Comparing Long-Term Placement Outcomes of Residential and Family Foster Care: A Meta-Analysis

Child maltreatment and behavioral health outcomes in child welfare: Exploring the roles of severity and polyvictimization

BACKGROUND

Child maltreatment and polyvictimization are known risk factors for long-term detrimental health and development outcomes, including behavioral health challenges. However, effects from specific types and combinations of maltreatments are unclear. This study examined the association between maltreatment or polyvictimization and behavioral health in a child welfare sample.

PARTICIPANTS AND SETTING

Medical records of children with child welfare involvement with at least one behavioral health condition (i.e., mental, behavioral or neurodevelopmental disorder, ICD-10 F01-F99) between 1/1/2018-12/31/2021 were extracted from a large, academic hospital system.

METHODS

Behavioral health complexity was categorized as non-chronic, non-complex chronic, or complex chronic using the Pediatric Medical Complexity Algorithm. Partial proportional logistic regression models adjusted for age, sex, race/ethnicity, caregiver type, and physical health complexity generated odds of behavioral health complexity by maltreatment type (physical abuse, sexual abuse, neglect) and maltreatment combinations.

RESULTS

The analytic sample included 3992 participants (mean age 7.6 (Standard Deviation, 5.0) 44 % female, 29 % white, 32 % black, 22 % Hispanic). Participants who experienced physical abuse (Odds Ratio [OR]: 1.79, 95 % Confidence Interval [CI]: 1.10-2.91), or neglect (OR: 1.69, 95 % CI: 1.38-2.07) were more likely to have increasing behavioral health complexity versus those without maltreatment. Participants with both physical abuse and neglect were over twice as likely (OR: 2.44, 95 % CI: 1.88-3.16) to have increasing behavioral health complexity versus those who did not experience maltreatment.

CONCLUSION

Results emphasize the differential impacts of maltreatment and polyvictimization exposures on behavioral health complexity among children with child welfare involvement that can guide risk assessment and clinical care.

Lifetime victimization experiences, depressiveness, suicidality, and feelings of loneliness in youth in care

BACKGROUND

Research has demonstrated the damaging effects of poly-victimization on the mental health of children and adolescents. However, few studies have been conducted in high-risk youth in care (Y-IC) samples.

OBJECTIVE

The study examines the frequency of lifetime victimization and the association of poly-victimization and victimization types on depressiveness, suicidality, and feelings of loneliness among Y-IC.

PARTICIPANTS AND SETTING

164 participants aged 14 and 21 years (M = 17.39, SD = 1.95), who live in family-based care or residential care.

METHODS

The Juvenile Victimization Questionnaire (JVQ) was used to assess lifetime victimization. The Patient Health Questionnaire (PHQ-9), and the Loneliness Scale-SOEP (LS-S) to measure depressiveness, suicidality, and loneliness. Hierarchical regression models were calculated.

RESULTS

Participants reported on average 12.66 (SD = 6.58) victimization experiences. The female and diverse gender groups reported higher rates of victimization, loneliness, depressiveness, and suicidality than the males. Participants in residential care reported more victimizations and stronger feelings of loneliness than those in family-based care. Poly-victimization was not associated with any of these internalizing symptoms but peer victimization was significantly associated with depressiveness (β = 0.23, p = .002) and loneliness (β = 0.22, p = .006), sexual victimization with depressiveness (β = 0.22, p = .004).

CONCLUSION

Y-IC show high levels of victimization and internalizing symptoms, with higher burden on girls and youth living in residential care. Findings underscore the relevance of social exclusion experiences among peers within Y-IC. Interventions should address multiple forms of victimization, with a special focus on sexual and peer victimization.

