Effects of Child Protective Custody Status and Health Risk Behaviors on Health Care Use Among Adolescents

Antenatal Psychiatric Hospitalization: Factors Associated With Newborns' Custody Under Child Protective Services (CPS)

BACKGROUND

Psychiatric illness during pregnancy is associated with adverse obstetric outcomes, but investigations into its impact on parenting capacity are limited. Child Protective Services (CPS) contact disproportionately impacts families marginalized by poverty, mental health disorders, and substance use disorders. Recently, there have been investigations into the significance of psychiatric illness and nonmental health-related factors that predict CPS custody arrangements.

OBJECTIVE

To identify clinical factors associated with newborns' custody under CPS for mothers with antenatal psychiatric hospitalization.

METHODS

We conducted a retrospective review of electronic medical records over a 10-year period (2012-2021) for patients who were pregnant during their inpatient psychiatric hospitalizations. We followed 81 patients (18 to 43 years old) who delivered within the hospital. The study endpoint was whether the newborn was placed under CPS custody. For the purposes of this study, psychiatric illness was categorized by the presence or absence of psychotic symptoms. We utilized logistic regressions to investigate the associations of these demographic and clinical factors with the study outcome of CPS custody.

RESULTS

For the entire study population, 64.2% of newborns had CPS custody arrangements. In multivariate analysis, after adjusting for potential confounders, patients with psychotic symptoms were at increased odds of having CPS custody arrangements (odds ratio = 8.43; 95% confidence interval 2.16-32.85) compared with patients without psychotic symptoms. Furthermore, multivariate analyses revealed that patients with a history of homelessness also had a higher risk (odds ratio = 6.59; 95% confidence interval: 1.24-35.13) of CPS custody arrangements for their newborns than those without a history of homelessness.

CONCLUSIONS

The results of this study suggest that among pregnant and psychiatrically hospitalized patients, those with psychotic symptoms are significantly more likely to have CPS custody arrangements compared to those without psychotic symptoms. However, it is important to note that psychotic symptoms were not definitive for the inability to parent appropriately. In fact, nearly 25% of the study population who had psychotic symptoms were able to successfully transition home with their newborns as mothers. This emphasizes the importance of optimizing the management of psychotic symptoms, particularly among those who have children or plan to have children. The findings of this study also highlight the chronic impacts that those who have struggled with homelessness may experience, including parenting capacity after homelessness resolves.

Enrollment and outcomes of home visiting for mothers with and without a history of out-of-home care

Women previously in out-of-home care (i.e., foster care) experience poorer health and psychosocial outcomes compared to peers, including higher pregnancy rates and child protective services involvement. Home visiting programs could mitigate risks. Studies examining home visiting enrollment for women with a history of out-of-home care are needed. Women previously in out-of-home care based on child welfare administrative data between 2012 and 2017 (n = 1375) were compared to a demographically matched sample (n = 1375) never in out-of-home care. Vital records data identified live births in the two groups. For those who had given live birth (n = 372), linked administrative data were used to determine and compare rates of referral and enrollment into home visiting, and two indicators of engagement: number of days enrolled, and number of visits received. Women previously in out-of-home care were referred for home visiting more often than their peers. There were no differences in rates of enrollment. Women previously in out-of-home care remained enrolled for shorter durations and completed fewer home visits than peers. Findings suggest barriers to home visiting enrollment and retention in home visiting programs for women previously in out-of-home care. Studies with larger samples and more complete assessments of outcomes are warranted.

Mental Health Diagnoses, Health Care Utilization, and Placement Stability on Antipsychotic Prescribing Among Foster Care Youth

OBJECTIVE

This study sought to examine how mental health diagnoses, health care utilization and foster care placement instability affect antipsychotic prescribing and how these factors may contribute to disproportionate antipsychotic prescribing among youth in foster care.

METHODS

This retrospective cohort study utilized EHR data that were linked to administrative child welfare data. Two outcome variables were analyzed: 1) any antipsychotic prescription documented and 2) number of antipsychotic prescriptions documented. Predictor variables included foster care status, number of unique mental health diagnoses, counts of health care encounters over the study period, and counts of foster care placements. Covariates included gender, persons of color, and age in years. Models were estimated using logistic regression for the dichotomous outcome and Poisson regression for the count outcome.

RESULTS

Increased antipsychotic prescribing among children in foster care persists even after accounting for mental health diagnoses and health care utilization. However, the number of placements modified the effect of foster care involvement on antipsychotic prescribing such that after 2 placement changes, the odds of being prescribed an antipsychotic surpassed the effect of foster care involvement. More mental health diagnoses, more inpatient and emergency health care encounters, and more foster care placements were associated with an increased odds of being prescribed an antipsychotic and an increased count of antipsychotic prescriptions. Decreased primary care encounters were associated with increased odds of antipsychotic prescriptions, and decreased specialty encounters were associated with higher counts of antipsychotic prescriptions.

CONCLUSIONS

Placement instability is associated with disproportionate antipsychotic prescribing among youth in foster care.