Mental health care for foster children in California

This paper reports on a study conducted to assess the health care needs of foster children in California. To evaluate foster children's mental health problems and the services provided to meet them, 154 program administrators, social workers, foster parents, and health care providers were interviewed in 14 counties. Foster parents and social workers were interviewed in groups, and foster parents and administrators also completed questionnaires. We found that although all counties care immediately for children who are injured, abused, or ill, only one county performs routine mental health evaluations of all children, and in most counties less than a third of children ever receive such evaluations. Informants identified mental health problems as more severe than medical problems in this population, and they identified four major barriers to access to appropriate therapy. Recommendations are that all children should receive comprehensive mental health evaluations, and procedures for immediate and ongoing care with consistent providers who are sensitive to foster children's needs should be included in case management plans, and covered by improved payment mechanisms. Additionally, communication, coordination and joint planning should be instituted among relevant agencies to address foster children's needs, and increased resources and training should be directed towards social service agencies and foster parents.     

Improving outcomes for babies and toddlers in child welfare: A model for infant mental health intervention and collaboration

Children under three comprise a sizable and growing proportion of foster care placements. Very young children who enter the child welfare system experience disruptions of critical attachments that are essential to this formative stage of brain development, as well as other traumatic events, leaving them at great risk for lifelong impairments. To reverse these concerning outcomes, babies who have been removed from their homes require intensive, relationship-based interventions that promote secure attachment to a primary caregiver and holistic attention the child's developmental needs. Child welfare decision-makers must be informed of infant brain development and knowledgeable about the particular needs and circumstances of each child. This article describes a model with these features that has been developed and tested in the Bronx, New York, one of the nation's poorest urban counties with high rates of foster care. The Project utilizes evidence-based Child-Parent Psychotherapy (CPP) as its core intervention, and emphasizes collaboration and information sharing– driven by the CPP clinician– with judges, child welfare workers, attorneys and other social service and mental health providers, thereby encouraging developmentally and relationally informed case planning and permanency decisions. The model is evaluated using pre and post treatment psychosocial measures and program outcome data. Results indicate improvement in parenting interactions, positive child welfare outcomes (including increased rates of reunification, fewer returns to foster care), and improved safety and wellbeing. Results highlight the need for child welfare practices to be more closely aligned with the current science of infant brain development, and to incorporate a specialized approach to address the unique needs of infants.     

An empirical analysis of behavioral and emotional problems of foster children as related to re-placement in care

Foster care is seen as a temporary service. However, for many children, foster care involves years of long term care. Most professionals feel that if a child must remain in care, the number of foster homes or re-placements the child experiences should be minimized. Evidence suggests that this lack of stability has a detrimental effect on the child's psychosocial development. Even though the research evidence supports the negative impact of re-placement on the foster child, little empirical research has dealt with identification of factors associated with children likely to be re-placed. This article focuses on foster children with behavioral and emotional problems and analyzes the association of these problems with placement stability and continuity. The findings report that children with behavioral and emotional problems are replaced in foster care more often than those children without similar problems.     

Reactive attachment disorder in looked‐after children

The great majority of children living in foster or residential care have been abused and neglected. Mental health problems are common and the nature of these problems may be rooted in early attachment relationships. The carers of 82 children in care in Scotland and 125 children from local schools completed questionnaires on mental health problems including Reactive Attachment Disorder. More than half (53%) of the children in care fulfilled criteria for mental health problems compared with 13% of the control group, and children living in care scored significantly higher for conduct problems, emotional problems (anxiety and depression), hyperactivity, problems with peer relations and Reactive Attachment Disorder. This has important implications for service development for this vulnerable group of children.     

Infant mental health and biological risk

Parents seldom seek help directly for infant mental health problems. Parents enter the health care system seeking advice for identified or presumed biological problems in their infants. Many of these biological problems, however, have major psychosocial components of importance to infant mental health. It is important that physicians deal directly with the psychosocial issues and avoid converting them into biological medical problems unintentionally. Three common types of problems and appropriate methods of management are discussed to ensure special recognition and effective handling by the physician of psychosocial problems and the promotion of mental health. The problems discussed are the following: Infants seen with defined medical conditions that generally have associated psychosocial problems including child abuse. Infants seen who have fully recovered from critical illnesses but are considered "at risk" for later developmental disability. Infants seen with normal variations of behavior that are misinterpreted by their parents or physicians as due to a medical problem. In infancy medical and psychosocial issues are so closely interwoven that it is critical that physicians learn to recognize the major psychosocial consequences of primary medical problems and the medical manifestations of primary psychosocial problems and their management.     

