A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities

Identifying Under- And Overutilization Patterns For Idaho Youth With Serious Emotional Disturbance

Children and adolescents with serious emotional disturbance represent 7-12 percent of all youth in the United States. In 2017, the State of Idaho implemented the Youth Empowerment Service program, which allows youth with serious emotional disturbance who are younger than age eighteen living in households with income up to 300 percent of the federal poverty level to qualify for Medicaid and receive intensive, community-based treatment. A uniquely detailed method was used to assess the need for services: the Child and Adolescent Needs and Strengths tool, a ninety-seven-indicator instrument administered by a clinician. We used these indicators and Idaho's 2018-22 administrative Medicaid claims data to study the association between children and adolescents' clinical needs complexity and their actual Medicaid behavioral and mental health service use. Our findings show that there was a substantial proportion of youth who were underusing Medicaid behavioral and mental health care services, and there were virtually no overusers. Our findings have implications for the appropriateness of Medicaid utilization management in behavioral health care and program efforts to maintain families with youth having serious emotional disturbance in the Youth Empowerment Service program.

Psychiatric Residential Treatment Facilities for Child Behavioral Health Services in North Carolina Medicaid

Background

Psychiatric residential treatment facilities (PRTFs) are non-hospital inpatient treatment settings for children with severe be-havioral health disorders. PRTFs are a restrictive and costly form of care that can potentially be avoided with community-based behavioral health services.

Methods

Statewide Medicaid enrollment and claims data for 2015-2022 were used to describe PRTF utilization in North Carolina. We examined annual episodes of care in PRTFs and compared trends before and during the COVID-19 public health emergency.

Results

From 2015 to 2022, 10,038 children insured by NC Medicaid entered a PRTF across 10,966 episodes of care. In the past five years (2018-2022), care in PRTFs resulted in Medicaid expenditures of over $550 million total, or over $100 million per year. In 2022, 42% of children who entered PRTFs were in foster care and 44% of children were placed in PRTFs outside of North Carolina.

Limitations

The analysis was limited to data collected for administrative purposes.

Conclusions

Current trends indicate an ongoing overrepresentation of children in foster care placed in PRTFs and increased out-of-state PRTF placements. Coordinated efforts in future research, policy, and practice are needed to determine the cause of these trends and iden-tify solutions.

What do child maltreatment reports to Child Protective Services tell us about the needs families and communities are experiencing?

Intake reports from child protective service (CPS) agencies are the foundation for subsequent decisions and services within the child welfare system. They provide valuable information for understanding children's needs, yet the unstructured way that information is captured makes the information ascertained in these reports difficult to summarize. Utilizing CPS intake reports from a mid-sized urban county in the southeastern United States (N = 2,724), our study had three aims: (1) develop a coding system to abstract information from narrative CPS intake reports, (2) examine the prevalence of maltreatment subtypes, and (3) compare prevalence of maltreatment subtypes by screen-in/screen-out decisions. Improper discipline/physical abuse was the most common maltreatment subtype (34.6 %); over 40 % of reports involved a physical act toward the child not resulting in injury. Salient risk factors included caregiver drug use (20.6 %) and domestic violence (19 %). While substantial discrepancies were not found between screened-in and screened-out cases with respect to maltreatment types, maltreatment type-specific codes, or contributory factors, they were found for reporter type and child age. Our coding system to extract and assess child maltreatment intake narrative data can provide local agencies with descriptive information about why children come to their agency's attention and provide nuanced details regarding the children's and families' needs. This coding framework could be used to develop validated intake tools to better document and categorize child maltreatment which could inform the assessment/investigation process and create targeted prevention and intervention services for families that come to the attention of CPS.

Parents' Perspectives in Accessing Psychiatric Residential Treatment for Children and Youth: Differential Experiences by Funding Source

Objective

There are well-documented disparities in access to mental health care for children and youth with significant behavioral health needs. Few studies that explored the differential experiences of families who use private vs public sources of financing (i.e., insurance and funding) in accessing residential treatment (RT) for children and youth. This study aimed to examine the lived experiences of families accessing psychiatric residential treatment (RT) and contextualize these experiences based on source of financing.

Methods

Twenty parents completed two interviews about their experiences with RT including the process for gaining access, length of stay, and aftercare. Parents were also asked about barriers (e.g., custody relinquishment), and facilitators (e.g., policies in the state) to accessing RT. Data were analyzed using content analysis.

Results

There were three distinct groups of families in the study. The first group includes lower income families whose children had public health coverage before needing RT. The second group comprises middle-income families whose children had private coverage but lived in states where there were no RTs that accepted private insurance or private payment and who did not have the means to send their child to RT in another state. The final group included higher income families with private insurance and enough private resources to overcome the limitations of insurance and state policies. This study illuminates key barriers and hardships for families accessing RT: 1) waiting long waiting periods and navigating complex systems; 2) inadequate lengths of stay; and 3) inadequate aftercare and support in the community transition.