Cumulative risk factors for injuries and poisoning requiring hospital care in youth with prenatal substance exposure: A longitudinal controlled cohort study

Aim: To investigate whether the youth with prenatal substance exposure (PSE) (aged 15-24 years, n = 615) had been in hospital care more often due to injuries and poisoning in comparison with unexposed matched controls (n = 1787). Methods: Data from medical records (exposure) and national health and social welfare registers (outcome and confounders) were combined and youths were monitored from birth until either outpatient or inpatient hospital care for injury or poisoning, death or the end of the study period (December 2016). Cox regression models were used in the analyses accounting for associated child and maternal risk factors. Results: Half (50.4%) of the exposed group and 40.6% of controls had been in hospital care due to injury or poisoning during the follow-up (p < 0.001). The difference between groups was diminished after controlling for postnatal child and maternal risk factors (hazard ratio [HR] = 0.88, 95% confidence interval [CI] 0.72-1.07, p > 0.05). Cumulative adversity, especially out-of-home care in combination with a diagnosed attention or behavioural dysregulation problem, posed the highest risk in both groups (exposed: HR = 1.65, 95% CI 1.24-2.19, p < 0.001; controls: HR = 1.84, 95% CI 1.33-2.56, p < 0.001). Conclusion: Hospital care for injury and poisoning is more common in youth with PSE, but this is largely explained by the related postnatal child and maternal factors. Long-term support to families with maternal substance abuse problems could prevent injury and poisoning among youth with PSE.

Out-of-home interventions for adolescents who were treated according to the Open Dialogue model for mental health care

BACKGROUND

The Open Dialogue approach (OD) emphasizes community-based psychiatric treatment for adolescents, but its success in achieving this is poorly documented.

OBJECTIVE

To analyse out-of-home intervention usage in a national sample of adolescent psychiatric patients and determine if OD is linked to increased time until out-of-home intervention.

PARTICIPANTS AND SETTING

The register-based cohort study included all adolescents aged 13-20 who received psychiatric treatment in Finland between 2003 and 2008. The research group (n = 780) included adolescents whose treatment was initiated in the Western Lapland catchment area, where OD covered the entire psychiatric service. The comparison group (n = 44,088) included the rest of Finland. National register data encompassed the period from treatment onset until the end of the 10-year follow-up or death. The primary outcomes of interest were the times to the first and second out-of-home intervention, including foster care, supportive housing, and hospitalization. The secondary outcomes included the clinical/demographic characteristics of adolescents treated out-of-home.

METHODS

The hypothesis was tested via an inverse probability of treatment-weighted Cox hazard model, plus within- and between-group comparisons to analyse the secondary outcome.

RESULTS

OD was associated with increased time to the first (adjusted hazard ratio [aHR]: 0.61, 95%CI: 0.52-0.72) and second (aHR: 0.75, 95%CI: 0.58-0.96) out-of-home interventions. In both service types, there was a subgroup of adolescents with repeated out-of-home interventions, who also demonstrated poorer long-term outcomes.

CONCLUSION

OD-based psychiatric services for adolescents are associated with fewer out-of-home interventions. The clinical significance of the findings warrants further research.

The mental health of all children in contact with social services: a population-wide record-linkage study in Northern Ireland

AIMS

Children in contact with social services are at high risk for mental ill health, but it is not known what proportion of the child population has contact with social services or how risk varies within this group compared to unexposed peers. We aim to quantify the extent and nature of contact with social services within the child population in Northern Ireland (NI) and the association with mental ill health. We also examine which social care experiences identify those most at risk.

METHODS

This is a population-based record-linkage study of 497,269 children (aged under 18 years) alive and resident in NI in 2015 using routinely collected health and social care data. Exposure was categorized as (1) no contact, (2) referred but assessed as not in need (NIN), (3) child in need (CIN) and (4) child in care (CIC). Multilevel logistic regression analyses estimated odds ratios (ORs) for mental ill health indicated by receipt of psychotropic medication (antidepressants, anxiolytics, antipsychotics and hypnotics), psychiatric hospital admission and hospital-presenting self-harm or ideation.

RESULTS

Over one in six children (17.2%, n = 85,792) were currently or previously in contact with social services, and almost one child in every 20 (4.8%, n = 23,975) had contact in 2015. Likelihood of any mental ill health outcome increased incrementally with the level of contact with social services relative to unexposed peers: NIN (OR 5.90 [95% confidence interval (CI) 5.10-6.83]), CIN (OR 5.99 [95% CI 5.50-6.53]) and CIC (OR 12.60 [95% CI 10.63-14.95]). All tiers of contact, number of referrals, number of care episodes and placement type were strongly associated with the likelihood of mental ill health.

