Children in foster care: factors influencing outpatient mental health service use

Psychopathology and mental health service use among youth in foster care admitted to a psychiatric inpatient unit: a 4-year retrospective controlled study

Youth in foster care (FC) are at increased risk of poor psychosocial outcomes. The aim of this study was to assess psychopathology and mental health service use among youth living in FC who require psychiatric hospitalisation. All individuals admitted to our Children and Adolescent Inpatient Psychiatry Unit between 2014 and 2017 who were in FC were systematically reviewed. The control group was defined as all youth living with their immediate family and hospitalised in our unit throughout 2016. We identified 89 patients placed in FC and 247 controls. Socio-demographic and clinical data were retrospectively collected from computerised charts. A survival analysis of emergency department visits and readmission to the hospital was conducted. Compared to controls, the FC group presented significantly higher rates of conduct disorder (78.7% vs 14.6%; p < 0.001) and substance use disorder (49.4% vs 27.5%; p < 0.001), mainly cannabis use (34.8% vs 16.6%; p < 0.001); higher rates of comorbidity (96.6% vs 55.9%; p < 0.001) and mean number of comorbid diagnoses (3.3 ± 1.1 vs 2.3 ± 0.5; p < 0.001). The FC group had a higher number of emergency room visits before and after admission than controls. FC youth were also 2.77 times more likely to visit the emergency department after discharge, and in a shorter time period, than controls (p = 0.004). Disruptive behaviours, substance use disorder, and comorbid psychopathology were all more prevalent among FC youth than controls. Specific strategies are needed to optimize community mental health resources and address the increased use of emergency services by these youth before and after hospitalisation.

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

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

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

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

A Family-Based Mental Health Navigator Intervention for Youth in the Child Welfare System: Protocol for a Randomized Controlled Trial

BACKGROUND

Youth in the child welfare system (child welfare-involved [CWI] youth) have high documented rates of mental health symptoms and experience significant disparities in mental health care services access and engagement. Adolescence is a developmental stage that confers increased likelihood of experiencing mental health symptoms and the emergence of disorders that can persist into adulthood. Despite a high documented need for evidence-based mental health services for CWI youth, coordination between child welfare and mental health service systems to increase access to care remains inadequate, and engagement in mental health services is low. Navigator models developed in the health care field to address challenges of service access, fragmentation, and continuity that affect the quality of care provide a promising approach to increase linkage to, and engagement in, mental health services for CWI youth. However, at present, there is no empirically supported mental health navigator model to address the unique and complex mental health needs of CWI youth and their families.

OBJECTIVE

Using a randomized controlled trial, this study aims to develop and test a foster care family navigator (FCFN) model to improve mental health service outcomes for CWI adolescents (aged 12-17 years).

METHODS

The navigator model leverages an in-person navigator and use of adjunctive digital health technology to engage with, and improve, care coordination, tracking, and monitoring of mental health service needs for CWI youth and families. In total, 80 caregiver-youth dyads will be randomized to receive either the FCFN intervention or standard of care (clinical case management services): 40 (50%) to FCFN and 40 (50%) to control. Qualitative exit interviews will inform the feasibility and acceptability of the services received during the 6-month period. The primary trial outcomes are mental health treatment initiation and engagement. Other pre- and postservice outcomes, such as proportion screened and time to screening, will also be evaluated. We hypothesize that youth receiving the FCFN intervention will have higher rates of mental health treatment initiation and engagement than youth receiving standard of care.

RESULTS

We propose enrollment of 80 dyads by March 2024, final data collection by September 2024, and the publication of main findings in March 2025. After final data analysis and writing of the results, the resulting manuscripts will be submitted to journals for dissemination.

CONCLUSIONS

This study will be the first to produce empirically driven conclusions and recommendations for implementing a family mental health navigation model for CWI youth with long-standing and unaddressed disparities in behavioral health services access. The study findings have potential to have large-scale trial applicability and be feasible and acceptable for eventual system implementation and adoption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04506437; https://www.clinicaltrials.gov/study/NCT04506437.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49999.

The intersection of adverse childhood experiences and mental health concerns for youth involved in the child welfare system

The present study sought to identify if there is distinct mental health symptomology among child welfare-involved youth depending on the category of adverse childhood experiences (ACEs) endorsed. A chart review of child welfare-involved youth (N = 129, ages 8-16) and caregiver reported ACEs and mental health/trauma symptoms was conducted. A K-means cluster analysis used ACE scores to identify groups of youth along two dimensions: household dysfunction and child abuse/neglect. The first cluster identified had low ACE scores outside of their system involvement (n = 62), the second predominantly endorsed household dysfunctions (n = 37), and the third predominantly endorsed abuse/neglect (n = 30). One-way analysis of variance tests revealed that youth in the systems-only cluster differed from youth in the other groups, while the two high ACE category groups did not differ from each other on mental health/trauma symptoms. These results have important implications for the screening and treatment referral processes in the child welfare system.

Risk profiles of suicide attempts among girls with histories of commercial sexual exploitation: A latent class analysis

BACKGROUND

Girls impacted by commercial sexual exploitation (CSE) in the juvenile legal system are three times more likely to have suicide attempts than girls without histories of exploitation. Yet, research on risk profiles and correlates that contribute to elevated suicide risk among girls with CSE histories remains scant.

