county characteristics in substantiation and out-of-home placement decisions in the United States. Using multilevel models, we analyzed data from counties in the United States available through the National Child Abuse and Neglect Data Systems and Adoption and Foster Care Analysis and Reporting System to investigate the interactions between children's race and the context in which they live. Our sample consisted exclusively of children whose cases had been investigated; therefore, we were able to focus on the role played by race and county characteristics in substantiation and out-of-home placement decisions made by Child Protective Services, net of the heightened risk factors (or potential biases) that lead to disparate rates of reporting. Adjusting for state and county of investigation, Black, American Indian/Alaskan Native, and multiracial children were more likely than White (non-Hispanic) children to be substantiated or placed out of home, whereas Asian children were less likely to be substantiated or placed out of home. Notably, differences across groups are far smaller in magnitude when demographic and geographic differences are taken into account. Higher county-level poverty, percentages of Black residents, and juvenile arrest rates were associated with lower odds of substantiation and out-of-home placement among investigated children, whereas an elevated percentage of single-headed households was associated with higher odds of both outcomes. We also found that living in a rural county was associated with greater odds of substantiation but lower odds of out-of-home placement. Important differences by race were found for these associations. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

African American perspectives on racial disparities in child removals

BACKGROUND

African American children are overrepresented in foster care at twice to three times the rate of white children. Scholars argue that racism and oppression underlie disproportionality (Križ & Skivenes, 2011).

OBJECTIVE

This study explored disproportionality as seen through the eyes of African American parents in the child welfare system. The aim was to understand why African American families are over-represented in child custody statistics and to improve family and parenting support for African American communities.

PARTICIPANTS & SETTING

Participants included twenty-one African Americans--12 women and 9 men, two of whom were foster parents and 19 of whom were parents involved with child welfare services. All participants reside in two impoverished areas in southern United States. Focus groups were used to collect data and were conducted at a community center.

METHODS

The method of analysis was constant comparison analysis (Strauss) and thematic analysis of the focus group discussions in the context of institutional policy.

FINDINGS

Six themes (profound lack of trust; overwhelming trauma; severe and persistent poverty; health and mental health; socio-economic conditions; and sense of social isolation were identified, along with three participant suggestions to improve child welfare services (family support services, economic revival, and better communication).

CONCLUSIONS

In the current study we note the strong link between poverty, child maltreatment, and child removal and conclude with an exploration of practice and policy implications with recommendations for a way forward. The need for culturally competent and trauma informed child welfare services is also discussed.

Are sexual minority youth overrepresented in foster care, child welfare, and out-of-home placement? Findings from nationally representative data

BACKGROUND

Preliminary evidence suggests that sexual minority (e.g. lesbian, gay, bisexual, and same-sex attracted) youth are overrepresented in child welfare services. Yet, no study to date has been able to test this hypothesis with national data.

OBJECTIVE

Using a two-study design, we test whether sexual minority youth are overrepresented in child welfare, foster care, and out-of-home placement using nationally representative data from the United States.

PARTICIPANTS AND SETTING

Study 1 data are from the National Longitudinal Study of Adolescent to Adult Health (n = 14,154; Mean age = 15.4). Study 2 data are from wave three of the National Survey of Child and Adolescent Well-Being II (n = 1309; Mean age = 15.0).

METHODS

For Study 1, we use adjusted logistic regression models to test differences in lifetime foster care involvement between sexual minority and heterosexual youth. In Study 2, we calculate a Disproportionality Representation Index (DRI) - a ratio of sample prevalence relative to the general population - to estimate whether sexual minority youth were overrepresented in child welfare and out-of-home care.

RESULTS

Study 1 results indicate that sexual minority youth are nearly 2.5 times as likely as heterosexual youth to experience foster care placement (aOR = 2.43, 95% CI 1.40, 4.21, p = .002). Results from Study 2 show that sexual minority youth were largely overrepresented in child welfare services (DRI = 1.95-2.48) and out-of-home placement (DRI = 3.69-4.68).

CONCLUSIONS

Findings are the first to demonstrate sexual minority youth's overrepresentation in child welfare, foster care, and out-of-home placement using nationally representative data and emphasizes the need for focused research on sexual minority youth involved in the child welfare system.

An examination of child protective service involvement among children born to mothers in foster care

OBJECTIVE

This study identified children born to mothers in foster care and documented Child Protective Service (CPS) involvement among children.

