An Integrative Data Analysis of Main and Moderated Crossover Effects of Parent-Mediated Interventions on Depression and Anxiety Symptoms in Youth in Foster Care

Without preventative intervention, youth with a history of foster care (FC) involvement have a high likelihood of developing depression and anxiety (DA) symptoms. The current study used integrative data analysis to harmonize data across four foster and kinship parent-mediated interventions (and seven randomized control trials) designed to reduce youth externalizing and other problem behaviors to determine if, and for how long, these interventions may have crossover effects on youth DA symptoms. Moderation of intervention effects by youth biological sex, developmental period, number of prior placements, and race/ethnicity was also examined. Youth (N = 1891; 59% female; ages 4 to 18 years) behaviors were assessed via the Child Behavior Checklist, Parent Daily Report, and Eyberg Child Behavior Inventory at baseline, the end of the interventions (4-6 months post baseline), and two follow-up assessments (9-12 months and 18-24 months post baseline), yielding 4830 total youth-by-time assessments. The interventions were effective at reducing DA symptoms at the end of the interventions; however, effects were only sustained for one program at the follow-up assessments. No moderation effects were found. The current study indicates that parent-mediated interventions implemented during childhood or adolescence aimed at reducing externalizing and other problem behaviors had crossover effects on youth DA symptoms at the end of the interventions. Such intervention effects were sustained 12 and 24 months later only for the most at-risk youth involved in the most intensive intervention.

Association of Timely Outpatient Mental Health Services for Youths After Psychiatric Hospitalization With Risk of Death by Suicide

IMPORTANCE

Timely outpatient follow-up care after psychiatric hospitalization is an established mental health quality indicator and considered an important component of suicide prevention, yet little is known about whether follow-up care is associated with a reduced risk of suicide soon after hospital discharge.

OBJECTIVE

To evaluate whether receipt of outpatient care within 7 days of psychiatric hospital discharge is associated with a reduced risk of subsequent suicide among child and adolescent inpatients and examine factors associated with timely follow-up care.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective, longitudinal cohort study used Medicaid data from 33 states linked with National Death Index data. The study population included all youths aged 10 to 18 years who were admitted to a psychiatric hospital from January 1, 2009, to December 31, 2013. Data analysis was completed from October 9, 2019, through May 15, 2020.

EXPOSURE

Mental health follow-up visits received within 7 days of hospital discharge.

MAIN OUTCOMES AND MEASURES

Suicides occurring in the 8 to 180 days after hospital discharge. Logistic regression modeled the association between demographic, clinical, and mental health service history factors and receipt of an outpatient visit within 7 days after discharge. Poisson regression estimated the association between suicide risk and outpatient visits within 7 days after discharge, adjusting for confounding using inverse probability of treatment weights from the logistic model.

RESULTS

Of the total 139 694 youths admitted to a psychiatric hospital, 51.9% were female, 31.1% were aged 10 to 13 years, and 68.9% were aged 14 to 18 years. A total of 56.5% of the youths received a mental health follow-up visit within 7 days of discharge, and this was associated with a significantly lower odds of suicide (adjusted relative risk, 0.44; 95% CI, 0.23-0.83; P = .01) during the 8 to 180 days postdischarge period. Youths with longer lengths of stay (4-5 days: adjusted odds ratio [AOR], 1.20 [95% CI, 1.17-1.24]; 6-7 days: AOR, 1.47 [95% CI, 1.43-1.52]; 8-12 days AOR, 1.75 [95% CI, 1.69-1.81]; 13-30 days: AOR, 1.71 [95% CI, 1.63-1.78]), prior outpatient mental health care (AOR, 1.58; 95% CI, 1.51-1.65), and foster care placement (AOR, 1.32; 95% CI, 1.28-1.37) were more likely to receive 7-day follow-up, whereas those who were non-Hispanic Black (AOR, 0.82; 95% CI, 0.79-0.84), were older (AOR, 0.82; 95% CI, 0.80-0.84), were medically ill (AOR, 0.77; 95% CI, 0.74-0.81), and had managed care insurance (AOR, 0.88; 95% CI, 0.87-0.91) were less likely to receive follow-up visits.

CONCLUSIONS AND RELEVANCE

In this cohort study, risk of suicide during the 6 months after psychiatric hospitalization was decreased among youth who had an outpatient mental health visit within 7 days after discharge. Addressing disparities in timely continuity of care may help advance health equity agendas.