OBJECTIVE

We sought to examine suicide attempts profiles among CSE-impacted girls in the juvenile legal system.

PARTICIPANTS AND SETTING

We partnered with a specialty court for CSE-impacted youth in Los Angeles County.

METHODS

Data were collected from case files of the 360 girls participating in the court from 2012 to 2016. Latent class analysis was used to identify their profiles of risk indicators.

RESULTS

Four risk profiles for suicide attempts emerged: (1) Parental Incarceration (PI; 30 %), (2) Child Welfare Contact (CWC; 25 %), (3) Disruptive Behavior and Sleep Problems (DBS; 25 %), and (4) Pervasive Risk (PR; 22 %). Among youth in the PI group, 5 % had a suicide attempt; however, contrary to our hypothesis, no youth in the CWC group had a suicide attempt. Rates of suicide attempt were significantly higher among youth in the DBS group, as 14 % had a suicide attempt. As hypothesized, youth in the PR were associated with higher risk of suicide attempts, with 28 % reporting a prior suicide attempt.

CONCLUSIONS

Findings underscore the need for standardized suicide screenings and treatment referrals for girls with CSE histories and suggest an important opportunity for multidisciplinary collaboration with courts to improve suicide prevention strategies. The present study also supports the importance of examining risk across the socioecological context.

Leveraging Administrative Data to Better Understand and Address Child Maltreatment: A Scoping Review of Data Linkage Studies

BACKGROUND

This scoping review aimed to overview studies that used administrative data linkage in the context of child maltreatment to improve our understanding of the value that data linkage may confer for policy, practice, and research.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL, and ERIC electronic databases in June 2019 and May 2020 for studies that linked two or more datasets (at least one of which was administrative in nature) to study child maltreatment. We report findings with numerical and narrative summary.

RESULTS

We included 121 studies, mainly from the United States or Australia and published in the past decade. Data came primarily from social services and health sectors, and linkage processes and data quality were often not described in sufficient detail to align with current reporting guidelines. Most studies were descriptive in nature and research questions addressed fell under eight themes: descriptive epidemiology, risk factors, outcomes, intergenerational transmission, predictive modelling, intervention/service evaluation, multi-sector involvement, and methodological considerations/advancements.

CONCLUSIONS

Included studies demonstrated the wide variety of ways in which data linkage can contribute to the public health response to child maltreatment. However, how research using linked data can be translated into effective service development and monitoring, or targeting of interventions, is underexplored in terms of privacy protection, ethics and governance, data quality, and evidence of effectiveness.

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

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

Trauma-informed care for children involved with the child welfare system: A meta-analysis

BACKGROUND

There has been a burgeoning development of trauma-informed care (TIC) interventions for children involved with the child welfare system. A quantitative synthesis of these interventions' effects on child wellbeing is warranted for the advancement of evidence-based practices.

OBJECTIVES

We conducted a systematic review and meta-analysis to estimate TIC interventions' pooled effect on the wellbeing of children involved with the child welfare system, while examining factors that may moderate the effect.

METHODS

The search and review yielded 15 eligible studies. We first estimated the interventions' pooled effect based on a compound child wellbeing indicator, and then on three specific child wellbeing indicators: posttraumatic stress disorder (PTSD) symptom reduction, behavioral problem reduction, and other psychological wellbeing improvement. We further conducted subgroup meta-analyses to evaluate factors that may moderate the effect.

RESULTS

TIC interventions had a moderate effect as shown through the compound child wellbeing indicator (SMD = 0.47, 95% CI = [0.27, 0.67]) as well as the three specific indicators (SMD = 0.37 to 0.52, 95% CI = [0.02, 0.88]). Subgroup meta-analyses indicated that the intervention effects varied but generally remained at a moderate level across study and intervention characteristics.

CONCLUSIONS

The findings suggest that TIC interventions for children involved with the child welfare system are promising, but the effect may vary by intervention strategies and other factors. Implications for practices and research are discussed.

High value correlates of caregiver reported counseling service need and utilization for adolescents at-risk for childhood maltreatment and neglect

Adolescents with a history of child maltreatment experience increased risk for psychopathology that sets them on a trajectory towards a range of difficulties in adulthood. Various factors influence caregivers’ decisions to seek mental health services (MHS) that could improve developmental outcomes. The present study applied a machine learning algorithm, elastic net, to a sample of 878 adolescent-caregiver dyads from the Longitudinal Studies of Child Abuse and Neglect. Analyses simultaneously examined a large number of factors to determine their ability to discriminate between caregivers who perceived a need for MHS and those who did not, as well as caregivers who utilized MHS and those who did not. Results highlight family demographics, chronic parental stressors, youth psychopathology, and exposure to recent adversities as good classifiers of caregiver perceived need for (77.6%; sensitivity = .77; specificity = .78) and utilization of (71%; sensitivity = .71; specificity = .71) adolescent MHS. Elastic net identified adolescent clinical externalizing and internalizing problems, and parental stress related to child(ren)’s behavior as high value classifiers of both outcomes. Youth living with non-kin caregivers were also significantly more likely to utilize MHS. Findings highlight the importance of assessing clinical need, stress related to child(ren)’s behavior, and caregiver kinship in understanding the likelihood that at-risk families will seek adolescent MHS.

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.