Does poor school performance cause later psychosocial problems among children in foster care? Evidence from national longitudinal registry data

Research has shown that children in foster care are a high-risk group for adverse economic, social and health related outcomes in young adulthood. Children's poor school performance has been identified as a major risk factor for these poor later life outcomes. Aiming to support the design of effective intervention strategies, this study examines the hypothesized causal effect of foster children's poor school performance on subsequent psychosocial problems, here conceptualized as economic hardship, illicit drug use, and mental health problems, in young adulthood. Using the potential outcomes approach, longitudinal register data on more than 7500 Swedish foster children born 1973–1978 were analyzed by means of doubly robust treatment-effect estimators. The results show that poor school performance has a negative impact on later psychosocial problems net of observed background attributes and potential selection on unobservables, suggesting that the estimated effects allow for causal interpretations. Promotion of school performance may thus be a viable intervention path for policymakers and practitioners interested in improving foster children's overall life chances.     

Disentangling the effect of out-of-home care on child mental health

BackgroundChildren in out-of-home care are consistently found to have poor mental health compared to children in the general population. However, UK research has so far failed to disentangle the impact of the care system on children’s mental health outcomes from the effects of the adverse circumstances that led to their admission to care.ObjectiveThis research investigated the association between care placement and the presence of child mental health problems after controlling for children’s pre-care experiences. It also identified factors associated with mental health problems among children in care.Participants and SettingThe sample comprised three groups of children involved with child welfare services due to maltreatment, including children in out-of-home care (n = 122), reunified children (n = 82) and those who had never been in care (n = 159).MethodsThe mental health of the children in the three groups was compared, using information collected from their parents/foster carers and social workers.ResultsThe odds of a child in out-of-home care having a mental health problem were not significantly higher than those of a child who had never been in care (AOR = 1.24; p = 0.462). However, the odds of a child in out-of-home care having reactive attachment disorder (RAD) were significantly higher than those of a child who had never been in care (AOR=1.92; p = 0.032).ConclusionsThese findings make an important contribution to international debates about whether placing children in care is beneficial or detrimental to their wellbeing, and highlight a range of inter-linking factors associated with the mental health of children in out-of-home care.     

The profile and progress of neglected and abused children in long-term foster care

ObjectivesThis study compared the profile of neglected and abused children in the Australian foster care system as well as differences between maltreatment types in relation to parental contact, reunification and psychosocial progress in care.MethodThe case files of 235 children entering foster care were examined and their social workers were administered standardised questionnaires at the point of intake. All measures were repeated for those remaining in care 1 year and then again 2 years later.ResultsNeglected children were younger than non-neglected children, more likely to have a physical or mental disability, more likely to experience multiple forms of maltreatment and less likely to pose conduct problems for carers. Neglected children were more likely than non-neglected children to experience a decline in parental contact over time, and were less likely to be reunified with their families of origin. There was minimal difference between neglected and non-neglected in their psychosocial progress while in care. Aboriginal children were more likely to be reunified than non-Aboriginal children when neglect was attributable to transient factors (parental incapacity) but the reverse was true for non-neglected children.ConclusionsThe fact that neglected children more often require a second form of maltreatment before being removed from home suggests that children's services workers are less inclined to remove children for neglect than for other forms of maltreatment. As a consequence, those neglected children who are in care tend to come from more dysfunctional families than non-neglected children do, as evidenced by the relatively poorer parental contact and reunification results of neglected children.Practice implicationsNeglected children differ systematically from non-neglected children and suffer relative disadvantage in relation to multiple forms of maltreatment, parental contact, and reunification. The fact that declines in parental contact among neglected children in care occurred only when indirect contact was provided suggests that, wherever possible, care plans should include face-to-face visits and overnight stays rather than being restricted to less direct forms of contact. The difference in the success of reunification according to type of neglect (chronic or transient) also suggests that parental intervention programs need to focus their efforts on chronic factors rather than transient parental factors.     