A review of mental health treatment dropout by ethnic minority youth

A large proportion of treatments in youth mental health care are prematurely terminated by the patient. Treatment dropout can have severe consequences. Since ethnic minority youth are treated less often for mental disorders than other youth, it is important to analyse their risk for dropout and to determine if there are ethnicity-specific determinants. This review aimed to provide an overview of the findings from empirical studies on child and adolescent therapy dropout by ethnic minority and to determine if there were ethnicity-specific dropout determinants. An extensive literature search was performed to locate relevant journal articles. Identified articles were inspected for relevant references and these articles were then included in the meta-analysis. A total of 27 studies were accepted for analysis. The results showed that ethnic minority patients have a higher risk of treatment dropout than ethnic majority patients and that dropout rates are ethnically specific. Several differences in dropout predictors among the ethnic groups were found. In spite of diverse results, review limitations, and the lack of several key variables in the available research, some clinical recommendations are made. The review indicates that to prevent dropout, therapists should pay attention to variables such as ethnic background, therapist-patient ethnic match, and the quality of the therapeutic relationship.

Adverse childhood experiences among youth reported to child welfare: Results from the national survey of child & adolescent wellbeing

The negative influence of adverse childhood experiences (ACEs) on social, emotional, and behavioral (SEB) outcomes are well documented. However, no research to date has examined the effect of ACEs on SEB outcomes in youth who received mental health services after reporting to the child welfare system. This study's analyses of data from the National Survey of Child and Adolescent Well-Being II revealed that the most prevalent ACEs included hospitalization for a medical condition, neglect, and exposures to domestic and community violence. Logistic regression of this data showed that the odds of being diagnosed with internalizing problems increased with age and when sexual abuse was reported. The results also showed that compared to Caucasian youth, Latinos were less likely to be diagnosed with externalizing behaviors, even when sexual abuse had been reported. Contrary to one of this study's hypotheses, mental health service use within the past 18 months increased the odds of being diagnosed with SEB problems. These findings highlight the persistence of SEB problems despite receipt of mental health services. Future research should assess the impact of interventions that aim to mitigate poor SEB outcomes due to ACEs, especially sexual abuse.

The Protective Effect of Kinship Involvement on the Adjustment of Youth in Foster Care

Child maltreatment and family dysfunction (e.g., conflict) can have a long-term deleterious impact on youth well-being. Using a child welfare sample, this study examined whether dysfunction in the nuclear family of origin was associated with adjustment problems, including internalizing and externalizing behavior problems, beyond the effect of child maltreatment, and whether extended family (kinship) involvement protected against youth's adjustment problems. Participants included 171 children and adolescents (mean age = 10.15; 50.3% female) who entered foster care due to child maltreatment. Results indicated that greater dysfunction in the nuclear family of origin and child maltreatment were independently associated with greater internalizing and externalizing behavior problems. Results also showed that kinship involvement was protective against externalizing behavior problems. Moreover, kinship involvement buffered the association between dysfunction in family of origin and internalizing behaviors only at low levels of family dysfunction. These results support policies that encourage the involvement of extended and noncustodial family members in the lives of maltreated youth following their entry into foster care.

A model of integrated health care in a poverty-impacted community in New York City: Importance of early detection and addressing potential barriers to intervention implementation

Disruptive behavior disorders (DBDs) are chronic, impairing, and costly behavioral health conditions that are four times more prevalent among children of color living in impoverished communities as compared to the general population. This disparity is largely due to the increased exposure to stressors related to low socioeconomic status including community violence, unstable housing, under supported schools, substance abuse, and limited support systems. However, despite high rates and greater need, there is a considerably lower rate of mental health service utilization among these youth. Accordingly, the current study aims to describe a unique model of integrated health care for ethnically diverse youth living in a New York City borough. With an emphasis on addressing possible barriers to implementation, integrated models for children have the potential to prevent ongoing mental health problems through early detection and intervention.

Latino suicidal adolescent psychosocial service utilization: The role of mood fluctuations and inattention

BACKGROUND

Little is known about the specific factors related to whether or not Latino adolescents with suicide ideation (SI) will seek services. Utilizing Andersen's Behavior Model of Health Services Use (2008) the goal of this study is to identify the factors related to utilization of mental health services by Latino adolescents with SI to inform and improve suicide prevention efforts.

METHOD

Data from Wave 1 of the National Longitudinal Study of Adolescent Health was examined. Predispositional (gender, age), enabling/disabling (income, lack of insurance, difficulty obtaining medical care), and need (depressed mood, suicide attempt, perceived health, impulsivity, mood fluctuations, difficulties with attention, etc.) variables were examined via logistic regression as potential correlates of mental health service utilization.

RESULTS

Twenty-eight percent of the Latino adolescents with suicidal ideation (SI) in our sample received mental health services. Need factors such as daily mood fluctuations within the past 12 months (OR=4.78) and frequent difficulty focusing attention within the past week (OR=4.96), but not impulsivity, were associated with an increased likelihood of receiving mental health services. No additional associations were observed.

LIMITATIONS

The current study is based on cross-sectional data. Therefore, statements about causality cannot be made.