The trajectory of PTSD among youth in foster care: A survival analysis examining maltreatment experiences prior to entry into care

BACKGROUND

Youth in foster care are more likely than non-foster care youth to experience posttraumatic stress disorder (PTSD). While research has identified maltreatment as a risk factor for PTSD, this research remains limited because it tends to only (a) examine a single type or dimension of maltreatment and ignore the polyvictimization and heterogeneity in exposure, and (b) study this relation across a short period time or retrospectively at the end of care.

OBJECTIVE

The current study used survival analysis to simultaneously examine the influence of maltreatment characteristics on the risk of receiving a PTSD diagnosis at any time in care following entry into care.

PARTICIPANTS/SETTING

291 youth (Mean age at entry = 9.71; 53 % female; 49 % Black) in foster care and their primary caregivers from a large, Midwestern county.

METHODS

Information on PTSD diagnosis was extracted from Medicaid records, and information on maltreatment and time in care was extracted from case files. Survival analysis was then used to determine the association between maltreatment and risk of PTSD diagnosis.

RESULTS

When examined independently, each dimension (frequency, severity) of the four maltreatment types was significantly associated with PTSD diagnosis risk (all hazard ratio's [HR] > 1.00), except sexual abuse frequency. In the comprehensive model with all dimensions examined simultaneously, only neglect frequency for youth entering care in adolescence (HR: 1.13[1.03-1.23]), and neglect severity (HR: 1.27[1.05-1.52]) and emotional abuse frequency (HR: 1.24[1.00-1.53]) for youth entering care pre-adolescence, were associated with PTSD diagnosis risk. Additionally, age of entry into care was associated with PTSD diagnosis risk (HR: 2.34[1.88-2.92]), as adolescents tended to spend fewer days in care before receiving a diagnosis.

CONCLUSIONS

Results suggest that researchers who study PTSD in youth in foster care should consider the entirety of youth's maltreatment exposure and the context of care to more accurately determine what aspects of youth's history contributes to receiving a PTSD diagnosis.

Foster Parents' Parenting and the Social-Emotional Development and Adaptive Functioning of Children in Foster Care: A PRISMA-Guided Literature Review and Meta-Analysis

Children in foster care (CFC) are at increased risk for negative developmental outcomes. Given the potential influence of foster parents' parenting on the development of CFC, this literature review and meta-analysis provide an initial overview of how parenting factors in foster families relate to CFC's developmental outcomes. We aimed to explore (1) whether foster parents' parenting conceptualizations are related differently to various CFC developmental outcome variables and (2) how characteristics of foster parents and CFC moderate these associations. Following the recommendations of the PRISMA statement, we searched four databases in 2017 (with an update in May 2020). Forty-three primary studies were coded manually. The interrater agreement was 92.1%. Parenting variables were specified as parenting behavior, style, and goals and were distinguished further into functional and dysfunctional parenting. CFC development was divided into adaptive (including cognitive) development and maladaptive development. Meta-analyses could be performed for foster parenting behavior and developmental outcomes, as well as for functional parenting goals and maladaptive socioemotional outcomes in CFC. Associations between functional parenting behavior and adaptive child development were positive and negative for maladaptive child development, respectively. For dysfunctional, parenting effects were in the opposite direction. All effects were small to moderate. Similar results were found descriptively in the associations of parenting style and child developmental outcomes. We found similar effect sizes and directions of the associations between parenting behavior in foster families and the child's developmental outcomes as those previously reported for biological families. These findings provide strong support for the significant role of parenting in foster families regarding children's development in foster care.

Invited Commentary: Biomarkers for Mortality Among Individuals With a History of Out-of-Home Care-Implications for Study Design and Conceptualizations of Risk

Out-of-home care in childhood and adolescence has been shown to be associated with elevated risk for all-cause mortality in adulthood, with adverse socioeconomic, psychosocial, and health-related trajectories hypothesized to mediate this relationship. In the research letter by Batty and Hamer (Am J Epidemiol. 2021;190(1):176-178), the authors used data from the 1970 British birth cohort (n = 8,581) to examine risk of biomarkers for mortality in adults with a history of out-of-home care. While markers of inflammation, glucose metabolism, and lipids were less favorable in the exposed versus unexposed, differences between groups were small and were completely attenuated after adjustment. This study raises important issues regarding the design and conceptualization of future studies on the long-term outcomes of out-of-home care recipients. Such studies require more detailed information on duration of care, type of care setting, and reasons for care, all of which could affect outcome risk. Because the duration of follow-up is long, and attrition likely, authors should consider use of novel analytical techniques to account for selection bias, such as inverse probability weighting. Finally, a "chain-of-risk" approach to understanding outcomes might be warranted, given that risk is likely explained by accumulation of and prolonged exposure to adverse socioeconomic, psychosocial, and health risks.

Mental Health Management Among Older Youth in Foster Care: Service Utilization and Preparedness

PURPOSE

The aim of the study was to document mental health service use (counseling and medication) among youth in foster care, examine how prepared they feel to manage their mental health, and investigate predictors of service use and preparedness.

METHODS

The study includes a representative sample of youth in California foster care at age 17 years who participated in in-person, structured interviews (n = 727). Survey measures captured youth characteristics, their mental health service use, and their level of preparedness to manage their mental health. Data from a child welfare worker survey were used to capture county-level service availability, helpfulness, and coordination. Binary and ordered logistic regression were used to predict mental health service use and preparedness.