Prognosis of children admitted to institutional care during infancy

The present study has investigated the prognosis of infants admitted to institutional care. The follow-up was made after five and ten years. Three groups of children were studied: those who were in adoptive homes, foster homes and biological homes, respectively, at the time of the investigation. Approximately 50% of the total population was treated in hospital after the neonatal period. More children in foster and biological homes were hospitalized because of trauma. At 4 years of age the psychomotor development was considered normal in 77% of the adopted children compared to approximately 55% in the other two groups. Furthermore, the children in foster and biological homes demonstrated a higher rate of psychological or behavioral disturbances. The children who were in foster homes had experienced more separations and 39% of them had been subjected to 6 or more placements. The experiences of institutional care per se in infancy do not predispose the child to health and behavioral problems. The determining factor for optimal development seems to be permanency of care and parenting capability.     

SUPPORTING STUDENTS IN FOSTER CARE

Students living in foster care are at risk for experiencing many challenges in school, spanning domains of social–emotional, behavioral, and academic functioning. They are twice as likely to be absent from school and to have received and out‐of‐school suspension and up to three and a half times more likely to receive special education services. Therefore, it is important for schools to recognize and respond to the unique needs of students in foster care to provide the necessary resources for school success. When working with students in foster care, school psychologists should be equipped to support the success of these students by determining what the needs of students in foster care are, and how to meet identified needs. The current paper will discuss the education‐related vulnerabilities and presenting problems for children in foster care and outline social–emotional, behavioral, and academic supports that school psychologists can offer.     

Children and mothers in war: an outcome study of a psychosocial intervention program

The present study was designed to evaluate the effects on children (age: M = 5.5 years) in war-torn Bosnia and Herzegovina of a psychosocial intervention program consisting of weekly group meetings for mothers for 5 months. An additional aim was to investigate the children's psychosocial functioning and the mental health of their mothers. Internally displaced mother-child dyads were randomly assigned to an intervention group receiving psychosocial support and basic medical care (n = 42) or to a control group receiving medical care only (n = 45). Participants took part in interviews and tests to provide information about war exposure, mental health, psychosocial functioning, intellectual abilities, and physical health. Results showed that although all participants were exposed to severe trauma, their manifestations of distress varied considerably. The intervention program had a positive effect on mothers' mental health, children's weight gain, and several measures of children's psychosocial functioning and mental health, whereas there was no difference between the two groups on other measures. The findings have implications for policy.     

IDENTIFYING PSYCHOSOCIAL DYSFUNCTION IN SCHOOL-AGE CHILDREN: THE PEDIATRIC SYMPTOM CHECKLIST AS A SELF-REPORT MEASURE

The Pediatric Symptom Checklist (PSC) is a brief, well-validated parent-report questionnaire designed to detect psychosocial dysfunction in school-age children during pediatric primary care visits. This study assessed the utility of the PSC when completed by children (PSC-Y) ages 9-14 in a public school when parents are not available (n = 173). The PSC-Y identified 20% of children as having psychosocial problems, a rate similar to other low-income samples. When compared with teacher ratings of attention and behavior problems, the PSC-Y showed a sensitivity of 94% and a specificity of 88%. The PSC-Y correlated significantly with teacher and parent measures of child dysfunction, and with child-reported symptoms of depression and anxiety. Three quarters of the children identified by the PSC-Y were not identified by parents on the PSC. These children had impairment on all other measures, but fewer than one in five had received mental health services, suggesting the PSC-Y identified children with unmet mental health needs. The PSC-Y has the potential to be a rapid, easily administered tool for large-scale mental health screening in schools.     

Child abuse treatment and follow-up: Can the pediatrician help improve outcome?