CONCLUSIONS

These findings suggest that emotion regulation (e.g., daily mood fluctuations) and neurocognitive factors (e.g., difficulty with focusing attention) may be important factors to consider in the clinical assessment of Latino adolescents with SI.

Enrolment of children and adolescents in psychosocial care: more likely with low family social support and poor parenting skills

Knowledge about determinants of child and adolescent enrolment in psychosocial care concerns only single types of care and usually only socio-demographic factors. The social environment is also a likely key determinant but evidence is lacking. The aim of this study was to examine the associations between family social support, parenting skills and child and adolescent enrolment in psychosocial care. We obtained data on 1,331 children (response rate 56.6%), 4-18 years old, enrolled in preventive child health care, and child and adolescent social care and mental health care because of psychosocial problems, and on 463 children (response rate 70.3%) not enrolled in psychosocial care. Results showed that enrolment in psychosocial care was associated with low family social support (odds ratio; 95%-confidence interval: 3.2; 2.4-4.4), and with poor parenting skills, i.e. poor supervision (1.5; 1.1-2.1) and inconsistent disciplining (1.5; 1.1-2.1). Children's psychosocial problems partially mediated the associations with family social support and completely with parenting skills. Children's problems did not moderate the associations. Positive parenting was not associated with care enrolment. We conclude that low family social support and poor parenting are important factors associated with enrolment, in particular because they are associated with more frequent occurrence of children's psychosocial problems. This implies that professionals and policymakers need to be aware that factors in children's social environment are related with enrolment in psychosocial care, in addition to children's psychosocial problems.

Engaging foster parents in treatment: a randomized trial of supplementing trauma-focused cognitive behavioral therapy with evidence-based engagement strategies

The goal of this study was to examine the impact of supplementing Trauma-focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2006) with evidence-based engagement strategies on foster parent and foster youth engagement in treatment, given challenges engaging foster parents in treatment. A randomized controlled trial of TF-CBT standard delivery compared to TF-CBT plus evidence-based engagement strategies was conducted with 47 children and adolescents in foster care and one of their foster parents. Attendance, engagement, and clinical outcomes were assessed 1 month into treatment, end of treatment, and 3 months post-treatment. Youth and foster parents who received TF-CBT plus evidence-based engagement strategies were more likely to be retained in treatment through four sessions and were less likely to drop out of treatment prematurely. The engagement strategies did not appear to have an effect on the number of canceled or no-show sessions or on treatment satisfaction. Clinical outcomes did not differ by study condition, but exploratory analyses suggest that youth had significant improvements with treatment. Strategies that specifically target engagement may hold promise for increasing access to evidence-based treatments and for increasing likelihood of treatment completion.

Interorganizational relationships among family support organizations and child mental health agencies

This study examined: (1) qualitative aspects of close working relationships between family support organizations and child mental health agencies, including effective and ineffective characteristics of the relationship and aspects that they would change, and (2) the impact of the working relationship upon the family support organization. Semi-structured interviews were conducted with 40 directors of family support organizations characterized as having a close working relationship with a child mental health agency. Three main themes emerged regarding the quality of the working relationship: (a) interactional factors, including shared trust, communication, collaboration and service coordination; (b) aspects of the inner context of the family support organization, mental health agency, or both, including alignment of goals and values and perceptions of mental health services; and (c) outer contextual factors external to the organizations, such as financial and county regulations. Responses to the perceived impact of the relationship was divided into two themes: positive impacts (e.g. gained respect, influence and visibility), and negative impacts (e.g. lack of trust). This study lays the foundation for future research to better understand the mechanisms underlying interorganizational relationships in communities among different types of providers to create a more seamless continuum of services for families of children with mental health conditions.

Improving foster parent engagement: using qualitative methods to guide tailoring of evidence-based engagement strategies

This qualitative study examined applicability and need for tailoring of an evidence-based engagement intervention, combined with Trauma-Focused Cognitive Behavioral Therapy, for foster parents. Qualitative methods were used, including individual interviews with participating foster parents (N = 7), review of interview findings with an independent group of foster parents (N = 5), and review of the combined foster parent findings by child welfare caseworkers (N = 5), an important stakeholder group. The engagement intervention, with its primary focus on perceptual barriers (e.g., past experiences with mental health), was relevant for the foster care population. However, the study identified areas for tailoring to better recognize and address the unique needs and situation of foster parents as substitute caregivers. Perceptually focused engagement interventions may have broad applicability to a range of populations, including foster parents, with the potential for improving caregiver participation in children's mental health services.

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.