METHODS

Probabilistically linked birth and CPS records from California (2009-2012) were used to identify all mothers in foster care on or after conception. Children were followed prospectively using linked records to identify CPS involvement occurring during the first three years of life. Differences between reported and unreported children were examined using χ2 tests. The Latent Class Analysis (LCA) identified classes of children born to mothers in care who were at increased risk of CPS involvement. Model fit was assessed using the Bayesian Information Criterion, entropy, and likelihood ratio tests. For each of the classes, the relationship to the distal outcome (i.e., a maltreatment report by age three), was examined.

RESULTS

Findings indicate that 53% of children born to mothers in care were reported. The proportion of children reported to CPS for maltreatment declined over time, from 63% of children born to mothers in foster care in 2009, to 46% in 2012. The LCA documented three distinct classes of mother-child dyads with varying risk of report. More than one third of children in Class 1 and nearly 70% of children in Class 3 were reported.

CONCLUSIONS

This study was the first to develop multi-dimensional class profiles of two-generation CPS involvement among mother-child dyads. This study documents that mothers' experiences in care and mental health conditions vary widely, underscoring the importance of providing services that fit the needs of dyads.

Temporary placements: A crisis-management strategy for physically abused children?

A large majority of children who are placed outside the family home experience temporary placements (between 1 to 60 days) at some point in time. Yet, information on the use of temporary placements remains fragmentary, with only occasional indirect references. This scant information does, however, suggests a particular link between physical abuse and temporary placements. The objective of the present study is to describe the context in which temporary placements are used by children's services in Quebec (Canada) while analyzing the associative link between temporary placements and physical abuse as the reason for the placement. Our study is based on a population cohort of 10,181 children placed in Quebec who have been followed for four years. Propensity-weighted multinomial regression analysis was used to assess the relative importance of the various individual pre-placement factors that may be associated with physical abuse. Results show that children investigated for physical abuse alone are 6.335 times more likely to have temporary placement trajectories compared to children investigated for other reasons. Cases that involved physical abuse combined with other reasons, were between 33.4% and 41% more likely to involve trajectories with temporary placements, than cases that were investigated for reasons other than physical abuse. Sex, age, and history of services have been used as covariates. In conclusion, the use of temporary placements is discussed with regards to the mandate of child-protection services and of certain etiological profiles of physical abuse.

State-level variation in the relationship between child removals and opioid prescriptions

BACKGROUND

One of the most devastating impacts of the U.S. opioid crisis is the challenge it creates for dependent parents to care for their children, potentially leading to the child being removed from their home. However, existing studies of the link between child removals and opioid prescriptions have either focused on a single state or estimated a national average.

OBJECTIVE

To estimate state-level associations between child removals and opioid prescriptions.

PARTICIPANTS AND SETTING

U.S. counties from 2010 to 2015.

METHODS

We performed longitudinal regression analysis in which the rates for all removals and removals associated with parental drug abuse were employed as dependent variables. In addition to the opioid prescription rate, additional explanatory variables included child removal risk factors, county fixed effects, year fixed effects, and state-specific time trends. Interaction variables were used to estimate state-specific relationships.

RESULTS

We found substantial variation in the association between child removals and opioid prescriptions. Twenty-three states had a positive association, fifteen had a negative association, and twelve did not have a statistically significant association. A one-standard deviation increase in the prescription rate was associated with a 37% (p < .001) increase in the removal rate for parental drug abuse in Illinois, while in New Hampshire it was associated with a 28% (p < .001) decrease.

CONCLUSIONS

The substantial variation in state-level relationships between child removals and opioid prescriptions may reflect differences in the extent to which states have experienced the opioid crisis and indicate the need for interventions that account for those differences.

End-of-life trends and patterns among children in the US foster care system: 2005-2015

Drawing on national, longitudinal Adoption and Foster Care Analysis, and Reporting System data (2005-2015), demographic, health, foster care, and geographic characteristics of decedents (N = 3653) aged 1-17 years were examined. On average, decedents were 6 years old, the highest proportion died as infants, and experienced significant trauma in their short lives either through maltreatment or exposure to parental substance use. A noted increase in Medicaid coverage among decedents over time suggests critical access to concurrent treatment and hospice care, but this is unavailable to children with private insurance. This study has policy implications related to the 2010 Affordable Care Act.

Predictors of psychological recommendations in child protection evaluation

Child protection matters from an important social and legal challenge, in which psychologists may be called upon to address a series of questions relevant for judicial decision-making. In an explorative manner, the current study investigates variables that influence psychological evaluators' recommendations in child protection cases. The data is based on a quantitative content review of 103 psychological evaluation reports, conducted at an institute of forensic psychology in Germany. Using bivariate and logistic regression analyses, the following predictors were analyzed in this study: Child-related factors, familial risk factors, and general custody criteria. The outcome measure was the evaluator's recommendation regarding long-term placement of the child and long-term custody arrangements. Evaluators were more likely to recommend permanent foster placement if the child showed insecure or disorganized attachment patterns, especially when combined with developmental delays, or if the child was temporarily in institutional or foster placement at the time of evaluation. The results support the conclusion that the most important factors for psychological expert recommendations refer to the "harm of the child" criterion in terms of developmental and psychological maladaptation.