The pediatric role in the management of child abuse and neglect has been largely limited to detecting and reporting cases, with little involvement in long-term treatment and follow-up. A review of published clinical experience indicates that customary protective services' “treatment” strategies are all too often ineffective at preventing reabuse, improving child health and developmental status, and improving family functioning. When foster care is used as a treatment modality, children run the added risk of never returning home, nor being freed for adoption, and they may suffer the emotional harm of repeated foster placements. This situation is likely to worsen, in the light of recent cutbacks in social service programs, at a time of rising reports of maltreatment. The pediatrician is widely recognized as an expert in children's health and development, and he can effectively use his position to influence the management of cases and thereby the outcome, by actively participating in treatment decision making and providing close follow-up in a limited but important way. In order to do this, he must first become acquainted with the effects of maltreatment upon children's health and development and with the general principles and available modalities of treatment. He must be sympathetic and supportive of the difficult role of the protective service worker who must make treatment decisions. His role is to assist the worker by making medical resources available in order to adequately define the child's needs and the capacity of the family to meet those needs. Essential to answering these questions is the availability of a child development clinic and mental health resources. After ensuring that the child and family are thoroughly assessed and the treatment plan tailored to the child's and family's needs, the pediatrician provides continual longitudinal follow-up, monitoring the child's health and developmental status. If the child is placed in foster care, the physician observes the child's adjustment and provides advice and consultative assistance when needed to help foster parents manage health, developmental or behavior problems. Periodically he also meets with the natural family to keep them informed about their children's health and development and to ensure they are making good use of treatment. Finally, he communicates closely with the child protective service worker and participates in interdisciplinary staff meetings to review and evaluate treatment progress in the hopes of shortening the time needed to make decisions regarding placement.     

Adverse childhood experiences among children placed in and adopted from foster care: Evidence from a nationally representative survey

Despite good reason to believe that children in foster care are disproportionately exposed to adverse childhood experiences (ACEs), relatively little research considers exposure to ACEs among this group of vulnerable children. In this article, we use data from the 2011–2012 National Survey of Children’s Health (NSCH), a nationally representative sample of non-institutionalized children ages 0–17 in the United States, to estimate the association between foster care placement and exposure to an array of ACEs. In adjusted logistic regression models, we find that children placed in foster care or adopted from foster care, compared to their counterparts, were more likely to experience parental divorce or separation, parental death, parental incarceration, parental abuse, violence exposure, household member mental illness, and household member substance abuse. These children were also more likely to experience ACEs than children across different thresholds of socioeconomic disadvantage (e.g., children in households with incomes below the poverty line) and across different family structures (e.g., children in single-mother families). These results advance our understanding of how children in foster care, an already vulnerable population, are disproportionately exposed to ACEs. This exposure, given the link between ACEs and health, may have implications for children’s health and wellbeing throughout the life course.     

The handicapped child and child abuse

For a group of children with handicaps, growth and development are also affected by abuse or neglect. Our understanding of the problems of the abused, handicapped child emerges from experience with 37 children with cerebral palsy who have been maltreated, coupled with a review of the literature in related areas. We identify the following four problems as crucial to the study of abuse and neglect to the child with handicaps: (1) abuse that causes handicaps, (2) abuse that occurs to the handicapped child, (3) compromises in care that can occur when the handicapped child becomes involved with the medical and legal systems, and (4) arrangements for foster care or other out-of-home placement for the child with handicaps. We conclude that the very systems designed to protect and care for the child often fail, leaving the handicapped child without opportunity to reach developmental potential. In light of our observations, we recommend that the pediatrician not only be aware of the existence of abuse and neglect in the population of handicapped children, but also serve in the dual role of coordinator of services and advocate for these children.     

Behavior problems of children in foster care: Associations with foster mothers’ representations,commitment, and the quality of mother–child interaction

This study investigated different environmental and contextual factors associated with maltreated children's adjustment in foster care. Participants included 83 children (52 boys), ages 1–7 years, and their foster caregivers. Quality of interaction with the foster caregiver was assessed from direct observation of a free-play situation; foster caregiver attachment state of mind and commitment toward the child were assessed using two interviews; disruptive behavior symptoms were reported by foster caregivers. Results showed that quality of interaction between foster caregivers and children were associated with behavior problems, such that higher-quality interactions were related to fewer externalizing and internalizing problems. Foster caregivers’ state of mind and commitment were interrelated but not directly associated with behavior problems of foster children. Type of placement moderated the association between foster caregiver commitment and foster child behavior problems. Whereas greater foster caregiver commitment was associated with higher levels of adjustment for children in foster families (kin and non-kin), this was not the case in foster-to-adopt families. Finally, the associations between foster child behavior problems and history of maltreatment and placement related-risk conditions fell below significance after considering child age and quality of interaction with the foster caregiver. Findings underscore the crucial contribution of the foster caregiver–child relationship to fostering child adjustment and, thereby, have important implications for clinical services offered to this population.     