RESULTS

Youth reported high rates of mental health service use and one-fifth of the sample reported feeling less than prepared to manage their mental health. Youth who screened positive for mental disorders were less prepared than their peers to manage their mental health. Physical (odds ratio [OR] = 1.44; p < .05) and sexual abuse (OR = 2.04; p < .001) predicted past year use of counseling. Sexual abuse also predicted medication use (OR = 1.97; p < .01). Youth who identified as 100% heterosexual were less likely than non-100% heterosexual peers to use counseling (OR = .58; p < .05). The results also suggest geographic variation in use. Finally, caseworkers' perception of greater helpfulness of services in the county they worked predicted greater mental health preparedness (OR = 1.23; p < .05).

CONCLUSIONS

Mental health service use remains high among youth in foster care. Youth with particular characteristics may benefit from interventions aimed at preparing them for managing their mental health in adulthood.

Child maltreatment by nursing staff and caregivers in German institutions: A population-representative analysis

BACKGROUND

Child maltreatment by caregivers seem to make a significant contribution to general maltreatment rates. Interestingly, research assessing prevalence rates of maltreatment mainly focuses on individual components either in relation to different types of maltreatment or in relation to different types of institutions.

OBJECTIVE

The current study assesses prevalence rates for child maltreatment by caregivers in hospitals, rehabilitation centers, facilities for the disabled, schools, Kindergartens, and after-school care or residential care.

PARTICIPANTS AND SETTING

In a cross-sectional survey, a representative sample of the German population above the age of 14 (N = 2,516) was selected in a random route approach. Participants were questioned retrospectively for the experience of physical, emotional and sexual abuse and neglect by caregivers in institutions.

RESULTS

The results demonstrate a relatively high rate of child maltreatment in German institutions. In detail, during inpatient stays in medical institutions, 19.0% of the participants reported to have experienced at least one type of maltreatment by nursing staff. Furthermore, 30.3% reported to have experienced at least one type of maltreatment by teachers during school life and 11.6% reported maltreatment by caregivers in care facilities. A significant number of participants reported multiple forms of maltreatment in all assessed institutions. Younger age of the respondents was associated with lower prevalence rates, which could be attributed to higher awareness for maltreatment in institutions nowadays.

CONCLUSIONS

Our results demonstrate that child maltreatment by caregivers in institutions is a prevalent problem. A higher awareness for caregivers as potential perpetrators of maltreatment in institutions, including schools, medical institutions and care facilities, is needed in order to improve this alarming situation.

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.

Resource Intensity for Children and Youth: The Development of an Algorithm to Identify High Service Users in Children's Mental Health

Children’s mental health care plays a vital role in many social, health care, and education systems, but there is evidence that appropriate targeting strategies are needed to allocate limited mental health care resources effectively. The aim of this study was to develop and validate a methodology for identifying children who require access to more intense facility-based or community resources. Ontario data based on the interRAI Child and Youth Mental Health instruments were analysed to identify predictors of service complexity in children’s mental health. The Resource Intensity for Children and Youth (RIChY) algorithm was a good predictor of service complexity in the derivation sample. The algorithm was validated with additional data from 61 agencies. The RIChY algorithm provides a psychometrically sound decision-support tool that may be used to inform the choices related to allocation of children’s mental health resources and prioritisation of clients needing community- and facility-based resources.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

A decade lost: does educational success mitigate the increased risks of premature death among children with experience of out-of-home care?

Background

Past research has consistently identified children with out-of-home care (OHC) experience as a high-risk group for premature mortality. While many have argued that educational success is a key factor in reducing these individuals’ excessive death risks, empirical evidence has hitherto been limited. The aim of the current study was therefore to examine the potentially mitigating role of educational success in the association between OHC experience and premature mortality.

Methods

Drawing on a Stockholm cohort born in 1953 (n=15 117), we analysed the associations among placement in OHC (ages 0–12), school performance (ages 13, 16 and 19) and premature all-cause mortality (ages 20–56) by means of Cox and Laplace regression analyses.

Results

The Cox regression models confirmed the increased risk of premature mortality among individuals with OHC experience. Unadjusted Laplace regression models showed that, based on median survival time, these children died more than a decade before their majority population peers. However, among individuals who performed well at school, that is, those who scored above-average marks at the age of 16 (grade 9) and at the age of 19 (grade 12), the risks of premature mortality did not significantly differ between the two groups.

Conclusion

Educational success seems to mitigate the increased risks of premature death among children with OHC experience.

Exposure to out-of-home care in childhood and adult all-cause mortality: a cohort study

Background: Children placed in out-of-home care (OHC) have exceedingly high rates of health problems. Their poor health tends to persist across adolescence and into young adulthood, resulting in increased risks of mortality. Yet, very little is known about this group’s mortality risks later in life. The aim of this study was to investigate whether OHC was associated with the risk of all-cause mortality across adulthood, and whether these risks varied across different placement characteristics. Moreover, the study addressed potential confounding by including two comparison groups with children who grew up under similarly adverse living conditions but did not experience placement.

Methods: Data were derived from a 60-year follow-up of a Stockholm cohort born in 1953 (n = 15 048), of whom around 9% have had experiences of OHC. The associations between OHC and subsequent all-cause mortality were analysed by means of Cox’s proportional hazards regression models.

