Externalizing problems in young foster children: Prevalence rates, predictors and service use

Abstract

Objective

Examining the prevalence of externalizing problems, their predictors and mental health service use for these problems by foster children and foster parents in a representative group of foster children aged 3 to 12 in Flanders.

Method

Survey data were collected on 212 foster children, who had been in the foster family for approximately four months. Foster parents filled out a Child Behavior Checklist to measure foster children's externalizing problems. Foster care workers reported on several potential risk variables for externalizing problems and on foster children's and foster parent's mental health service use. Predictors of externalizing problems were identified from a large number of variables using the method of purposeful selection of variables in linear regression.

Results

40.6% of the foster children had externalizing problems. Foster children who were placed because of behavioral problems had more externalizing problems. Only 20.9% of the foster children with externalizing problems and only 13.9% of their foster parents received professional help.

Conclusions

This study showed that externalizing problems are prevalent in this young foster care population, that it is hard to predict which foster children had externalizing problems, and that foster children and their foster parents rarely receive services for these problems. These findings call for a standard protocol of assessment of foster children's externalizing problems. Moreover, from a preventive viewpoint, guidelines are needed to systematically link young foster children with externalizing problems and their foster parents to appropriate services.

Introduction

Child welfare services intervene when the physical integrity or the affective, moral, intellectual or social development of children are in danger due to negative life events, relational conflicts or the circumstances they live in. When the safety of the child cannot be guaranteed through home-based interventions, an out-of-home placement is necessary. Regarding out-of-home placements, UN guidelines for the alternative care of children (United Nations General Assembly, Human Rights Council, 2010) state that the use of residential care should be limited and alternative care for young children, especially those under the age of three years, should be provided in family-based settings. In the Flemish jurisdiction, family foster care is the first alternative to be considered for all children and youth in need of an out-of-home placement (Vlaams Parlement, 2012). The number of foster placements of minors (children between 0 and 18 years) in Flanders (i.e., the Dutch speaking part of Belgium) has increased from 2779 in 2000 to 4184 in 2010. This increase is mainly attributable to the increase of placements of children under the age of three (increase of 91% during the last 10 years) and the increase of placements of children aged three to 12 (increase of 57% during the last 10 years). The number of foster placements of children aged between 12 and 18 has increased less (36% during the last 10 years). As a consequence, in 2010 the majority of foster children (52%) were aged between three and 12 (Pleegzorg Vlaanderen, personal communication, August 2, 2012). In this article we report on the externalizing problems in this age group of foster children and service use for these problems. We focus on externalizing problems of foster children, because children with these problems are less likely to be reunited with their parents (Landsverk, Davis, Ganger, Newton, & Johnson, 1996). Moreover, externalizing problems predict foster parents feeling burdened and are important predictors of placement disruptions (McCarthy et al., 2003, Oosterman et al., 2007, Vanderfaeillie et al., 2008). It is particularly important to gain insight into externalizing problems in this group of young foster children since the onset of aggressive behavior in childhood is associated with antisocial behavior in adulthood (Moffitt, Caspi, Harrington, & Milne, 2002). Identification of and service use for externalizing behaviors in this young subpopulation of foster children is, thus, a necessary condition in order to ensure the well-being of children in care (Levitt, 2009). For a good understanding of our results, we first briefly describe the organization of foster care in Flanders. Next, we review the findings and shortcomings of previous studies concerning foster children's externalizing problems and service use for these problems. After formulating our research questions, we report and discuss our results.