Age-specific risk factors associated with placement instability among foster children

Placement instability places foster children at an increased risk of negative developmental outcomes. Previous research has yielded inconsistent results on risk factors for placement instability. Therefore, we investigated two research questions: (1) Which child attributes and case histories are associated with placement disruptions (moves indicative of child, agency or caregiver dissatisfaction with the existing placement)?; and (2) How do associations of child attributes and case histories with placement disruptions vary by developmental stage --early childhood (0-5 years), middle childhood (6-12 years), and adolescence (13 years or older)? Using a complete entry cohort of 23,765 foster children in Texas, our results demonstrated that the effects of different risk factors varied by placement end reason and across developmental stages. Of note, kinship placement, compared to non-relative foster care, and placement with all siblings were each associated with an increased risk of substandard care disruptions. Placements with females or Hispanic children were at an increased risk of child-initiated disruption, whereas placements with Black children were more likely to end due to placement mismatch or substandard care reasons. Finally, the adolescence age group was always associated with the greatest increase in risk regardless of disruption reason. These findings provide researchers, caseworkers, and policymakers important information on the risk factors for placement instability among children in foster care.

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) - a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs. The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.

Neglected children with severe obesity have a right to health: Is foster home an alternative?-A qualitative study

OBJECTIVE

To explore key person's perspectives of foster home placement or notification of risk of harm to Social Services of children with severe obesity.

METHODS

This case study research was performed in the southwest of Sweden and based on interviews with nine informants: a foster home youth, two foster parents, a social worker, two hospital social workers, a pediatric physician, a pediatric nurse, and a psychologist. Content analysis was used for narrative evaluations, within- and cross case analyses and displays.

RESULTS

Positive health outcomes of the foster home placement were described as a healthy and normalized weight status, a physically and socially active life, and an optimistic outlook on the future. The foster parents made no major changes in their family routines, but applied an authoritative parenting style regarding limit setting about sweets and food portions and supporting physical activity. The professionals described children with severe obesity as having suffered parental as well as societal neglect. Their biological parents lacked the ability to undertake necessary lifestyle changes. Neglected investigations into learning disabilities and neuropsychiatric disorders were seen in the school and healthcare sector, and better collaboration with the Social Services after a report of harm might be a potential for future improvements. Rival discourses were underlying the (in) decision regarding foster home placement.

CONCLUSION

A child's right to health was a strong discourse for acting when a child was at risk for harm, but parental rights are strong when relocation to a foster home is judged to be necessary.

Intergenerational transmission of out-of-home care in Sweden: A population-based cohort study

The objective of this study is to examine the intergenerational transmission of out-of-home care. This population-based study used data from the Swedish National Registers and included all children born in Sweden between 1990 and 2012 (followed for up to 13 years), whose parents were both born in Sweden between 1973 and 1980 (278 327 children; 145 935 mothers; 146 896 fathers). Cox regression models are used to obtain crude and adjusted hazard ratios (HR) of OHC placement among children based on parents' history of OHC. Compared with children whose parents both did not have a history of OHC, the risk of being placed in OHC was greater when both parents spent time in OHC (crude HR = 48.70, 95% CI 41.46-57.21; adjusted HR = 3.04, 95% CI = 2.54-3.64), however, children who had only one parent who spent time in care were also at higher risk (mothers only adjusted HR = 2.37, 95% CI = 2.08-2.70; fathers only adjusted HR = 1.33, 95% CI = 1.13-1.55). The crude rate of placement in OHC was highest for children whose parents were placed in care during adolescence, but after adjusting for social and behavioral covariates, children whose parents were in care in early childhood were at greater risk of OHC than children whose parents were in care in adolescence. To reduce this intergenerational transmission of OHC, more supports should be provided to parents who spent time in OHC to ensure a successful transition to parenthood.