Results: Individuals who were placed in OHC at any point during their formative years had increased mortality risks across ages 20 to 56 years. Elevated risk of mortality was particularly pronounced among those who were placed in adolescence and/or because of their own behaviours. Children who were exposed to OHC had increased risks of mortality also when compared with those who grew up under similar living conditions but did not experience placement.

Conclusions: Children in OHC constitute a high-risk group for subsequent mortality. In order to narrow the mortality gap, interventions may need to monitor not only health aspects but also to target the cognitive and social development of these children.

Examining the association between suicidal behaviors and referral for mental health services among children involved in the child welfare system in Ontario, Canada

Although various studies have investigated factors associated with mental health service utilization, few studies have examined factors associated with referral for mental health services among maltreated children. The objective of this study was to examine the association between suicidal thoughts and self-harming behavior and referral for mental health services among children involved in the Child Welfare System in Ontario, Canada. Data for this study were obtained from the Ontario Incidence Study of Reported Child Abuse and Neglect 2013. An estimate 57,798 child maltreatment investigations was analyzed using binary logistic regression with referral for mental health service as the outcome variable. Of the 57,798 cases, 4709 (8.1%), were referred for mental health services. More than seven out of ten maltreated children who engaged in self-harming behavior and two out of three maltreated children who expressed suicidal thoughts were not referred for mental health services. In the multivariate logistic regression model, children who expressed suicidal thoughts had 2.39 times higher odds of being referred for mental health services compared to children with no suicidal thoughts (AOR = 2.39, 99% C.I. 2.05-2.77) and children who engaged in self-harming behavior had 1.44 times higher odds of being referred for mental health services compared to children who did not engage in self-harming behavior (AOR = 1.44, 99% C.I. 1.24-1.67), both after controlling for child demographic characteristics, maltreatment characteristics, and child functioning concerns. Given that referral is the initial step towards mental health service utilization, it is important that child welfare workers receive the necessary training so as to carefully assess and refer children in care who expressed suicidal thoughts or engaged in self-harming behavior for appropriate mental health services. The paper discusses the results and their implications for child welfare policy and practice.

Feeling Heard and Not Judged: Perspectives on Substance Use Services Among Youth Formerly in Foster Care

Youth in foster care have limited access to substance use services for a variety of reasons. Attempts to unpack this health disparity have focused on foster care systems, administrators, providers, and foster parents. This study seeks to understand the perspectives of youth themselves, with the hope of understanding their experiences with and preferences for such services. Analyses of focus groups with youth who had recently left foster care suggested concrete and perceptual facilitators/barriers to treatment. Concrete facilitators/barriers included the need for expanding social support, access to multiple service options, and tailored intervention approaches. Perceptual concerns revolved around understanding each individual's readiness to change, feeling judged by authority figures, and desiring help from people with lived experience. Participants also described novel intervention ideas, including a focus on technology-based approaches. By relying on youth voices, we can improve upon the current state of substance use interventions within foster care.

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

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

Effectiveness of manualized case management on utilization of evidence-based treatments for children and adolescents after maltreatment: A randomized controlled trial

The objective of this study was to compare structured case management (CM) to usual care (UC) for helping victims of child abuse and neglect (CAN) with mental disorders access evidence-based treatment (EBT). N=121 children and adolescents aged 4-17 with a history of CAN and a current mental disorder were recruited in three German states in a multi-center parallel group trial. They were randomly assigned, stratified by study site and level of psychosocial functioning, to receive CM additionally to UC or only UC. CM was delivered by trained professionals and volunteers, most of them affiliated to local child welfare agencies or NGOs. UC comprised child welfare services typically delivered in Germany. The primary outcome was EBT utilization after 6 months. Secondary outcome was the time until commencement of EBT. Outcomes were determined by semi-structured clinical interviews with assessors blinded to group allocation. Predictors of access to EBT and barriers to utilization of treatment were analyzed. The intent to treat analysis showed that after 6 months 23 of 60 participants recruited to CM (38%) and 19 of 61 participants recruited to UC (31%) were using EBT, χ² (1, N=121)=0.689, p=.261. Female gender, out-of-home placement, and home state were significant predictors of access to EBT. Less than 40% of participants across both groups were successfully referred to EBT. Access to EBT seems to be in part due to system-level barriers, namely lack of implementation of EBT in community settings.

TRIAL REGISTRATION

DRKS00003979 German Clinical Trials Register.

Psychocultural Correlates of Mental Health Service Utilization Among African American and European American Girls

Structural equation modeling was used to examine the effects of cultural factors (ethnic identity, perceived discrimination), family relations, and child problem type on mental health service utilization in a community sample of 1,480 adolescent girls (860 African American, 620 European American) between ages 15 and 17 years enrolled in the Pittsburgh Girls Study. Results revealed ethnic identity, caregiver attachment, and conduct disorder were related to service use among African American girls. Among European American girls, correlate patterns differed by clinical need. Findings highlight the need for research on health disparities to examine racially specific influences on service utilization.

For Better or Worse? Change in Service Use by Children Investigated by Child Welfare Over a Decade

BACKGROUND

Children, particularly minority children, referred to child welfare because of suspected maltreatment are vulnerable and need many services. We sought to assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased.