CONCLUSION

Children who have contact with social services account for a large and disproportionate amount of mental ill health in the child population. Likelihood of poor mental health across indicators is highest in care experienced children but also extends to the much larger population of children in contact with social services but never in care. Findings suggest a need for targeted mental health screening and enhanced support for all children in contact with social services.

Child Welfare Reform: A Scoping Review

While there have been ongoing calls to reform child welfare so that it better meets children's and families' needs, to date there have been no comprehensive summaries of child welfare reform strategies. For this systematic scoping review, we summarized authors' recommendations for improving child welfare. We conducted a systematic search (2010 to 2021) and included published reviews that addressed authors' recommendations for improving child welfare for children, youth, and families coming into contact with child welfare in high-income countries. A total of 4758 records was identified by the systematic search, 685 full-text articles were screened for eligibility, and 433 reviews were found to be eligible for this scoping review. Reviews were theoretically divided, with some review authors recommending reform efforts at the macro level (e.g., addressing poverty) and others recommending reform efforts at the practice level (e.g., implementing evidence-based parenting programs). Reform efforts across socioecological levels were summarized in this scoping review. An important next step is to formulate what policy solutions are likely to lead to the greatest improvement in safety and well-being for children and families involved in child welfare.

Foster children's perspectives on participation in child welfare processes: A meta-synthesis of qualitative studies

The objective of this meta-synthesis was to systematically synthesise qualitative research that explores foster children's perspectives on participation in child welfare processes. Searches were conducted in Medline (OVID), Embase, PsycINFO, and Social Science Citation Index. Children in non-kinship foster care in any setting (high-income, middle-income, low-income countries) who self-reported their experiences of care (removal from home, foster family processes, placement breakdown) were eligible for inclusion. Selected studies took place in 11 high-income countries. A total of 8436 citations were identified and 25 articles were included in this meta-synthesis. Studies summarized the views of 376 children. Children had been in foster care between two weeks and 17 years. Findings synthesize 'facets' of children's participation (e.g., being asked vs making decisions), as well as children's perceived barriers and facilitators to participation. A main priority for children was the quality of their relationships, especially in terms of values (e.g., fairness, honesty, inclusivity). No one way of participating in child welfare processes is better than another, as some children more clearly expressed a desire for passive listening roles and others indicated a desire for active roles in decision-making. However, meaningful adults in foster children's lives have a responsibility to act in a way that strengthens the emphasis on children's needs and voices.

Long-term Health and Social Outcomes in Children and Adolescents Placed in Out-of-Home Care

IMPORTANCE

Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification.

OBJECTIVE

To estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors.

DESIGN, SETTING, AND PARTICIPANTS

This cohort and cosibling study of all children born in Finland between 1986 and 2000 (N = 855 622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021.

EXPOSURES

Placement in out-of-home care up to age 15 years.

MAIN OUTCOMES AND MEASURES

Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality.

RESULTS

A total of 30 127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2-5.1) years and 2 (1-3) placement episodes before age 15 years. Compared with their siblings, individuals who had been placed in out-of-home care were 1.4 to 5 times more likely to experience adverse outcomes in adulthood (adjusted hazard ratio [aHR] for those with a fall-related injury, 1.40; 95% CI, 1.25-1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56-6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74-4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25-5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56-6.43; cumulative incidence, 3.1% vs 0.6%). Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings.

CONCLUSIONS AND RELEVANCE

Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.