In Flanders, the Youth Welfare Agency organizes help for children who are living in a problematic educational situation or who have committed a crime (Departement Welzijn Volksgezondheid en Gezin, 2010). A problematic educational situation is defined as: “a situation that endangers the physical integrity, the affective, moral, intellectual, or social development of young people because of negative life events, relational conflicts or the circumstances they live in” (Decreet van 7 maart 2008 inzake bijzondere jeugdbijstand, 2008). In such cases, minors and their families can be referred to services subsidized by the Youth Welfare Agency. Preferably, the help offered by these services is organized on a voluntary basis. If this is no (longer) possible, an arbitration committee is contacted that consults the parents, the child and the social worker. After this mediation process, either the interference ends (if the committee decides that no intervention is necessary), help is offered on a voluntary basis (if the parents finally agree) or help is made compulsory (Decreet van 7 maart 2008 inzake bijzondere jeugdbijstand, 2008, Nouwen et al., 2012). In this last case, the youth court decides on the type of service offered to the parents and the child. In 2011, 43.59% of the support offered by the Youth Welfare Agency was offered on a voluntary basis (Agentschap Jongerenwelzijn, 2012a). Placing a child in a foster family is just one of many optional measures that can be taken when children are living in a problematic educational situation (e.g., home-based family support, residential care). Foster placements made up 28.2% of the private special youth care services in 2011. Of all the children placed in a private out-of-home service (e.g., group homes, family homes) in 2011, 46% resided in a foster family. In 2004 this was only 38.4% (Agentschap Jongerenwelzijn, 2012b). The limited capacity of home-based family support services and the high occupancy of other out-of-home services have led to the increase of foster placements (since the government puts no limitation on the number of foster placements).

Seventeen foster care agencies, spread across Flanders, are subsidized by the Youth Welfare Agency. By law, these agencies are responsible for the selection and pre-service training of foster parents, on-going support for foster parents and monitoring of the foster placement (Besluit van de Vlaamse regering inzake de erkenningsvoorwaarden en de subsidienormen voor de voorzieningen van de bijzondere jeugdbijstand, 1994).

Legal requirements for foster parents are very limited: they have to be older than 18 years, in good health, and have a Police Clearance Certificate (Verreth, 2009). Foster care agencies have considerable autonomy in the additional skills/competencies they require from foster parents. Being able to communicate openly and clearly, being able to collaborate in a team and share parenthood, being capable of helping children in changing their behaviors and in developing a positive self-image, and being aware of the impact that fostering might have on their own family life are competencies that are evaluated during selection of non-kinship foster parents by all foster care agencies (De Maeyer, Klingels, Vanderfaeillie, & Van Holen, 2012). Less is known about the requirements for kinship foster parents.

Non-kinship foster parents are also obliged to complete a pre-service training (Verreth, 2009). In most foster care agencies, a modified version of the Samenwerking Teamgeest Aspirant Pleegouder (STAP) program (which is similar to the Model Approach to Partnerships in Parenting (MAPP) (Mayers-Pasztor, 1987)) is used. In a combination of individual and group sessions, several topics are discussed: motivation to foster, collaboration, attachment, challenging behaviors of foster children, parenting skills, and the impact of foster care on the foster family. Kinship foster parents are not obliged to complete this pre-service training. They are screened by the foster care agency or evaluated during the first months of the kinship placement. The evaluation criteria are not clearly defined and can differ between the agencies.

Besides the recruitment, selection/screening, and matching of foster child and foster family, foster care agencies monitor foster care placements. A full-time foster care worker is responsible for 25 foster care placements. The social worker organizes support for the foster child, optimizes contacts with birthparents and family, and coaches and trains foster parents (Verreth, 2009). Although foster care workers are legally obliged to have at least seven face-to-face contacts a year with the parties involved (foster child, foster parents, and birthparents) and certain aspects of good practice (e.g., the use of care plans) are made obligatory (www.pleegzorgvlaanderen.be), foster care workers have considerable autonomy. Although foster care workers often (in 66% of the cases) have more than the minimal seven contacts with the parties involved (Sprangers, 2009), the high caseload hinders them from providing intensive support to foster parents. Bronselaer, Vandezande, and Verreth (2011), for example, found that only 40% of Flemish foster parents had contact (face-to-face or by telephone) at least once a month with their foster care worker. We should add that, besides individual counseling, most foster care agencies also offer (non mandatory) group training to foster parents. Foster care agencies organize on average four collective training sessions a year (Bronselaer, Vandezande, & Verreth, 2012). However, Bronselaer et al. (2012) found that 77.7% of foster parents did not attend any group training during the past five years.