METHODS

We used 2 national data sets (the National Survey of Child and Adolescent Well-Being [NSCAW] I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), and dental services and overall service use.

RESULTS

In NSCAW II more children were young, had lower Child Behavior Checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services, and a decrease in MH services on the bivariate level (all P < .01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children, and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities.

CONCLUSIONS

These data showed no change in MH services over time for children referred for child welfare evaluation, but improvement in dental services was noted. Racial and ethnic disparities persist. Decrease in MH services occurred predominantly among children whose MH symptoms were below the clinical range.

The Effect of Race/Ethnicity on the Relation between Substance Use Disorder Diagnosis and Substance Use Treatment Receipt among Male Serious Adolescent Offenders

The high rates of substance disorders in the juvenile justice system, as well as the relation between substance use and reoffending, suggest the importance of substance use treatment service and understanding the factors that influence treatment provision. The current study tested whether race/ethnicity affects the relation between substance use disorder diagnosis and the receipt of substance use treatment services among a sample of male serious juvenile offenders (N=638). Findings showed that among adolescents with a substance use disorder diagnosis, there were no race/ethnicity differences in substance use treatment receipt. However, among adolescents without a substance use disorder diagnosis, non-Hispanic Caucasians were more likely to receive substance use treatment than were Hispanics or African-Americans. Additionally, findings showed that there were race/ethnicity differences in service receipt at moderate levels of substance use problems, such that non-Hispanic Caucasians were more likely to receive substance use treatment than Hispanics or African-Americans. There were no race/ethnicity differences in treatment receipt when substance use problems were either very severe or very low. Results suggest that race/ethnicity may play a role in service provision in the juvenile justice system when levels of need are less clear.

Kinship foster care among African American youth: Interaction effects at multiple contextual levels

This study investigated the effects of kinship foster care on mental health outcomes among African American youth. Longitudinal data were used from a nationally representative sample of children and adolescents who were the subject of child protective services investigation from 1999 to 2000 (n=5,501). The secondary analyses focused on African American youth (n=225) placed into foster care. In structured interviews, current caregivers reported on youth internalizing and externalizing behaviors immediately following placement into out-of-home care and 18-months later. Path analysis tested a theoretical model that compared placements with kin to other formal out-of-home arrangements in context of setting characteristics, including aspects of caregiver and neighborhood disorder. Results suggested significant increases in internalizing symptoms over time for youth with more baseline mental health problems, as well as those placed in more distressed neighborhoods. Increased externalizing symptoms occurred among youth with greater baseline behavior problems, those placed in more problematic neighborhoods, and youth who experienced a placement change between assessments. Additionally, a combination of placement characteristics predicted increases in externalizing problems; youth placed in kinship foster care with older caregivers in poorer health exhibited greater increases in externalizing problems. Findings highlighted important contextual considerations for out-of-home placement among African American youth.

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

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

Factors contributing to reduced caregiver strain in a publicly-funded child mental health system

This study examined caregiver strain in families who initiated mental health services for their child. Predictors of strain and the bidirectional relation between strain and child symptoms were examined. Participants included 218 children ages 4-13 with disruptive behavior problems and their caregivers, plus 96 psychotherapists, recruited from six publicly-funded clinics. Child disruptive behavior severity and caregiver strain were assessed at baseline, four, and eight months. Multilevel models were used to examine predictors of reduced caregiver strain, and autoregressive cross-lagged models were used to examine the bidirectional relations between change in caregiver strain and behavior problems over time. There were small to medium decreases in caregiver strain over the eight months after the initiation of mental health services, but few factors predicted change other than initial behavior problem severity. While more severe initial child symptoms predicted greater reductions in caregiver strain, greater child symptom severity sustained at four months predicted lesser improvements in caregiver strain. Simultaneously, greater caregiver strain predicted less improvement in child symptom severity, suggesting that child symptom severity and caregiver strain impact each other over time. These results suggest that attending to both child and caregiver factors may be important in maintaining improvements after initiating usual care.

Behavioral health services following implementation of screening in Massachusetts Medicaid children

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Childhood adversity and adult depression among the incarcerated: differential exposure and vulnerability by race/ethnicity and gender

The relationship between childhood adversity and adult depression is well-established but less is known about the association between childhood adversity and adult depression among the incarcerated. In this paper, we examine differential exposure and vulnerability to childhood adversity by race/ethnicity and gender on adult depression among the incarcerated in the United States. We address three research questions: does exposure to childhood adverse experiences vary by race/ethnicity and gender? Is there an association between these childhood adverse events and depression and does the strength of the association vary by the specific adverse experiences? And does vulnerability to childhood adversity vary by gender and race/ethnicity? Using the 2004 Survey of Inmates in State and Federal Correctional Facilities (SI-SFCF), we measure four key childhood adverse events - parental/caretaker substance abuse, physical assault, having been placed in foster care, and sexual assault. We use ordinary least squares regression and a series of interaction effect analyses to examine differential exposure and vulnerability to the four childhood adverse experiences by race/ethnicity and gender. Incarcerated women are more likely to report parental substance abuse, but all inmates/prisoners are similarly vulnerable to this experience. For the other three adverse experiences measured, we find that there are important racial/ethnic and gender differences in both exposure and vulnerability. African American men and women are more vulnerable to the effects of physical and sexual victimization than White and Hispanic men and women. Women are much more likely to be exposed to sexual victimization, but men who report this experience are significantly more depressed. Hispanic women and White men and women are more likely to report foster care, but all inmates/prisoners who report foster care experiences are significantly more depressed than other inmates/prisoners, with the exception of white men. The findings indicate that there are significant differences in exposure and vulnerability to childhood adversity by race/ethnicity and gender. We conclude that in order to effectively design and implement programs to decrease the probability that childhood adversity is a risk factor for adult depression interventions must be targeted toward specific, vulnerable groups according to race/ethnicity and gender.

Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment

BACKGROUND

Every year a large number of children around the world are removed from their homes because they are maltreated. Child welfare agencies are responsible for placing these children in out-of-home settings that will facilitate their safety, permanency, and well-being.However, children in out-of-home placements typically display more educational, behavioural, and psychological problems than do their peers, although it is unclear whether this results from the placement itself, the maltreatment that precipitated it, or inadequacies in the child welfare system.

OBJECTIVES

To evaluate the effect of kinship care placement compared to foster care placement on the safety, permanency, and well-being of children removed from the home for maltreatment.

SEARCH METHODS

We searched the following databases for this updated review on 14 March 2011: the Cochrane Central Register of Controlled Trials(CENTRAL),MEDLINE, PsycINFO, CINAHL, Sociological Abstracts, Social Science Citation Index, ERIC, Conference Proceedings Citation Index-Social Science and Humanities, ASSIA, and Dissertation Express. We handsearched relevant social work journals and reference lists of published literature reviews, and contacted authors.

SELECTION CRITERIA

Controlled experimental and quasi-experimental studies, in which children removed from the home for maltreatment and subsequently placed in kinship foster care were compared with children placed in non-kinship foster care for child welfare outcomes in the domains of well-being, permanency, or safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently read the titles and abstracts identified in the searches, and selected appropriate studies. Two review authors assessed the eligibility of each study for the evidence base and then evaluated the methodological quality of the included studies.Lastly, we extracted outcome data and entered them into Review Manager 5 software (RevMan) for meta-analysis with the results presented in written and graphical forms.

MAIN RESULTS

One-hundred-and-two quasi-experimental studies,with 666,615 children are included in this review.The 'Risk of bias' analysis indicates that the evidence base contains studies with unclear risk for selection bias, performance bias, detection bias, reporting bias, and attritionbias, with the highest risk associated with selection bias and the lowest associated with reporting bias. The outcome data suggest that children in kinship foster care experience fewer behavioural problems (standardised mean difference effect size -0.33, 95% confidence interval (CI) -0.49 to -0.17), fewer mental health disorders (odds ratio (OR) 0.51, 95% CI 0.42 to 0.62), better well-being (OR 0.50,95% CI 0.38 to 0.64), and less placement disruption (OR 0.52, 95% CI 0.40 to 0.69) than do children in non-kinship foster care. For permanency, there was no difference on re unification rates, although children in non-kinship foster care were more likely to be adopted(OR 2.52, 95% CI 1.42 to 4.49), while children in kinship foster care were more likely to be in guardianship (OR 0.26, 95% CI 0.17 to 0.40). Lastly, children in non-kinship foster care were more likely to utilise mental health services (OR 1.79, 95% CI 1.35 to 2.37).

AUTHORS' CONCLUSIONS

This review supports the practice of treating kinship care as a viable out-of-home placement option for children removed from the home for maltreatment. However, this conclusion is tempered by the pronounced methodological and design weaknesses of the included studies.

Problem-specific racial/ethnic disparities in pathways from maltreatment exposure to specialty mental health service use for youth in child welfare

The authors examined racial/ethnic differences in pathways from maltreatment exposure to specialty mental health service use for youth in contact with the Child Welfare system. Participants included 1,600 non-Hispanic White, African American, and Latino youth (age 4-14) who were the subjects of investigations for alleged maltreatment and participated in the National Survey of Child and Adolescent Well-Being. Maltreatment exposure, internalizing, and externalizing problems were assessed at baseline and subsequent specialty mental health service use was assessed 1 year later. Maltreatment exposure predicted both internalizing and externalizing problems across all racial/ethnic groups, but non-Hispanic White youth were the only group for whom maltreatment exposure was linked with subsequent service use via both internalizing and externalizing problem severity. Only externalizing problems predicted subsequent service use for African American youth and this association was significantly stronger relative to non-Hispanic White youth. Neither problem type predicted service use for Latinos. Future research is needed to understand how individual-, family-, and system-level factors contribute to racial/ethnic differences in pathways linking maltreatment exposure to services via internalizing/externalizing problems.

Are we reaching them yet? Service access patterns among attendees at the headspace youth mental health initiative

BACKGROUND

Australian young people have a high prevalence of mental health problems but low rates of service use. This article examines whether the Australian National Youth Mental Health Foundation, headspace, has helped redress this through providing youth-specific services.

METHOD

The article compares headspace service use demographics with population data from the Australian Survey of Mental Health and Wellbeing from 2007.

RESULTS

Headspace has improved access relative to the population, particularly among males and socially and economically excluded young people.

CONCLUSIONS

Despite overall successes, certain ethnic and age groups appear under-represented and in need of more careful targeting by youth mental health services.