Reasons for placement decisions in a case of suspected child abuse: The role of reasoning, work experience and attitudes in decision-making

Child welfare and child protection workers regularly make placement decisions in child abuse cases, but how they reach these decisions is not well understood. This study focuses on workers' rationales. The aim was to investigate the kinds of arguments provided in placement decisions and whether these arguments were predictors for the decision, in addition to the decision-makers' risk assessment, work experience and attitudes towards placement. The sample consisted of 214 professionals and 381 students from the Netherlands. The participants were presented with a vignette describing a case of alleged child abuse and were asked to determine whether the abuse was substantiated, to assess risks and to recommend an intervention. The participants' placement attitudes were assessed using a structured questionnaire. We found that the participants provided a wide range of arguments, but that core arguments - such as the suspected abuse, parenting and parent-child interaction - were often missing. Regression analyses showed that the higher the perceived danger to the child and the more positive the participants' attitudes towards placement, the more likely the participants would be to propose placing the child in care. Arguments related to the severity of the problems (i.e., suspected abuse, parenting and the child's development) as well as the parents' perceived cooperation also influenced placement decisions. The findings indicate trends in the decision-making process, in the sense that participants who decided to place the child out-of-home emphasized different arguments and had different attitudes towards out-of-home placement than those who did not. We discuss the implications of our findings.

Parenting intervention effects on reunification: A randomized trial of PMTO in foster care

Evidence-supported parenting interventions (ESPIs) have expanded into child welfare because a growing research base has demonstrated positive results among children with serious emotional and behavioral problems. Despite a clear federal policy emphasis on reunification, few randomized trials have tested ESPIs with biological families of children in foster care; even fewer studies have investigated the distal outcomes of ESPIs. The aim of the current study was to examine the effects of Parent Management Training, Oregon (PMTO) model on reunification. Children in foster care with emotional and behavioral problems were randomized to in-home PMTO (n = 461) or services as usual (SAU) (n = 457). Cox regression models tested whether children in the PMTO group achieved higher rates of reunification. We applied life tables data for integrals calculations to estimate days saved in foster care. Analyses were conducted as intent-to-treat (ITT), and per protocol analysis (PPA). ITT results showed reunification rates were 6.9% higher for the PMTO group (62.7%) than the SAU group (55.8%) with 151 days saved per typical child. PPA indicated that intervention completion strengthened effects as PMTO completers' reunification rates (69.5%) were 13.7% higher than the SAU group (55.8%), and were 15.3% higher than non-completers (54.2%). Days saved were also greater for completers as compared to the SAU group (299 days) and non-completers (358 days). Overall, findings suggest that an in-home parenting intervention positively affected reunification as delivered to biological parents of children and youth in foster care with serious emotional and behavioral problems. Implications and future considerations for research are discussed.

Educational attainment for youth who were maltreated in adolescence: Investigating the influence of maltreatment type and foster care placement

Decades of research have consistently shown a link between foster care and low rates of high school completion. Despite the overwhelming knowledge surrounding this association, it remains unclear whether the low rates of high school completion are due to placement in foster care or the maltreatment and other contextual factors that foster care youth have experienced. This study examined the extent to which (a) maltreatment type and (b) foster care placement were associated with the educational attainment of 337 maltreated adolescents. Logistic regression analyses were conducted using two waves of data and the ACR dataset of the National Survey of Child and Adolescent Well-Being (NSCAW). After controlling for academic risk factors related to the adolescents (age, race, and gender), their family (household poverty and parental education), and their environment (community environment), neither maltreatment type nor foster care placement status were associated with subsequent high school completion. Overall, only 58% of the maltreated adolescents reported completing their education. That is about 15% less than the national average at the time data were collected for this study. Results, overall, suggest a need for educational supports and interventions for youth who experience maltreatment during their adolescent years, regardless of maltreatment type and foster care placement.

Age and other risk factors related to reentry to care from kin guardian homes

Although kinship guardianship is an increasingly important foster care exit pathway for children in the United States, research on the factors leading to kinship guardianship breakdown is lacking. This study examines the factors associated with guardianship breakdown for children who exited foster care to kinship guardianship in California between 2003 and 2010 (N = 18,831). Specifying time-dependent Cox relative risk models, children's age trajectories are directly accounted for in the analysis. This allows differentiation between duration dependence (i.e., time spent in guardianship) and children's development (expressed as age). Overall, 17.3% of children reentered care by 2017. Early adolescents, age 13-15 years (HR = 1.63, p < .001), and late adolescents, age 16-17 years (HR = 1.93, p < .001), had an increased hazard of reentry compared with children under the age of six. Children with a history of mental health concerns had more than twice the hazard of reentering than children without such a history (HR = 2.18, p < .001). Our findings indicate that transition to adolescence was associated with increased risk of reentry into care, highlighting the need for guardianship support services leading up to, and during, this child developmental stage.

Course of Disinhibited Social Engagement Disorder From Early Childhood to Early Adolescence

OBJECTIVE

Disinhibited social engagement disorder (DSED) is poorly understood beyond early childhood. The course of DSED signs in a sample of children who experienced severe, early deprivation from early childhood to early adolescence was examined using variable-centered (linear mixed modeling) and person-centered (growth mixture modeling) approaches.

