Psychopathology, physical complaints and health risk behaviors among youths who were victims of childhood maltreatment: A comparison between home and institutional interventions
Highlights
► We compared youths who received intervention from Child Protective Services. ► We included youths who did not receive intervention. ► We assessed childhood adversity, psychopathology, physical symptoms, risk behaviors. ► All groups appear to be similar in terms of global outcomes. ► Specific risk behaviors are associated with different childhood interventions.
Introduction
The ability of Child Protective Services (CPS) to protect maltreated children has been intensely debated. For instance, Gregoire and Hornby (2011) argued that the child protection system is useless because evidence suggests that the system fails to detect many maltreated children (see also Sedlak et al., 2010). The CPS system has also been criticized for political reasons (Costin, Karger, & Stoesz, 1996) and for failing to protect children from many risks, including involvement in violence; bullying; alcohol, tobacco and illicit drug use; and unprotected sex (e.g., Gregoire & Hornby, 2011). However, Spinelli and Howard (2011) argued that child protection agencies should continue their efforts to identify and protect maltreated children, although their effectiveness must be improved.
Another subject of debate is the effectiveness of the interventions and services that children and their families receive in different settings. The decision to remove a child from the home is one of the applied interventions, but the decision-making process is complicated for the CPS professionals because they “can never know with certainty whether the course they chose for a given child is the best one, since they cannot possibly know what would have happened to the child had they decided differently” (Davidson-Arad, Englechin-Segal, & Wozner, 2003, p.734).
The functions of CPS include receiving, screening, and investigating reports of child abuse and neglect from the community to determine whether they meet the criteria defining maltreatment. Additionally, CPS agencies usually receive information from a larger array of child welfare services, which may include foster care, adoption services, and residential care facilities for children (see Schene, 1998 for further explanation). Removal from the home is a decision made with court approval and must occur if the child's safety is in danger, such as in situations of extreme neglect (e.g., refusal or unreasonable failure to provide necessary food, clothing, and shelter, or abandonment), and other types of maltreatment, such as sexual abuse, or when the parents are unable to handle child rearing responsibilities as a consequence of alcohol or drug use. The decision to remove a child from home may also follow the failure of an intervention conducted while the child remained in the home, an increase in risk factors, or non-acceptance or refusal of the interventions that are offered.
Removing the child from the home should be avoided; such a decision should be the last alternative and only a temporary measure. However, removal from the home can be positive for many maltreated children. Overall, children removed from the home are more likely to have experienced more serious and chronic maltreatment, such as sexual abuse (Tjaden & Thoennes, 1992), than children who remain at home, and the parents of removed children are more likely to be unable to handle child rearing responsibilities (Zuravin & DePanfilis, 1997).
However, the studies that have compared maltreated children who are placed in out-of-home care with those who remain at home have reported contradictory results. Some studies have found no differences among children who received various different CPS interventions. Two studies that compared maltreated children placed in care with those who remained at home showed that they did not differ with respect to juvenile delinquency (Runyan & Gould, 1985) or adult delinquency (DeGue & Widom, 2009). Similarly, a study found no differences in psychological functioning between female victims of sexual abuse who were placed in foster care and those who remained at home (Leifer & Shapiro, 1996). Another study showed few differences in terms of physical development and mental health needs between children who remained with their biological parents, in kinship care, or in foster homes (Leslie et al., 2005). Yet another study of 2453 children aged 4–17 years indicated that placement has little effect on children's cognitive skills or behavioral problems (Berger, Bruch, Johnson, James, & Rubin, 2009).
Other studies have shown that children placed in out-of-home care have more negative outcomes than maltreated children who remained at home. One study evaluated children who entered foster care, children who were maltreated but remained in the home, and children who had not experienced foster care or maltreatment yet had similar at-risk demographic characteristics. The study found that children who were placed in foster care after kindergarten had more behavior problems than those who remained at home (Lawrence, Carlson, & Egeland, 2006). In the same study, it was found that children placed in foster care and children who remained at home were more likely to have psychopathology at 17.5 years of age compared to a control group. Another study examined the prevalence of post-traumatic stress symptoms in a nationally representative sample of 1848 children and adolescents (aged 8–14) who were reported to CPS. The prevalence of post-traumatic stress symptoms was higher for children who were placed in out-of-home care compared with those who remained at home (Kolko et al., 2010). Moreover, a study using a cohort of children who entered foster care in their first year of life showed that those who remained in foster care had the poorest developmental outcomes compared with children who returned home or were adopted (Lloyd & Barth, 2011).
Among the children in out-of-home placements, those placed in institutions may have more negative outcomes than maltreated children who remain at home and children placed in foster homes. A longitudinal study evaluated three groups of Romanian children, including a group of children who were abandoned at birth in an institution and remained at the institution, a group of children who were abandoned at birth in an institution but were subsequently placed in foster care, and a third group of children reared with their biological families (Nelson et al., 2007). The researchers found that the cognitive outcomes of the children who remained in institutions were below those of children reared with families and children placed in foster care.