Family Histories and Multiple Transitions Among Homeless Young Adults: Pathways to Homelessness

This study explored the early family histories of homeless young adults, the types and number of transitions they experienced, and their pathways to the street. Intensive qualitative interviews were audio taped and transcribed with 40 homeless young adults 19 to 21 years of age in the Midwest. Findings show that family backgrounds were generally characterized by substance use, child maltreatment, and witnessing violence, all of which provide social context for understanding why so many of these young people opted to leave home in search of an alternative living situation. The current findings also reveal that while some young adults ran away from home as adolescents, others were "pushed out" (i.e., told to leave), or removed by state agencies. Current study findings illustrate that young adults' trajectories are marked by multiple living arrangements such as home, foster care, detention facility, and drug rehabilitation. Overall, study results show that young adults' family histories place them on trajectories for early independence marked by multiple transitions and numerous living situations, culminating in a lack of a permanent residence to call home.

Mental health services expenditures among children placed in out-of-home care

This study examined Florida Medicaid mental health expenditures for children in out-of-home care. Child welfare and Medicaid administrative databases were analyzed using two-part models to identify characteristics associated with expenditures. Mental health expenditures were higher for older children, boys, children who were abused or lost their caregivers, or with a longer length of stay in out-of-home care. In contrast, African American children were less likely to have positive expenditures than White children, but among youth with positive expenditures, African Americans had higher expenditures. In addition, among youth with positive expenditures, substance use and affective disorders were associated with higher expenditures.

Prevalence and Predictors of Service Utilization Among Racially and Ethnically Diverse Adolescents in Foster Care Diagnosed With Mental Health and Substance Abuse Disorders

This study examined the prevalence of mental health and substance abuse disorders and service utilization among a racially and ethnically diverse group of foster youth. Self-report data on symptoms and service receipt were used to identify whether groups of adolescents defined by their race and ethnicity were equally likely to receive services given the presence of a mental health or substance use disorder. Study findings showed that Caucasians are more likely to receive mental health services than African Americans. Race was not a significant predictor of accessing substance abuse services. Hispanic ethnicity was not a predictor of receipt of mental health or substance abuse treatment services. Implications for future research, practice, and policy are discussed.

Foster Care Placement, Poor Parenting, and Negative Outcomes Among Homeless Young Adults

Although homeless youth with and without foster care histories both face adverse life circumstances, little is known about how these two groups compare in terms of their early histories and whether they face similar outcomes. As such, we compared those with and without a history of foster care placement to determine if the associations between a history of poor parenting and negative outcomes including depression, delinquency, physical and sexual victimization, and substance use, are similar for these two groups. The sample consisted of 172 homeless young adults from the Midwestern United States. Multivariate results revealed that among those previously in foster care, a history of physical abuse and neglect were positively associated with more depressive symptoms whereas sexual abuse and neglect were related to delinquency and physical victimization. Additionally, lower caretaker monitoring was linked to greater delinquent participation. Among those without a history of foster care, physical abuse was related to more depressive symptoms whereas sexual abuse was positively correlated with delinquency, sexual victimization, and substance use. Furthermore, lower monitoring was related to more substance use. Our findings are discussed in terms of a social stress framework and we review the implications of foster care placement for homeless young adults.

The Impact of Continued Contact with Biological Parents upon the Mental Health of Children in Foster Care

This study examined depression and externalizing problems of children in foster care using a subsample of data (N = 362) from the National Survey of Child and Adolescent Well-Being. Our findings indicated that more frequent contact with the biological mother was marginally associated with lower levels depression and significantly associated with lower externalizing problem behaviors. The association with externalizing problem behavior was significant even after controlling for gender and exposure to violence. Further, differences with regard to gender were revealed. Specifically, girls had higher depression scores than boys even after controlling for exposure to violence. Results suggest that supporting frequent, consistent, visitation may impact the levels of depression and externalizing programs children in foster care exhibit.

Concordance of mental health impairment and service utilization among children in care

This paper describes caregiver-reported patterns of mental health service use for 347 pre-adolescent children in foster and kinship care in New South Wales (NSW), Australia. Children's mean time in care and mean time with their present caregivers were 4.3 and 3.3 years respectively. Forty-four percent of children received individual therapy or counselling, 45% received interventions in the form of clinical guidance for their caregivers, and 31% received both forms of service. Among children scoring in the clinical range on any CBCL sub-scale (N = 191), equivalent rates of mental health service use were 60%, 55% and 41% respectively. Although not directly comparable, these findings describe a higher rate of service use than that reported for children in care elsewhere. While children with more complex and severe difficulties had higher rates of service use, there was no evidence of variable access for treatment of different types of disorder. Predictors of service use are reported and contrasted with previous findings. The paper considers several features of the NSW child welfare, health and education systems that may account for the relatively high rate of service use.