METHOD

The study included 124 children with a history of institutional care from a randomized controlled trial of foster care as an alternative to institutional care and 69 community comparison children matched by age and sex. DSED signs were assessed at baseline (mean age 22 months), 30, 42, and 54 months of age, and 8 and 12 years of age using a validated caregiver report of disturbed attachment behavior.

RESULTS

Variable-centered analyses based on intent-to-treat groups indicated that signs of DSED decreased sharply for children randomized to foster care and decreased slightly but remained high for children randomized to care as usual. Person-centered analyses showed 4 profiles (i.e., elevated, persistent modest, early decreasing, and minimal). Elevated and persistent modest courses were associated with greater placement disruptions (F3,99 = 4.29, p = .007, partial eta-squared [η2] = 0.12), older age at placement into foster care (F3,56 = 3.41, p < .05, partial η2 = 0.16), and more time in institutional care (F3,115 = 11.91, p < .001, partial η2 = 0.24) compared with decreasing and minimal courses.

CONCLUSION

Early and sustained placement into families after deprivation is associated with minimal or decreasing signs of DSED across development. Shortening the amount of time children spend in institutions and preserving placements could help decrease signs of DSED into early adolescence in previously institutionalized children.

Child abuse and neglect in institutional settings, cumulative lifetime traumatization, and psychopathological long-term correlates in adult survivors: The Vienna Institutional Abuse Study

Child maltreatment (CM) in foster care settings (i.e., institutional abuse, IA) is known to have negative effects on adult survivor's mental health. This study examines and compares the extent of CM (physical, emotional, and sexual abuse; physical and emotional neglect) and lifetime traumatization with regard to current adult mental health in a group of survivors of IA and a comparison group from the community. Participants in the foster care group (n = 220) were adult survivors of IA in Viennese foster care institutions, the comparison group (n = 234) consisted of persons from the Viennese population. The comparison group included persons who were exposed to CM within their families. Participants completed the Childhood Trauma Questionnaire, the Life Events Checklist for DSM-5, the PTSD Checklist for DSM-5, the International Trauma Questionnaire for ICD-11, and the Brief Symptom Inventory-18 and completed a structured clinical interview. Participants in the foster care group showed higher scores in all types of CM than the comparison group and 57.7% reported exposure to all types of CM. The foster care group had significantly higher prevalence rates in almost all mental disorders including personality disorders and suffered from higher symptom distress in all dimensional measures of psychopathology including depression, anxiety, somatization, dissociation, and the symptom dimensions of PTSD. In both groups, adult life events and some but not all forms of CM predicted PTSD and adult life events partly mediated the association of PTSD and CM. Explanations for the severe consequences of CM and IA are discussed.

Child abuse and neglect in institutional settings, cumulative lifetime traumatization, and psychopathological long-term correlates in adult survivors: The Vienna Institutional Abuse Study

Child maltreatment (CM) in foster care settings (i.e., institutional abuse, IA) is known to have negative effects on adult survivor's mental health. This study examines and compares the extent of CM (physical, emotional, and sexual abuse; physical and emotional neglect) and lifetime traumatization with regard to current adult mental health in a group of survivors of IA and a comparison group from the community. Participants in the foster care group (n = 220) were adult survivors of IA in Viennese foster care institutions, the comparison group (n = 234) consisted of persons from the Viennese population. The comparison group included persons who were exposed to CM within their families. Participants completed the Childhood Trauma Questionnaire, the Life Events Checklist for DSM-5, the PTSD Checklist for DSM-5, the International Trauma Questionnaire for ICD-11, and the Brief Symptom Inventory-18 and completed a structured clinical interview. Participants in the foster care group showed higher scores in all types of CM than the comparison group and 57.7% reported exposure to all types of CM. The foster care group had significantly higher prevalence rates in almost all mental disorders including personality disorders and suffered from higher symptom distress in all dimensional measures of psychopathology including depression, anxiety, somatization, dissociation, and the symptom dimensions of PTSD. In both groups, adult life events and some but not all forms of CM predicted PTSD and adult life events partly mediated the association of PTSD and CM. Explanations for the severe consequences of CM and IA are discussed.

Child welfare organizations: Do specialization and service integration impact placement decisions?