Stunting, double orphanhood and unequal access to public services in democratic South Africa

Orphans who lack household or community support face significant socio-economic disadvantages. In particular, they are at greater risk of malnutrition and stunting in developing countries. Children who have no living parents, also called double orphans, are most likely to require support from extended families or public institutions. This paper explores how WASH infrastructure, and public health and social services relate to stunting. It is one of the first studies to analyse these factors with a specific focus on double orphans, who tend to live in under-serviced areas with high stunting rates and poor access to public resources. We collate a cross sectional spatial dataset with local child stunting rates from 2013, rates of double orphanhood, private household resources, and public services from 2011 for South Africa, a country where the HIV/AIDS pandemic has led to high rates of double orphanhood. We estimate spatial econometric models that account for unobserved regional shocks and measurement bias, but which do not address other biases. Our results show that high stunting rates, particularly in areas with high proportions of double orphans, overlap strongly with poor provision of WASH and the availability of household resources. By contrast, other softer services accessed outside the home, such as access to health, social welfare and early childhood development facilities are not correlated with stunting in the same way. WASH is more strongly related to reduced stunting when infrastructure covers larger geographic areas and with the combined use of services from adjacent areas. This occurs because of economies of scale in provision and preventing transmission of disease across regions. Policy makers can explore the option to reduce stunting by expanding geographic networks of WASH service delivery into under-serviced areas where double orphans tend to locate.

The EU Strategy on the Rights of the Child and the European Child Guarantee—Evidence-Based Recommendations for Alternative Care

Protection and promotion of child rights are referred to as a central purpose of the European Union (EU). Therefore in 2021, the EU Strategy on the Rights of the Child and the European Child Guarantee were published to enable children to have the best possible life in the EU and worldwide. Member states were invited to implement the directions of both documents into practice. The present study analyses and showcases the evidence on how to progress implementation of the Strategy and the Guarantee regarding alternative care in Portugal. A literature review was conducted based on international literature. Evidence-based recommendations for the Portuguese transition process towards quality, family and community-based care are stated. De-institutionalisation and strengthening specific services—kinship care, special guardianship, and foster care—are advocated, namely specialising the workforce, and promoting training for kinship carers and prospective special guardians. To conclude, the revision and monitoring of the measures for children in need of alternative care are suggested as well as integrating and publishing data from the diverse services of the alternative care system.

Social Support Is Related to the Use of Adaptive Emotional Regulation Strategies in Ecuadorian Adolescents in Foster Care

Adolescents in foster care are exposed to maltreatment and inadequate social support which can have lasting repercussions on their emotional development. The aim of this study was to examine the effect of social support on the use of emotional regulation strategies in Ecuadorian adolescents in foster care and non-foster peers. This study recruited 181 adolescents, 56 in foster care and 123 non-foster peers, from various locations in Quito, Ecuador. Participants completed the Cognitive Emotion Regulation Questionnaire (CERQ) and the Multidimensional Scale of Perceived Social Support (MSPSS). Using linear regression, we found that being in foster care was related to lower perceived social support. The non-foster care control group reported using more emotion regulation strategies, both adaptive and maladaptive (acceptance, rumination, refocusing to planning, and self-blaming), than the foster care group. Greater social support was associated with the use of more positive strategies (reappraisal, positive refocusing, and refocusing to planning) and less maladaptive strategies (catastrophizing). Youth in foster care have less social support than their non-foster peers. This puts them at risk, as social support has an important role in the use of healthy emotion regulation skills in adolescents.

Experience of child welfare services and long-term adult mental health outcomes: a scoping review

PURPOSE

This is the first comprehensive review of empirical research that investigated the association between receipt of child welfare services and adult mental health outcomes. The review summarised the results of studies about mental health outcomes of adults with a history of child welfare involvement.

METHODS

A scoping review methodology was used to search five electronic databases (MEDLINE, EMBASE, PsychINFO, IBSS, Social Policy and Practice). Studies were included if they examined any child welfare exposure (including receipt of services while remaining at home/being placed in care) and adult mental health status.

RESULTS

In total 4591 records were retrieved, of which 55 met the eligibility criteria. Overall, receipt of child welfare services was associated with an increased risk of adult mental ill-health, suicide attempt and completed suicide. Results regarding potential moderating factors, such as gender and care-related experiences, were mixed. Relatively few studies investigated the reasons for requiring child welfare services, the experience of abuse or neglect or the adult outcomes of child welfare service users who remained in their own homes. Mental ill-health was defined and measured heterogeneously and details about the nature and type of welfare service utilisation were lacking.