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

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

Patterns and Predictors of Mental Healthcare Utilization in Schools and other Service Sectors among Adolescents at Risk for Depression

This study examined racial/ethnic and socioeconomic differences in service utilization across sectors (specialty mental health, school, primary care) for youth at risk of depression. Our sample included 362 adolescents who were enrolled in a larger project examining the effects of an indicated school-based depression prevention program. Service use across sectors mirrored national trends and previous research findings in which the education sector was most frequently utilized for mental health services. Race/ethnicity was significantly associated with parent-reported specialty mental health service utilization, even when controlling for other predictors of use. The study also suggests that racial disparities in service access generally appear to be reduced through the availability of education sector mental health services. Socioeconomic status was not associated with service use in any sector when controlling for other predictors. Parent-child agreement was moderate for report of specialty mental health service use and low for report of use of services within the education and primary care sectors.

Mental health services use by children investigated by child welfare agencies

OBJECTIVE

To examine the rates and predictors of mental health services use for a nationally representative cohort of youths who had been investigated for alleged maltreatment.

METHODS

Data came from caregiver and caseworker baseline and 18-month interviews in the second National Survey of Child and Adolescent Well-being. These interviews took place from March 2008 to September 2008 and September 2010 to March 2011. Data on family and child characteristics and service use were gathered and examined by using weighted univariate and multivariate analyses.

RESULTS

Children had numerous challenges: 61.8% had a previous report of maltreatment, 46.3% had poor socialization skills, and 23.9% had a mental health problem measured by the Child Behavior Checklist (CBCL). At baseline, 33.3% received some mental health service and this varied by age, with younger children receiving fewer services. This percentage decreased to 30.9% at the 18-month follow-up, although the youngest children had increases in services use. For younger children, race/ethnicity, out-of-home placement, chronic physical health problems, low adaptive behaviors, and CBCL scores in the clinical range were related to use. For children ≥ 11, out-of-home placement, high CBCL scores, and family risk factors predicted services use at 18 months.

CONCLUSIONS

Mental health services utilization increases as young children come into contact with schools and medical providers or have more intensive involvement with child welfare. Minority children receive fewer services adjusting for need. Over the 18-month follow-up, there was a decrease in service use that may be a result of the tremendous financial challenges taking place in the United States.

Effects of mental health disorders on the risk of juvenile justice system involvement and recidivism among children placed in out-of-home care

This study examined the effect of specific mental health disorders on the risk of juvenile justice system involvement and subsequent recidivism among maltreated children placed in out-of-home care. The sample was comprised of all children in Florida aged 7-17 years who were investigated for maltreatment and subsequently placed in out-of-home care between July 1, 2004, and June 30, 2005 (N = 5,720). Presence of mental health disorders and absence of a caregiver were both significantly associated with juvenile justice involvement. Among all examined mental health disorders, conduct disorder was the strongest predictor of juvenile justice involvement. Findings also indicated that, compared to children who did not have identified mental health disorders, children diagnosed with mental health disorders were approximately 80% more likely to experience recidivism. Implications of these findings are discussed.

Are two voices better than one? Predicting permanency in minority youth using multi-informant mental health and strength data

Among youth in child welfare ages 6-17 years, 40 % meet the criteria for one or more DSM diagnoses. For minority youth in child welfare, poor mental health is compounded by limited access to care and racial disparity bias, leading to poorer outcomes. This paper uses data collected and analyzed by an automated behavioral health assessment system for a multiyear study that focused on ways to improve case planning in child welfare. Youth, their caseworkers, and, in some cases, parents completed assessments that measured and monitored the youths' needs and strengths. More than 60 % of youth participating in the study were African-American; permanency rates after six months of case planning were found to be only one third. Predictive factors related to better behavioral health and permanency outcomes are identified and discussed, as well as the implications for improving case planning by incorporating the views of multiple informants, including the youth.

Adoptive parents' suspicion of preadoption abuse of their adopted children and the use of support services

BACKGROUND

Adopted children have a higher risk of developmental, mental, behavioural and social problems compared with non-adopted children, and their use of postadoption support services is of interest. Little attention has been given to the impact of preadoption abuse on the use of these services, and therefore this study examines whether or not adoptive parents' suspicion of preadoption abuse has a significant impact on the use of support services by adopted children.

METHODS

Data from the National Survey of Adoptive Parents, a US nationally representative survey of adopted children, were used to examine parents' suspicion of preadoption abuse and its effects on the use of postadoption support services by children aged 6-17 years (n = 1411). Statistical analyses were used to examine the relationship between suspected abuse and the use of support services while controlling for characteristics of the adopted child and adoptive parents/household.

RESULTS

Seven out of 10 adopted children have used some form of support service, and a larger percentage of 6- to 12-year-old children suspected of experiencing preadoption abuse used a support service compared with children not suspected of experiencing abuse. Significant relationships existed between various types of suspected preadoption abuse and the use of different types of postadoption support services. These relationships may go unaccounted for when only examining if any preadoption abuse occurred, or if any support service was used.

CONCLUSIONS

The type of preadoption abuse suspected appears to play a modest role in predicting the type of postadoption support services used by an adopted child. Giving further attention to understanding the relationship between different types of preadoption abuse and types of postadoption support services may help better understand the problems and difficulties experienced by adopted children.