The objective of this study was to contribute to the understanding of the child welfare organization by testing the hypothesis that the characteristics of organizations influence decisions made by child protection staff for vulnerable children. The influence of two aspects of organizational structure on the decision to place a child in out-of-home care were examined: service integration and worker specialization. A theoretical framework that integrated the Decision-Making Ecology Framework (Baumann et al., 2011) and Yoo et al. (2007) conceptual framework of organizational constructs as predictors of service effectiveness was tested. Secondary data analysis of the Ontario Incidence Study of Reported Child Abuse and Neglect - 2013 (OIS-2013) was conducted. A subsample of 4949 investigations from 16 agencies was included in this study. Given the nested structure of the data, multi-level modelling was used to test the relative contribution of case and organizational factors to the decision to place. Despite the reported differences among child welfare organizations and research that has demonstrated variance in the placement decision as a result of organizational factors, the structure of the organization (i.e., worker specialization and service integration) showed no predictive power in the final models. The lack of variance may be explained by the relatively low frequency of placements during the investigation phase of service, the hierarchical impact of the factors of the DME and the limited information available regarding the structure of child welfare organizations in Ontario. Suggestions for future research are provided.

Child strengths and placement stability among racial/ethnic minority youth in the child welfare system

While all children deserve a stable living environment, national data illustrate that many states struggle to achieve placement stability for youth in the child welfare system as a significant number of children in foster care continue to experience multiple placements while in state custody. Prior research has not considered the impact of youth protective factors or strengths on the frequency of placement changes that youth experience while in the child welfare system. This study examined the association between strengths measured at multiple levels (i.e., individual, family, and community) and placement stability among 4022 minority youth (aged 10-18) using administrative and clinical data from the Illinois child welfare system. Negative binomial regressions at the family level revealed that youth with at least one loving and supportive family member experienced 16% fewer placement changes than youth without family strengths. At the community level, youth attending schools that work to create an environment that meets its students' needs experienced 13% fewer placement changes than youth without educational supports. These findings can inform the quality of treatment and services provided to minority youth in the child welfare system.

Exit Outcomes for Probation-Supervised Youth in Foster Care: An Examination of Past Child Protection Involvement

Research on youth in foster care has focused on those placed for reasons of maltreatment rather than delinquency, yet most states provide foster care services to youth under probation supervision. This analysis generated knowledge about youth in probation-supervised foster care (PSFC) in California by examining the relationship between past child protective services (CPS) involvement and exit type. CPS records were extracted to identify 17-year-old youths in PSFC between 2008 and 2012 ( N = 11,188). The relationship between allegations of maltreatment and exit type was assessed using regression models. Of the PSFC youth, 64.6% had previous allegations of maltreatment and a quarter had been reported at least 6 times. Youth with a history of placement in CPS foster care were more likely to age out relative to achieving permanency in comparison to PSFC youth with no maltreatment history (relative risk ratio = 2.20; 95% confidence interval [1.90, 2.55]). As the number of reports increased, the likelihood of exiting care by aging out increased relative to achieving permanency ( p < .001). The findings suggest a majority of PSFC youth had maltreatment histories, the overlap between CPS and probation was constant, and maltreatment records may characterize youth in PSFC at risk of negative exits from care.

Placement Stability, Cumulative Time in Care, and Permanency: Using Administrative Data from CPS to Track Placement Trajectories

Objectives: The Quebec Youth Protection Act was amended in 2007. The main goal of this reform was to improve placement stability for children who are removed from their home for their protection. Among several legal provisions introduced was the establishment of maximum age-specific durations of out-of-home care, after which a plan must be established to provide stability for children placed in substitute care by finding permanent homes for them. The purpose of this study is (1) to examine trends in placement use and placement stability since the reform and (2) to document the current frequency of each type of placement setting, the cumulative time in care before the exit to permanency, and the sustainability of the permanency outcome. Methods: The study relies on 3 entry cohorts of all children investigated who received protection measures in the province of Quebec during 3 specific time frames before and after the reform (n = 9620, 8676, 8425). Cohorts were observed for a period varying from 3 to 4 years. Administrative data from all 16 child protection agencies were used to track placement trajectory indicators and to compare cohorts. Results: There has been a decrease in the proportion of children receiving protection measures who were placed in care since the reform, and placement in kinship care has become more frequent among children placed. Placement stability improved slightly after the reform. Overall, for infants, the most frequent type of permanency attained is adoption, while reunification is the option most often indicated for older children. Some children are at a greater risk of experiencing unstable placement trajectories: young children have a high rate of reunification breakdown, some wait a long time to be adopted, and adolescents are frequently removed from the substitute care setting where they were supposed to stay until the age of 18. Conclusions: The results suggest interesting avenues for policy makers and service providers to improve the stability of placement trajectories. Advantages and disadvantages of administrative data are discussed.