Mental Health Services for Children and Youth in the Child Welfare System: A Focus on Caregivers as Gatekeepers

Caregivers serve as gatekeepers for children while in the child welfare system, but few studies have focused on the caregiver and the factors that influence the use of mental health services for the children under their care. The purpose of this study was to examine the child's mental health need, the caregiver's level of stress, depression, and social support, and the utilization of mental health services by children using the three most common types of caregivers in the child welfare system (i.e., birth parent, relative caregiver, and foster parent). Data comes from the Patterns of Care (POC) study of five public sectors of care. The present study examined parents/caregivers and youth from the child welfare sector. Findings suggest that while birth parents were more likely to endorse more risk factors for themselves, and the children under their care had a higher level of mental health need, they were the least likely to utilize mental health services for the children under their care. Implications for the child welfare and mental health systems are discussed.

State variation in psychotropic medication use by foster care children with autism spectrum disorder

OBJECTIVE

The objective of this study was to compare on a national cohort of children with autism spectrum disorder (ASD) the concurrent use of >or=3 psychotropic medications between children in foster care and children who have disabilities and receive Supplemental Security Income, and to describe variation among states in the use of these medications by children in foster care.

METHODS

Studied was the concurrent use of >or=3 classes of psychotropic medications, identified from the 2001 Medicaid claims of 43406 children who were aged 3 to 18 years and had >or=1 annual claim for ASD. Medicaid enrollment as a child in foster care versus a child with disabilities was compared. Multilevel logistic regression, clustered at the state level and controlling for demographics and comorbidities, yielded standardized (adjusted) estimates of concurrent use of >or=3 medications and estimated variation in medication use within states that exceeded 1 and 2 SDs from the average across states.

RESULTS

Among children in foster care, 20.8% used >or=3 classes of medication concurrently, compared with 10.1% of children who were classified as having a disability. Differences grew in relationship to overall use of medications within a state; for every 5% increase in concurrent use of >or=3 medication classes by a state's population with disabilities, such use by children in a state's foster care population increased by 8.3%. Forty-three percent (22) of states were >1 SD from the adjusted mean for children who were using >or=3 medications concurrently, and 14% (7) of the states exceeded 2 SDs.

CONCLUSIONS

Among children with ASD, children in foster care were more likely to use >or=3 medications concurrently than children with disabilities. State-level differences underscore policy or programmatic differences that might affect the receipt of medications in this population.

What research tells us about the intersecting streams of homelessness and foster care

This paper reviews mounting evidence linking foster care and homelessness and considers new approaches for intervention. Although there is no causal evidence that family homelessness leads to foster care or vice versa, the association no longer originates solely from samples of homeless people, but also from samples of people with childhood histories of foster care. Many programs work with families, children or youth based on their current living situations and limits imposed by funders. This results in discontinued services when the living situations change. Given the strong and consistent associations between homelessness and foster care, a better approach is to design programs that work with transient families regardless of their living situation. Parenting is key. Whether the parents are living with their children in homeless circumstances or are formerly homeless parents working to reunify with their children, coordinated, comprehensive, trauma-informed and family focused programs are needed to support parenting and family stability.

Health service access across racial/ethnic groups of children in the child welfare system

OBJECTIVE

This study examined health service access among children of different racial/ethnic groups in the child welfare system in an attempt to identify and explain disparities.

METHODS

Data were from the National Survey of Child and Adolescent Well-Being (NSCAW). N for descriptive statistics=2,505. N for multiple regression model=537. Measures reflected child health services need, access, and enabling factors. Chi-square and t tests were used to compare across racial/ethnic groups. A logistic regression model further explored the greatest disparity identified, that between non-Latino/a Black and White children in caseworker-reported access to counseling.

RESULTS

In general, caseworker reports of health care service receipt did not differ across racial/ethnic groups. However, Latino/a children had better reported access to vision services than non-Latino/a White children, and counseling access was lower for non-Latino/a Black children than non-Latino/a White children. Caseworkers' self-reported efforts to facilitate service access did not vary by race/ethnicity for any type of health care. In the multiple regression model, both private health insurance and a lack of insurance were negatively associated with counseling access, while a history of sexual abuse, adolescence, and greater caseworker effort to secure services were positively associated with access. Race was just barely nonsignificant after controlling for other factors expected to affect access.

CONCLUSIONS

One possible reason why Black children are less likely to be identified as needing counseling is the fact that they are less likely than White children to have reports of sexual abuse, which strongly predicts counseling access.

PRACTICE IMPLICATIONS

First, child welfare practice may be more equitable than many believe, with generally comparable health service access reported across children's racial/ethnic groups. Second, caseworkers may be under-identifying need for counseling services among Black children, although this might reflect less frequent reports of sexual abuse for Black children. Third, both privately insured and uninsured children were less likely to receive needed mental health counseling than those with public insurance. This suggests that policy makers should focus on increasing the numbers of children enrolled in public health insurance programs such as Medicaid and the State Children's Health Insurance Program (SCHIP).