CONCLUSION

There is a need for detailed, longitudinal studies to better understand the relative contribution of pre-existing adversity versus experiences during and after exposure to child welfare services on adult mental health outcomes. More standardised measures of mental ill-health and greater detail from authors on specific care exposure are also needed.

Predictors of quality of life among youths in foster care-a 5-year prospective follow-up study

PURPOSE

Few studies have investigated possible predictors of positive outcomes for youths in foster care. The aim of this prospective follow-up study was to examine quality of life (QoL) among youths in foster care and to assess whether contextual and child factors predicted QoL.

METHODS

Online questionnaires were completed by carers in Norway in 2012 (T1, n = 236, child age 6-12 years) and by youths and carers in 2017 (T2, n = 405, youth age 11-18 years). We received responses on 116 of the youths at both T1 and T2, and our final sample consisted of 525 youths with responses from T1 and/or T2. Child welfare caseworkers reported preplacement maltreatment and service use at T1. We assessed mental health and prosocial behavior at T1 by having carers complete the Strength and Difficulties Questionnaire and QoL at T2 with youth-reported KIDSCREEN-27. We analyzed the data using descriptive statistics, t-tests and multiple linear regressions, and we used multiple imputation to handle missing data.

RESULTS

Youths in foster care had lower QoL across all dimensions compared to a Swedish general youth sample. QoL scores among our sample were similar to Norwegian youths with ill or substance abusing parents and to European norm data. Youths reported the highest QoL scores on the parent relations and autonomy dimension. Male gender, younger age, kinship care and prosocial behavior five years earlier predicted higher QoL.

CONCLUSION

Similar to other at-risk youths, youths in foster care seem to have lower QoL than the general Scandinavian population. Despite early adversities, they had good relations with their current carers. Adolescent girls seem especially vulnerable to low QoL and might need extra support to have good lives in foster care.

Reporte de padres, profesores y cuidadores sobre problemas de comportamiento externalizado de niños y adolescentes en acogimiento residencial versus niños que viven con sus familias

Resumen Los comportamientos externalizados en niños y adolescentes en acogimiento residencial se presentan con regularidad, convirtiéndose en predictores de conductas delictivas, dinámicas relacionales disfuncionales, consumo de sustancias, entre otros. El objetivo general del presente estudio fue identificar y comparar problemas de comportamiento externalizado de niños y adolescentes en acogimiento residencial y con sus familias, reportados por padres, profesores y cuidadores. La muestra estuvo conformada por 222 adolescentes y preadolescentes entre los 11 y 16 años del Distrito Federal de Caracas y del Estado Miranda-Venezuela. El instrumento utilizado fue el Cuestionario sobre el Comportamiento de Niños y Niñas de 6-18 años. No se encontraron diferencias estadísticamente significativas entre los grupos. Sin embargo, la puntuación en ruptura de normas es más alta en el grupo que vive en acogimiento residencial, contrario a la del grupo control cuya puntuación más alta fue en conducta agresiva. Los hallazgos permiten entrever que, aunque en los reportes de padres, profesores y cuidadores no se encontraron diferencias entre los grupos en relación con el comportamiento externalizado, los puntajes altos pueden concebirse como conductas en riesgo ante las cuales hay que actuar con cautela y hacer seguimiento.

The psychobiological consequences of child separation at the border: lessons from research on attachment and emotion regulation

In the spring of 2018, the Attorney General of the United States issued a memorandum declaring a "zero tolerance policy" under which all adults entering the United States illegally would be criminally prosecuted, and, if traveling with minor children, forcibly separated from their children. Although the government was ordered to reunite the children with their parents it is still unclear how many children have been or remain separated. Given the high risk of permanent harm to a vulnerable population, and the fact that this risk may continue into the near future, we present a review of what nearly eight decades of scholarly research has taught us about the damaging impact of deprivation and separation from parents. The article briefly reviews the origins of attachment theory as well as empirical studies that examine the psychobiological impact on children who experienced parental deprivation or separation. The paper concludes with recommendations, for future research.