Placement and Delinquency Outcomes Among System-Involved Youth Referred to Multisystemic Therapy: A Propensity Score Matching Analysis

Multisystemic therapy (MST) was developed to help youth with serious social, emotional, and behavioral problems. Research on the efficacy and effectiveness of MST has shown positive outcomes in different domains of development and functioning among various populations of youth. Nonetheless, even with a large body of literature investigating the treatment effects of MST, few studies have focused on the effectiveness of MST through large-scale dissemination efforts. Utilizing a large sample of youth involved in a statewide dissemination of MST (n = 740; 43% females; 14% Black; 29% Hispanic; 49% White; Mage = 14.9 years), propensity score matching was employed to account for baseline differences between the treatment (n = 577) and comparison (n = 163) groups. Treatment effects were examined based on three outcomes: out-of-home placement, adjudication, and placement in a juvenile training school over a 6-year period. Significant group differences remained after adjusting for baseline differences, with youth who received MST experiencing better outcomes in offending rates than youth who did not have an opportunity to complete MST due to non-clinical or administrative reasons. Survival analyses revealed rates of all three outcomes were approximately 40% lower among the treatment group. Overall, this study adds to the body of literature supporting the long-term effectiveness of MST in reducing offending among high-risk youth. The findings underscore the potential benefits of taking evidence-based programs such as MST to scale to improve the well-being and functioning of high-risk youth. However, strategies to effectively deliver the program in mental health service settings, and to address the specific needs of high-risk youth are necessary.

Continuity for children after guardianship versus adoption with kin: Approximating the right counterfactual

Over the past two decades there has been a rapid increase in the number of children and youth living in guardianship and adoptive homes who were previously in foster care. Further, previous studies compared outcomes for children in guardianship homes to those for children in adoptive homes, despite the fact that many factors likely affect the selection of foster youth into different types of permanent placements. This study examined two counterfactuals for guardianship as a permanent placement type: adoption only and adoption or long-term-fostercare (A+LTFC). Longitudinal outcomes were tracked for children who exited foster care with relatives through guardianship (N=4,884) or adoption (N=12,163), as well as children in long-term foster care with relatives (N=4,840). Propensity scores were used to match children on key indicators. In the matched sample of guardianship versus adoption cases only, children who exited to guardianship were more likely to experience discontinuity than children who exited through adoption, 11% vs. 6% respectively. However, when guardianship was compared to the combination of adoption or long-term foster care, children in guardianship experienced the same proportion of discontinuity, 11% vs. 11% respectively. These results suggest that simply matching guardianship to adoption without taking into account LTFC may be the wrong way to estimate the "what if" counterfactual if children were not discharged to guardianship. Findings also support the use of guardianship as a potential solution for children in LTFC whose caregivers are not planning to adopt.

Can Housing and Service Interventions Reduce Family Separations for Families Who Experience Homelessness?

Family break-up is common in families experiencing homelessness. This paper examines the extent of separations of children from parents and of partners from each other and whether housing and service interventions reduced separations and their precursors among 1,857 families across 12 sites who participated in the Family Options Study. Families in shelters were randomized to offers of one of three interventions: permanent housing subsidies that reduce expenditures for rent to 30% of families' income, temporary rapid re-housing subsidies with some services directed at housing and employment, and transitional housing in supervised facilities with extensive psychosocial services. Each group was compared to usual care families who were eligible for that intervention but received no special offer. Twenty months later, permanent housing subsidies almost halved rates of child separation and more than halved rates of foster care placements; the other interventions did not affect separations significantly. Predictors of separation were primarily homelessness and drug abuse (all comparisons), and alcohol dependence (one comparison). Although housing subsidies reduced homelessness, alcohol dependence, intimate partner violence, and economic stressors, the last three variables had no association with child separations in the subsidy comparison; thus subsidies had indirect effects via reductions in homelessness. No intervention reduced partner separations.

The Interplay Between Housing Stability and Child Separation: Implications for Practice and Policy

Greater understanding of how residential stability affects child separation and reunification among homeless families can guide both child welfare and homeless policy and practice. This article draws upon two longitudinal studies examining services and housing for homeless families and their relationship to family and housing stability. Both studies were conducted in the same state at roughly the same time with similar instruments. The first study, examining families' experiences and outcomes following entry into the homeless service system in three counties in Washington State, found that at 18 months following shelter entry, families that are intact with their children were significantly more likely to be housed in their own housing (46%) than families that were separated from one or more of their children (31%). The second study, a quasiexperimental evaluation of a supportive housing program for homeless families with multiple housing barriers, found that the rates of reunification for Child Protective Services (CPS)-involved families receiving supportive housing was comparable to that for families entering public housing without services, but significantly higher than the rate of reunification for families entering shelter. Taken together, the findings from both studies contribute to the evidence underscoring the importance of housing assistance to homeless families involved in the child welfare system.