Achieving better health care outcomes for children in foster care

This article reviews the challenges health care systems face as they attempt to improve health care outcomes for children in foster care. It discusses several of the promising health care strategies occurring outside the perimeter of child welfare and identifies some of the key impasses in working alongside efforts in child welfare reform. The authors posit that the greatest impasse in establishing a reasonable quality of health care for these children is placement instability, in which children move frequently among multiple homes and in and out of the child welfare system. The authors propose potential strategies in which efforts to improve placement stability can serve as a vehicle for multidisciplinary reform across the health care system.

Medical and mental health of children entering the utah foster care system

BACKGROUND

Investigators from several states have reported that children entering foster care are at risk for medical and mental health conditions. Additional information based on data from a larger statewide population of children in foster care would assist in the development of appropriate strategies of care for these children.

OBJECTIVES

The purpose of this work was to describe the prevalence of medical and mental health conditions, the number of referrals for specialty care, the use of medications and to compare the prevalence of these conditions across age groups of children entering foster care in Utah.

METHODS

We conducted an analysis of a statewide database containing abstracted medical and mental health information from the initial medical and mental health assessments of all children entering foster care between January 1, 2001, and December 16, 2004.

RESULTS

Of the 6177 children who entered foster care during the study period, 83% were white and 24% were Hispanic. One or more acute or chronic medical conditions were present in 54%, and 44% had >/=1 mental health condition. The most prevalent medical conditions in all of the children were overweight or obesity (35%), 30% had a referral for specialty care. The most prevalent mental health conditions were oppositional defiant disorder or conduct disorder (18%), reactive attachment and adjustment disorders (17%), and mood disorders (15%). The frequency of psychotropic medication use increased with age. Of the 2747 children of all ages with a diagnosed mental health condition, 35% were receiving psychotropic medications.

CONCLUSIONS

This study of a statewide cohort of children entering foster care supports and strengthens previous evidence that children in foster care are more likely to have more health care needs compared with the general pediatric population. Focused strategies are needed that address prevalent conditions, the need for continuity of care, ongoing mental health services, and medication management.

A qualitative study of early family histories and transitions of homeless youth

Using intensive qualitative interviews with 40 homeless youth, this study examined their early family histories for abuse, neglect, and other family problems and the number and types of transitions that youth experienced. Multiple forms of child maltreatment, family alcoholism, drug use, and criminal activity characterized early family histories of many youth. Leaving home because of either running away or being removed by child protective services often resulted in multiple transitions, which regularly included moving from foster care homes to a group home, back to their parents, and then again returning to the streets. Although having experienced family disorganization set youth on trajectories for early independence, there were many unique paths that youth traveled prior to ending up on the streets.

Disparities in the reporting and treatment of health conditions in children: an analysis of the Medical Expenditure Panel Survey

OBJECTIVES

To determine whether racial and ethnic disparities in health care use differ for physical and behavioral health conditions.

DATA SOURCES

Secondary analysis of the 1996-1997 Medical Expenditure Panel Survey.

STUDY DESIGN

Retrospective cohort study of children aged 2-18 years old who were members of participating households. Children were categorized as Hispanic, black, or white. Differences in caregiver-reported behavioral and physical health conditions and services use were compared, and estimates were weighted to reflect the complex sampling scheme.

PRINCIPAL FINDINGS

Of eligible children weighted to represent over 44 million in each year, 13-15 percent were Hispanic, 14 percent black, and 68-70 percent white. After adjusting for potential confounding, Hispanic and black children were less likely to report externalizing behavioral conditions than white children. Black but not Hispanic children were more likely than white children to report asthma. In addition, Hispanic and black children were less likely to report ambulatory visits, and black children were less likely to report receiving a prescription medication than white children. There were no differences in reported emergency room visits or hospitalizations. Interactions between race and various health conditions, health status, insurance, and income were not significant.

CONCLUSIONS

In this nationally representative sample, we identified racial and ethnic disparities in the reporting of health conditions and the use of discretionary health services. Disparities differed between those with behavioral conditions and those with physical conditions. These disparities were not explained by traditional measures including the presence of health conditions, health status, insurance, and family income, and suggest that national surveys such as Medical Expenditure Panel Survey may benefit from the inclusion of additional explanatory measures.

Mental health needs and treatment of foster youth: barriers and opportunities

This article reviews current research on emotional and behavioral disorders among children in foster care and summarizes findings regarding utilization of mental health services in this population. Barriers to needed care are explored, practice and policy implications of lack of care are discussed, and alternative, evidence-based treatment options for foster youth are examined and proposed.