Conclusions

This study is among the first to examine how access to RT differs by whether a family has access to public or private resources. Taken together, these findings support the importance of insurance and financing for families accessing RT for their children and the need for systemic changes in policies and practices to reduce disparities in access.

1915(c) Medicaid Waivers for Children With Severe Emotional Disturbance: Participant Characteristics, Enrollment, and Out-of-Home Service Use

Several states have invested in 1915(c) Home and Community Based Service (HCBS) Medicaid policies to improve outcomes and reduce costs for children and youth with significant behavioral health needs, or Severe Emotional Disturbance (SED). However, little is known about these programs and the children they serve. Through a retrospective cross-sectional analysis, this study aimed to understand if the program was successfully reaching its target population: children and youth with the highest clinical need, at the greatest risk for out-of-home care, and who may not otherwise be eligible for Medicaid through other avenues. Results describe the demographic, clinical, and service use characteristics of children and youth enrolled in one SED Waiver program, comparing them with those of similar, non-waiver enrolled children with behavioral health needs. Findings report that the waiver program examined rarely served children and families not otherwise eligible for Medicaid, but that waiver-enrolled children and youth had substantially more severe clinical need, were at higher risk for out-of-home placement and incurred greater public expenditures for service use. Findings suggest the program studied is serving children with more significant psychiatric needs, as the program intends, but points to the need for further research to understand the impacts of such programs on system and clinical outcomes.

A review of state regulations for child care: Preventing, recognizing and reporting child maltreatment

BACKGROUND

Prior to the COVID-19 pandemic, nearly 60% of children under 5 years of age were cared for in out-of-home child care arrangements in the United States. Thus, child care provides an opportunity to identify and address potential child maltreatment. However, during the pandemic, rates of reporting child maltreatment decreased-likely because children spent less time in the presence of mandated reporters. As children return to child care, states must have regulations in place to help child care providers prevent, recognize and report child maltreatment. However, little is known about the extent to which state regulations address child maltreatment. Therefore, the purpose of this cross-sectional study was to assess state regulations related to child maltreatment and compare them to national standards.

METHOD

We reviewed state regulations for all 50 states and the District of Columbia for child care centres ('centres') and family child care homes ('homes') through 31 July 2021 and compared these regulations to eight national health and safety standards on child maltreatment. We coded regulations as either not meeting, partially meeting or fully meeting each standard.

RESULTS

Three states (Colorado, Utah and Washington) had regulations for centres, and one state (Washington) had regulations for homes that at least partially met all eight national standards. Nearly all states had regulations consistent with the standards requiring that caregivers and teachers are mandated reporters of child maltreatment and requiring that they be trained in preventing, recognizing and reporting child maltreatment. One state (Hawaii) did not have regulations consistent with any of the national standards for either centres or homes.

CONCLUSIONS

Generally, states lacked regulations related to the prevention, recognition and reporting of child maltreatment for both centres and homes. Encouraging states to adopt regulations that meet national standards and further exploring their impact on child welfare are important next steps.

Barriers to Respite Care for Children with Special Health Care Needs

OBJECTIVE

The objective of this study was to estimate time-specific, population-based prevalence of 14 specific barriers to respite services, as reported by parents of children with special health care needs (CSHCN) with and without emotional, behavioral, or developmental problems (EBDPs), and to identify individual, family, and environmental characteristics associated with the most common barriers to respite care for families of CSHCN.

METHODS

Descriptive, bivariate, and multivariable logistic regression analyses were used to examine data from the National Survey of Children with Special Health Care Needs for 2005/2006 and 2009/2010.

RESULTS

Among families reporting unmet need for respite care services, service availability or transportation barriers (23.8%) and cost barriers (19.8%) were the most commonly reported obstacles among all CSHCN, followed by lack of knowledge about where to obtain respite services (12.1%) and inconvenient service times (11.3%). Reports of location or availability barriers decreased significantly from 2005 to 2009, but service time barriers increased simultaneously. All types of barriers to respite services were reported significantly more frequently by CSHCN with EBDPs than those without, even when other demographic factors were controlled for. CSHCN conditional severity and discontinuity in insurance were positively associated with cost barriers, whereas CSHCN public health coverage was associated with reduced rates of reported cost and information barriers to respite care.

CONCLUSION

Increased understanding of parent-reported barriers to respite care for families of CSHCN is critical to creating structural and practice-oriented solutions that address obstacles and increase access to respite care for these vulnerable families.

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

BACKGROUND

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

OBJECTIVES

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

PARTICIPANTS AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSIONS

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