More than half of Flemish foster parents ask for more support regarding the behavior of their foster child (Van Holen, 2005). Such help can be offered by mental health services or general parent education programs (such as Triple P). Since referrals to non-foster care services might be difficult, the Flemish government recently decided to subsidize a specific foster parent intervention, offered as a foster care service, in addition to regular casework. Strengthening Foster Parents in Parenting (SFP) offers additional training to foster parents of children aged between three and 18 years with externalizing behavioral problems (Vanschoonlandt, Van Holen, & Vanderfaeillie, 2012). SFP is currently being implemented and evaluated in a small, randomized controlled trial with 120 participating foster parents. Since there was no tradition of routinely screening the mental health needs of foster children, an enrollment procedure for SFP had to include a screening for behavioral problems. As part of this screening procedure, foster parents fill out a Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) and foster care workers fill out a questionnaire on risk factors in different domains (see further). Sixteen out of 17 licensed foster care agencies across Flanders implemented this systematic screening. Within these agencies, all new long-term placements are systematically screened during the fourth month after the start of the placement. Foster parents are informed about the screening at the start of the placement. In this manuscript, the data collected during the first one and a half years of this routine screening were used. Before discussing the results, we briefly review the literature on foster children's externalizing problems and service use for these problems.

Several studies have used a Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) to measure foster children's externalizing problems (Keil & Price, 2006). Prevalence rates of foster children with a clinical score on the externalizing subscale vary from 25% (Zima et al., 2000) to 60% (Sawyer, Carbone, Searle, & Robinson, 2007). A first drawback of these studies is that the prevalence rate is often studied within a wider age range of foster children (4–18 years, e.g., Armsden et al., 2000, Keller et al., 2001, Strijker et al., 2002). A conventional typology of foster children differentiates older “disaffected” foster children with a higher incidence of behavioral problems from younger “protected” children who are placed because of neglect and have fewer behavioral problems (Delfabbro et al., 2002, Farmer, 1996). It can thus be expected that the prevalence rates of externalizing problems are lower in children aged three to 12. The few studies that used the CBCL to investigate age differences, however, either did not find a significant difference in the prevalence of externalizing problems between children and adolescents (Heflinger et al., 2000, Sawyer et al., 2007), or found more externalizing behaviors in the group of foster children younger than 12 (Armsden et al., 2000). More research is needed about the prevalence rates of externalizing problems in this specific age group of foster children. Other drawbacks of previous studies are a low response rate (e.g., 42% in Minnis, Everett, Pelosi, Dunn, & Knapp, 2006) and/or a limited geographical scope (e.g., Sawyer et al., 2007), possibly limiting the representativeness of some prevalence data. Another limitation of previous studies is the inclusion of all children in foster care at one moment in time (e.g., Tarren-Sweeney & Hazell, 2006). This procedure may result in an underestimation of the number of foster children with externalizing problems who are placed in foster care because foster children with externalizing problems are less likely to remain in foster care. By making use of a routine screening procedure covering the whole of Flanders, including the evaluation of foster children's externalizing problems four months after the start of the foster placement, this study aims at rectifying the three last-mentioned drawbacks of previous studies. A last drawback of previous prevalence studies is the absence of a detailed focus on externalizing problem behaviors. Most studies report only prevalence rates of clinical scores on the externalizing CBCL scale (e.g., Leslie et al., 2004, Sawyer et al., 2007). Providing more detailed information about the specific externalizing problem behaviors of foster children (also those who do not have a clinical externalizing score) would be useful. Armsden et al. (2000), for example, found that at least one fifth of foster children often argued, demanded a lot of attention and couldn't concentrate. This information can be useful in order to better prepare and support foster parents.