Conversely, other studies have shown that maltreated children who remain at home have more behavior problems than children placed in out-of-home care (Colton et al., 1991, Polit et al., 1989). For instance, a prospective study compared children who returned to their biological families after placement in foster care with children who remained in foster care. The authors concluded that youths who returned to their biological families had more negative outcomes than youths who remained in foster care (Taussig, Clyman, & Landsverk, 2001). Another prospective study followed children who were removed from the home and placed in alternative care, children who remained at home, and children who remained at home despite a decision to remove them. At six months after the intervention, the results showed that the quality of life of the children who were removed from home was higher than that of the children who remained at home, especially in terms of physical and psychological measures. The type of alternative care also affected the quality of life. The children who were placed in foster care had a better quality of life than children who were placed in institutions (Davidson-Arad et al., 2003). At the fifteen-month follow-up, the quality of life of the children who were removed from home improved significantly compared with the children who stayed at home, whose low quality of life remained the same as that at the first evaluation. Regarding the type of alternative care received, the quality of life of children who were placed in foster care declined, except in the physical domain, where the improvement continued, while the quality of life of the children who were placed in institutions improved in all domains (Davidson-Arad, 2005).
In light of the previous discussion, it is inconclusive whether placement is generally beneficial, harmful, or inconsequential to the development and well-being of maltreated children. Further research into the results of interventions and services that children and families receive in different settings is needed (Davidson-Arad et al., 2003). Additionally, the majority of studies focus on comparisons between home care and foster care, or the reunification with family of origin after removal from the home, and they do not include institutional care.
In Portugal, where this study was conducted, decision making in child welfare cases is guided by what is in the child's best interest, similar to the process in other countries (Britner & Mossler, 2002), and remaining with the family of origin is considered to be in the child's best interest. Removing a child from the home is the last resort. This intervention must be a temporary; legislation requires that children return to their biological families after placement in an institution or foster care. The majority of the children who are removed from their family spend weeks or months in institutions or residential care, but some may be in care for a year or more. Only a small number of children are moved to a foster family. Additionally, similar to what has been found in other countries, a recent study performed in Portugal found that few adverse outcomes were detected among children who were subjects of child protection intervention in childhood (Pinto & Maia, in press).
The purpose of this investigation was to compare youths who were identified in childhood by CPS and received one of two different intervention measures: maltreated children who remained with parents and children who were removed and placed in residential institutions. Accordingly, by comparing family intervention to institutionalization, we aim to assess the following: (a) the prevalence of adverse events during childhood using two sources of information (official data and self-reports) and (b) current functioning in terms of global psychopathology, health complaints, and health risk behaviors. We also intend to compare the youths who received attention from CPS in childhood with youths from a similar social class who were not identified as having been maltreated during childhood. Lastly, using only youths with CPS records, we will examine the predictors of actual functioning, separating the contribution of childhood adversity itself from the contributions of the two different protective interventions.
Based on previous research, we expect to find (a) some adversity reported in the comparison groups, although more exposure to adversity in the CPS identified youths is expected; (b) more exposure to adversity in institutionalized youths than in children who remained with their parents; (c) more negative outcomes among the youths with CPS records than those in the comparison group; (d) more negative outcomes for institutionalized youths, due to long periods of institutionalization and the expected increase in exposure to adversity compared to children who remained at home.
Section snippets
Participants
We examined 380 cases of child abuse and neglect in the CPS records (from 1999 to 2006) from a district in the North of Portugal. The youths were selected based on three inclusion criteria: only cases of neglect and child abuse that had been validated and confirmed by CPS were included in the sample; all the children lived with their families for at least five years prior to being identified as suffering maltreatment; and all children were identified before they were 12 years old. Based on these
Results
Table 3 shows the record and self-report data for ten categories of childhood adversity for two groups based on having had different CPS interventions (home intervention vs. institutionalization). We also included only the self-report data from the comparison group. A consideration of the entire sample (N = 216) showed that emotional neglect was the most commonly reported form of child adversity (44.4%; n = 96). Among the CPS-identified youths (n = 136), the most common form of documented childhood
Discussion
This study evaluated the current health functioning of youths involved in the CPS system in childhood. The strength of this study is that it detailed which particular services children received in childhood and evaluated their health outcomes during adolescence and young adulthood. As expected, the majority of children with CPS records experienced higher rates of parental substance abuse and emotional neglect, as well as other adverse conditions. However, also as expected, we found some adverse
Acknowledgments
The authors thank the Fundação para a Ciência e Tecnologia (grant BD, FCT-SFRH/BD/45414/2008) for financing this project. The authors also express appreciation to the staff of the Comissão de Protecção das Crianças e Jovens.
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