The acculturation gap-distress hypothesis among high-risk Mexican American families

The authors tested the acculturation gap-distress hypothesis by examining whether parent-adolescent acculturation gaps were associated with greater conflict and youth conduct problems among 260 high-risk Mexican American families. The authors operationalized acculturation gaps in 2 ways: parent-youth mismatches in acculturation style, and parent-youth discrepancies in acculturation toward both mainstream and heritage cultures. Acculturation gaps were common, but results of hierarchical regression analyses indicated that parent-youth discrepancies in acculturation toward mainstream and heritage cultures were not related to increased conflict or youth conduct problems. Conduct problems were no higher in families in which the adolescent was more aligned with mainstream culture than the parent. Unexpectedly, the authors found more youth conduct problems in families in which the youth was more aligned with traditional culture than the parent. The results call into question the assumption that the more rapid acculturation of adolescents to American culture inevitably leads to distress in minority families.

A sampling bias in identifying children in foster care using Medicaid data

BACKGROUND

Prior research identified foster care children using Medicaid eligibility codes specific to foster care, but it is unknown whether these codes capture all foster care children.

OBJECTIVES

To describe the sampling bias in relying on Medicaid eligibility codes to identify foster care children.

METHODS

Using foster care administrative files linked to Medicaid data, we describe the proportion of children whose Medicaid eligibility was correctly encoded as foster child during a 1-year follow-up period following a new episode of foster care. Sampling bias is described by comparing claims in mental health, emergency department (ED), and other ambulatory settings among correctly and incorrectly classified foster care children.

RESULTS

Twenty-eight percent of the 5683 sampled children were incorrectly classified in Medicaid eligibility files. In a multivariate logistic regression model, correct classification was associated with duration of foster care (>9 vs <2 months, odds ratio [OR] 7.67, 95% confidence interval [CI] 7.17-7.97), number of placements (>3 vs 1 placement, OR 4.20, 95% CI 3.14-5.64), and placement in a group home among adjudicated dependent children (OR 1.87, 95% CI 1.33-2.63). Compared with incorrectly classified children, correctly classified foster care children were 3 times more likely to use any services, 2 times more likely to visit the ED, 3 times more likely to make ambulatory visits, and 4 times more likely to use mental health care services (P < .001 for all comparisons).

CONCLUSIONS

Identifying children in foster care using Medicaid eligibility files is prone to sampling bias that over-represents children in foster care who use more services.

Placement changes and emergency department visits in the first year of foster care

OBJECTIVES

Despite great needs, many children in foster care do not receive adequate medical care. Suboptimal care may be attributable in part to placement changes, which disrupt continuity of care by both a consistent surrogate parent and potentially a primary care physician. These disruptions in turn may lead to increased use of the emergency department (ED) for outpatient care. The primary aim of this study was to test whether a greater rate of placement changes was associated with increasing use of the ED among children in their first year of foster care. The secondary aim was to compare ED visit rates with rates of visits to other ambulatory care settings among children in foster care and other Medicaid-eligible children not in foster care.

METHODS

Using Medicaid claims linked to foster care administrative data, we assembled a retrospective cohort of foster children in a large urban municipality from 1993 to 1996. Eligible children spent at least 9 months in a new episode of foster care and were continuously eligible for Medicaid during a 1-year follow-up period. A comparison cohort was drawn from Medicaid-eligible children not in foster care during fiscal year 1995. The dependent variable was the rate of visits to the ED or other ambulatory care settings during a 1-year follow-up period. A negative binomial model estimated visit rates to the ED and other ambulatory care settings as the number of foster care placements increased. Potential interactions were considered between age and location of service use (ED or ambulatory care setting), between age and foster care placements, and between location of service use and number of foster care placements.

RESULTS

The 2358 children in the sample accounted for 1206 ED visits during the follow-up period; 38% experienced >or=2 placement changes. Children of all ages exhibited increasing reliance on the ED for ambulatory care services as the number of placements increased, with the rates of ED use more than doubling for all age groups beyond infancy. However, other ambulatory care service use increased by only 41% to 53%; there was much less utilization in these nonemergency settings for all children but particularly toddlers and infants, compared with their Medicaid-eligible peers. Although the absolute rates of all visits for younger foster children (<6 years of age) were low, older foster children had increasingly greater ED use than did their Medicaid-eligible peers, with nearly double the rate of ED visits in the adolescent age group. A temporal relationship between placements and ED visits was also identified; 75% of ED visits occurring within 3 weeks of a placement change occurred in the period after a placement change.

CONCLUSIONS

Foster children received fewer overall outpatient services than did their Medicaid-eligible peers, but with age and increasing numbers of placements, had higher visit rates and received a greater proportion of their overall outpatient care in the ED. These results suggest that poor access to nonemergent ambulatory care settings might have contributed to an increasing reliance on ED settings as foster care placements increased. The temporal relationship between ED visits and placement changes underscores the need for better health care management for foster children, particularly in the period after placement changes.

Outpatient mental health services for children in foster care: a national perspective

OBJECTIVE

To determine factors influencing the use of outpatient mental health services provided by mental health professionals (OMHS) for children in foster care using a national probability sample in the United States.