As Leslie, Gordon, Lambros, Premji, Peoples, and Gist (2005) state, the high rate of externalizing problems in foster children is thought to reflect multiple factors. The high prevalence of mental illness, drug/alcohol abuse, and involvement in violence of biological parents (Minnis et al., 2006) places foster children at a genetic risk for developing behavioral problems (Rutter, Silberg, O'Connor, & Simonoff, 1999). Moreover, before the placement, foster children often experienced threatening situations such as neglect, domestic violence, physical or sexual abuse in their family of origin (Oswald, Heil, & Goldbeck, 2010). An interaction between this genetic vulnerability and environmental risks places foster children at increased risk of behavioral problems before placement in foster care. The experience of removal from the home, community and friends and having to adjust to a new foster family can exacerbate problems (Carbone, 2009). However, to date, it remains unclear which risk and protective factors are important in predicting foster children's externalizing problems. Some studies did report the association of single risk factors with externalizing behaviors, e.g., gender (Hellinckx & Grietens, 1994), race (Keller et al., 2001), maltreatment history (Proctor, Skriner, Roesch, & Litrownik, 2010), and the number of previous out-of-home placements (Newton, Litrownik, & Landsverk, 2000) of the foster child, type of foster placement (non-kinship versus kinship) (Tarren-Sweeney & Hazell, 2006), contact frequency with (McWey, Acock, & Porter, 2010) and attitude of (Strijker & Knorth, 2009) biological parents, and foster care worker's education (Cheung, Goodman, Leckie, & Jenkins, 2011). To our knowledge, however, only one study took into account several retrospective and concurrent predictors of externalizing problems simultaneously to control for confounding factors. Tarren-Sweeney (2008) found that gender and reading difficulties of the foster child, a history of physical or emotional abuse, the age of entry into care, the foster parent's health, the number of events in the last year and an anticipation of restoration with the foster child's biological parents were significantly associated with externalizing problems in a linear regression model. Several authors state that more research is needed to understand the association between experiences before and during foster care placement and foster children's externalizing problems (Aguilar-vafaie et al., 2011, Oswald et al., 2010).

Screening foster children for externalizing problems is a first step in improving foster children's mental health and foster care's outcomes; offering treatment is the next (Levitt, 2009). To date, there have been few studies examining the service use by foster children or their foster parents (Minnis et al., 2006).

Rates of mental health service use by foster children in the US range from 26% (Bellamy, Gopalan, & Traube, 2010) to 56% (Garland, Landsverk, Hough, & Ellis-MacLeod, 1996). Results from a national US study (Leslie et al., 2004) of foster children in foster care for 12 months, found that 75.8% of the children with a clinical score on at least one broad-band CBCL scale received mental health services. In one Australian study, 26.9% of foster children aged six to 17 obtained professional help, while 53.4% of the foster parents reported that their foster child needed professional help (Sawyer et al., 2007). In another Australian study, 44% of the foster children aged four to nine received individual therapy (Tarren-Sweeney, 2010). Minnis et al. (2006) found that 18% of Scottish foster children aged five to 16 had contact with a child psychologist or psychiatrist. The prevalence rates above vary widely between studies, partly due to different definitions of mental health service use and different study populations (with respect to age of the foster children and time spent in foster care). Moreover, differences in policy might explain the differences in service use. Given the heterogeneity of social care and public health systems throughout the western world, findings of Anglo-Saxon studies do not offer clear guidance to policy makers in other countries (Tarren-Sweeney, 2010, p. 483). A study in Flanders is therefore necessary. Moreover, previous studies reported on foster children's service use for mental health problems in general, and not specifically for externalizing problems. Thus, the specific focus on service use by young foster children with externalizing problems is an added value of this study.

Externalizing problems of foster children have an impact on foster parents' stress (McCarthy et al., 2003) and parenting behavior (Vanderfaeillie, Van Holen, Trogh, & Andries, 2012), and are an important reason for placement breakdown in Flanders (Vanderfaeillie et al., 2008). Moreover, it has been shown that parent management training is a successful intervention in reducing children's externalizing behaviors in the general population (Maughan, Christianseri, Jensori, Olympia, & Clark, 2005). Consequently, several authors call for the involvement of foster parents in the treatment of foster children's externalizing behaviors (Leathers et al., 2009, Racusin et al., 2005). However, Tarren-Sweeney (2010) reported that only 45% of the foster parents received clinical guidance for managing their foster child's behavior or feelings. This support was mostly provided in combination with individual therapy for the foster child. Only 15% of the foster parents received clinical guidance without their foster child receiving individual therapy. To our knowledge, this is the only study investigating service use by foster parents. Moreover, this study reported on foster parents' service use in general, not specifically for foster children's externalizing problems. More research is needed to gain insight into the service use of foster parents for foster children's externalizing problems.