Estimating the number of children in formal alternative care: Challenges and results

Given the relatively large body of literature documenting the adverse impacts of institutionalization on children's developmental outcomes and well-being, it is essential that countries work towards reducing the number of children in alternative care (particularly institutional care), and, when possible, reunite children with their families. In order to do so, reliable estimates of the numbers of children living in such settings are essential. However, many countries still lack functional administrative systems for enumerating children living outside of family care. The purpose of this paper is to provide a snapshot of the availability and coverage of data on children living in residential and foster care from some 142 countries covering more than 80 per cent of the world's children. Utilizing these country-level figures, it is estimated that approximately 2.7 million children between the ages of 0 and 17 years could be living in institutional care worldwide. Where possible, the article also presents regional estimates of the number of children living in residential and foster care. This work represents an important step to systematically identify and compile sources of data on children in alternative care and provides updated global and regional estimates on the magnitude of the issue. Its findings contribute to raising awareness of the urgent need to strengthen the capacity of countries to improve national systems for counting, monitoring and reporting on these vulnerable children.

Impact of a Supportive Housing Program on Housing Stability and Sexually Transmitted Infections Among Young Adults in New York City Who Were Aging Out of Foster Care

Former foster youth are at increased risk of housing instability and sexually transmitted infections (STIs) during the transitional period following foster care. We measured housing stability using sequence analysis and assessed whether a supportive housing program in New York, New York, was effective in improving housing stability and reducing STIs among former foster youth. Matched administrative records identified 895 former foster youth who were eligible for the housing program during 2007-2010. The main outcomes included housing stability (as determined from episodes of homelessness, incarceration, hospitalization, and residence in supportive housing) and diagnosed STI case rates per 1,000 person-years during the 2 years after baseline. Marginal structural models were used to assess impacts of the program on these outcomes. Three housing stability patterns (unstable housing, stable housing, and rare institutional dwelling patterns) were identified. The housing program was positively associated with a pattern of stable housing (odds ratio = 4.4, 95% confidence interval: 2.9, 6.8), and negatively associated with diagnosed STI rates (relative risk = 0.3, 95% confidence interval: 0.2, 0.7). These positive impacts on housing stability and STIs highlight the importance of the supportive housing program for youths aging out of foster care and the need for such programs to continue.

The relative safety of paternal, maternal, and traditional foster care placements

When children are placed into foster care the caseworker must give preference to an adult relative, many of whom are grandparents, over an unrelated caregiver. This kinship preference is based in evolutionary biology, which suggests that the imperative to care for a child should be greater for kin versus non-kin. However, not all kin are related to a child in the same way, and level of paternity uncertainty may influence level of care provided. For instance, maternal grandparents can be assured that they share genetic material with their grandchild, while paternal grandparents may not have the same level of certainty. Owing to the possibility of paternity uncertainty, we hypothesize that out-of-home placements with paternal grandparents will be at a greater risk of subsequent investigations than placements with maternal grandparents or with foster parents. We secured data on placements n=560 of children ages 1.5 to 17 following a maltreatment investigation from a merger of the National Survey of Child and Adolescent Well-Being NSCAW II and the National Child Abuse and Neglect Data System NCANDS. Kaplan-Meier and multivariate Cox regression were used to examine the difference in time to the first new investigation by type of out-of-home placement while controlling for covariates. Consistent with our hypothesis, placements with paternal grandparents were at a higher risk of a subsequent investigations than placements with maternal grandparents or non-kin foster parents. Results suggest a need for further considerations of child safety in foster care based on genetic relatedness of caregivers.

Can Medicaid Claims Validly Ascertain Foster Care Status?

Medicaid claims have been used to identify populations of children in foster care in the current literature; however, the ability of such an approach to validly ascertain a foster care population is unknown. This study linked children in the National Survey of Child and Adolescent Well-Being-I to their Medicaid claims from 36 states using their Social Security numbers. Using this match, we examined discordance between caregiver report of foster care placement and the foster care eligibility code contained in the child's Medicaid claims. Only 73% of youth placed in foster care for at least a year displayed a Medicaid code for foster care eligibility. Half of all youth coming into contact with child welfare displayed discordance between caregiver report and Medicaid claims. Children with emergency department utilization, and those in primary care case management health insurance arrangements, had the highest odds of accurate ascertainment. The use of Medicaid claims to identify a cohort of children in foster care results in high rates of underascertainment. Supplementing administrative data with survey data is one way to enhance validity of ascertainment.