Abuse of children in foster and residential care

OBJECTIVE: There have recently been many debates in the UK about how to provide good care for children placed away from home. Professionals have realized that the level of child abuse in foster care and children's homes is high. This research examines the characteristics of physical and sexual abuse of children in foster and residential care in a city in England. The number of cases of abuse reported by pediatricians in this group was compared to the number reported by the same pediatricians for the population of Leeds as a whole. METHOD: This is a retrospective study of 158 children, fostered or in residential care who were involved in 191 episodes of alleged physical and/or sexual abuse assessed and reported by pediatricians over a 6 year period from 1990 to 1995 in Leeds, England. Details of the child including the reason for placement in care, their physical and mental health, abuse characteristics, including perpetrator and case management were studied. RESULTS (see Table 1): 158 incidents of abuse in 133 children in foster/residential care are described. In foster care, 42 children were physically abused, 76 were sexually abused, and 15 experienced both forms of abuse. In residential care, 12 children were physically abused, 6 were sexually abused, and 6 experienced both forms of abuse. In foster care 60% of sexual abuse involved girls and 60% of physical abuse involved boys. In residential care almost twice as many boys as girls were reported to be abused. Foster carers perpetrated the abuse for 41%, natural parents on contact for 23%, and children 20% of incidents. A significant proportion of abuse was severe with 1 death, 8 children with burns, 18 with genital, and 34 with anal penetration. Long-standing emotional, behavioral and learning difficulties were common. Most children (80%) had been abused prior to entry into care. Foster children were 7-8 times and children in residential care 6 times more likely to be assessed by a pediatrician for abuse than a child in the general population. CONCLUSIONS: Children in foster or residential care form an at risk group for maltreatment. Their special needs include additional measures to protect them from abuse.     

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

OBJECTIVE: To determine factors influencing outpatient mental health service use by children in foster care. METHOD: Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL). RESULTS: Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60. CONCLUSIONS: Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.     

Is higher placement stability in kinship foster care by virtue or design?

Prior research has repeatedly documented higher placement stability for children who enter kinship care rather than non-relative foster care. However, little is known about why, and under what circumstances, kinship care is more stable. This study uses longitudinal state administrative data to explore possible explanations. Results suggest that, while children in non-relative foster care are indeed at higher risk of any placement move than their peers in kinship care, this appears to be partly driven by child selection factors and policy preferences for kinship care. That is, the gap is not explained primarily by different rates of caregiver-requested moves. However, the gap was sizably smaller among select high-risk subgroups of foster children, suggesting that higher stability in kinship care may be partly explained by differences in the characteristics of children entering kinship care (versus non-relative foster care). Moreover, a large portion of the gap is explained by children in non-relative care being moved into kinship care; a move that is likely the result of policy preferences for kinship care rather than a defect in the initial placement. In sum, these results suggest that kinship care provides only a limited stability advantage, and the reasons for that advantage are not well understood.     

Hospital‐to‐school transition for children with chronic illness: Meeting the new challenges of an evolving health care system

Chronic illness is common and has a profound impact on the education of affected children. A variety of approaches and programs to facilitate the transition from hospital to school for children with chronic health problems has been described in the literature. Traditional transition plans may no longer be effective because medical service delivery has changed to reduce long‐term hospital stays while increasing outpatient care. As a result, comprehensive hospital‐to‐school transitions increasingly emphasize home and family involvement that includes homebound instruction strategies, flexible school days, using differentiated instructional strategies, increasing child autonomy, and addressing affective issues. This article describes the needs of children with chronic illness, identifies educational programming consistent with the current health care system, and describes current hospital‐to‐school transition plans that integrate systemic needs of schools and health care systems with the needs of children with chronic illness. © 2007 Wiley Periodicals, Inc.