METHOD

As part of the National Survey of Child and Adolescent Well-being, detailed survey data were collected on 462 children, ages 2-15, who had been in out-of-home care for approximately 12 months at the time of sampling. A multivariate logistic regression model was used to determine how clinical need, as measured by a Total Problem, Externalizing, or Internalizing Scale T-score of 64 or greater on the Achenbach Child Behavior Checklist (CBCL), and non-clinical factors affected OSMHS use.

RESULTS

Over half of the children in the sample received at least one OMHS. Need, older age, and history of sexual abuse history all positively predicted OMHS. A history of physical neglect negatively predicted OSMHS. African-Americans used fewer services than children of Caucasian ancestry at all values on the CBCL. This finding was particularly salient at lower levels of CBCL scores; at higher levels, the discrepancy in the use of services diminished but the proportion of children receiving services remained lower for African-American children.

CONCLUSIONS

This national study confirms previous findings regarding the use of mental health services based on regional data. Limitations in the use of services imposed by non-clinical factors, specifically, age, race/ethnicity and type of abuse, need to be examined in order to address implicit and explicit policies and practices that may result in inequitable distribution of services.

Behavioral and mental health problems in low-income children with special health care needs

This study examined caregiver perceptions of mental health problems and counseling needs in low-income children with special health care needs (CSHCN). Interviewers collected data from 257 caregivers of CSHCN (61% males; 60% African American; Mean age = 8.4 years) attending six Midwestern inner-city health clinics. Measures included the Child Behavior Checklist (CBCL) and an investigator-designed questionnaire. CBCL T-scores indicated that 38% of CSHCN had a behavioral or mental health problem, but only 26% of caregivers perceived the need for treatment or counseling. CSHCN should be assessed and referred appropriately for behavioral and mental health problems during routine health care visits.

Placement stability and mental health costs for children in foster care

OBJECTIVE

Although prior population-based studies have found that children in foster care use more mental health services than their Medicaid peers, less is known about how different experiences in foster care impact the likelihood of mental health service use. The primary aim of this study is to test the hypothesis that instability of foster care placements is associated with higher costs for mental health care services. The secondary aim is to test the hypothesis that foster care children are also more likely to generate high costs for mental health services if they generate higher costs for non-mental health claims.

METHODS

Using administrative child welfare data linked to Medicaid claims, we assembled a unique retrospective cohort of adjudicated dependent children >2 years old who entered foster care between July 1993 and June 1995, spent at least 9 months in care, and were Medicaid eligible during a 1-year follow-up period. The primary outcome was high mental health service use, defined as having costs in the top decile of the sample. The primary independent variables were the number of foster care placements during the year and whether placements were interrupted by a return home for at least 1 month during that year (episodic foster care). We used logistic regression to estimate the association between placements and service utilization, with adjustment for age and physical health care costs.

RESULTS

Of the 1635 children in the study, 41% had > or = 3 foster care placements, and 5% had episodic foster care during the year of observation. The top 10% of mental health service users accounted for 83% of the 2.4 million dollars in mental health costs. Both multiple placements and episodic foster care increased the predicted probability of high mental health service use. Higher physical health care costs also increased the probability of high mental health use for all children, but this increased probability was most dramatic among children with episodic foster care (probability of high mental health use: 0.78; 95% confidence interval: 0.42-0.94).

CONCLUSIONS

Foster care placement instability was associated with increased mental health costs during the first year in foster care, particularly among children with increasing general health care costs. These findings highlight the importance of interventions that address the global health of children in foster care and may permit better targeting of health care resources to subgroups of children most likely to use services.

Mental health services utilization by maltreated children: research findings and recommendations

Many maltreated children have, or are at risk for, emotional and behavioral disorders. Some of these children need mental health services but do not receive them because of service delivery and use barriers. Knowledge about the factors related to service utilization is needed to increase access to and use of services. Studies on mental health services utilization by maltreated children in foster care or otherwise monitored by child protective services are reviewed to ascertain service use correlates. Children in foster care had higher use rates than comparison groups of Aid to Families With Dependent Children not in foster care. Need and nonneed variables predicted service use. Race was the most consistent nonneed predictor. Future research needs include the development of conceptual models to guide research on service access and use. More work is needed on the conceptualization and operationalization of mental health services, need for services, and service use.

The importance of culture in treating abused and neglected children: an empirical review

There is growing evidence that cultural factors may influence symptom development and treatment referral patterns among abused and neglected children. To date, few treatment outcome studies have specifically examined the impact of race, culture, or ethnicity on treatment response among maltreated children. Those that have attempted to include these factors have typically suffered from lack of clarity of the meaning of these terms. This article reviews the available empirical evidence that addresses the influence of culture on symptom formation, treatment-seeking behaviors, treatment preference, and response following child maltreatment. Hypotheses regarding these findings are addressed, and implications for practice, research, and public policy are discussed.