Mental Health Problems in Young Children Investigated by U.S. Child Welfare Agencies

doi:10.1016/j.jaac.2012.03.006

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 51, Issue 6, June 2012, Pages 572-581

https://doi.org/10.1016/j.jaac.2012.03.006 Get rights and content

Objective

To examine the prevalence/predictors of mental health (MH) problems and services use in 12- to 36-month-old children who had been investigated for maltreatment.

Method

Data came from the second National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal study of youth ages 0 to 17.5 years referred to U.S. child welfare agencies. These analyses involved 1117 children 12 to 36 months of age. Sociodemographic, social services, developmental and health data were collected on the children and caregivers. Outcomes were scores over the clinical cutoffs on the Brief Infant Toddler Social and Emotional Assessment (BITSEA) Scales for 12- to 18-month-olds and the Child Behavior Checklist (CBCL) for 19- to 36-month-olds.

Results

In all, 34.6% of 12 to 18 month-olds scored high on the Problem Scale of the BITSEA, and 20.9% on the Competence Scale, whereas 10.0% of 19- to 36-month-olds scored over the CBCL clinical cut-off. Children of black ethnicity were less likely to have elevated scores on the BITSEA Problem Scale, whereas children who lived with a never-married caregiver were five times more likely to have elevated scores. Competence problems were associated with prior child welfare history. Elevated CBCL scores were associated with living with a depressed caregiver. Few children with identified MH problems, 2.2%, received an MH service. When we added parenting skills training that might be related to the treatment of child problems, 19.2% received a service.

Conclusions

Identifiable MH problems are common, but few children receive services for those problems. The lack of services received by these young, multi-challenged children is a services systems and social policy failure.

Section snippets

Design and Analytic Sample

Data came from the baseline interviews of NSCAW II, a longitudinal study of 5,872 youth ages 0 to 17.5 years referred to U.S. child welfare agencies where an investigation of potential maltreatment was completed during the sampling period, February 2008 to April 2009. Excluded were agencies in eight states that required contact of a caregiver by agency staff rather than by study staff.²² NSCAW II employed a two-stage, stratified sample design. The first stage selected geographic areas

Results

Baseline characteristics are shown in Table 1. Slightly more than 50% of each age group was male, approximately one third of each group was white, children in both age categories were usually in their homes with at least one biological parent, with 19- to 36-month-olds more likely (11.2%) than 12- to 18-month-olds (8.3%) to be living in out-of-home care. Children showed delays on the Vineland, with more than 40.2% of each age group showing severe/moderate delays in Daily Living Skills, whereas

Discussion

Data on the emotional/behavioral health of young children, which are available for the first time in NSCAW II, confirm what had been found for older children in NSCAW I⁵—namely, that the prevalence of MH problems is high, irrespective of placement. NSCAW II data also demonstrate that these young children bear the additional risks of delays in adaptive behaviors as measured by the Vineland, high rates of chronic health problems, considerable prior child welfare history, live in families with

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Mental and Physical Health Profiles of Maltreated Youth
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Citation Excerpt :
They also show elevated rates of chronic disease risk indicators, such as high blood pressure reactivity to stress (Gooding et al., 2016), cortisol dysregulation (Alink et al., 2012; Trickett et al., 2014), and elevated body mass index (BMI) (Schneiderman et al., 2011; Shin & Miller, 2012). They have high rates of a wide range of physical disorders, even at young ages and in samples that include a variety of maltreatment types (Dolan et al., 2012; Hansen et al., 2004; Horwitz et al., 2012; Leslie et al., 2005; O’Donnell et al., 2010; Ringeisen et al., 2008; Schneiderman et al., 2011; Stein et al., 2013). There is also evidence that children with maltreatment histories fall behind in their immunizations (Hansen et al., 2004).
To examine both mental and physical health profiles of children diagnosed as maltreated in the community, we studied diagnoses in the electronic health records (EHRs) of youth assigned maltreatment-related diagnoses (N = 406) and well-matched youth without a maltreatment-related diagnosis (N = 406) during a four-year period in a large healthcare system that covers eight hospitals and over 40 clinics. Data extracted automatically from the EHRs was supplemented by manual chart review. The odds of the maltreated group being assigned a code for mental illness was 2.69 times higher than the odds for the comparison group, with large differences in mood and anxiety disorders and suicidality. The odds of having an injury or poisoning diagnosis were 3.45 times higher in maltreated than in comparison youth. Maltreated youth were also less likely to have been immunized. Nevertheless, contrary to our hypothesis, maltreated youth had significantly lower rates of diagnoses across almost all major physical disease categories assessed and did not differ from comparison youth in terms of body mass index (BMI). Furthermore, maltreated youth were assigned fewer diagnoses than comparison youth whether they came in for at least one preventive visit or not. Findings suggest a need for health care professionals to be prepared to address the high rates of mental disorders in maltreated youth, to be more vigilant about possible physical disorders in this population, and to take greater advantage of opportunities to immunize these youth.
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The first justification criterion for screening of mental and behavioral health needs in foster care is whether there is sufficient prevalence and severity of the problem in the population of interest. Existing evidence has clearly established this to be the case; behavioral health needs are quite prevalent in the child welfare population in general, and the foster care population in particular (Casanueva et al., 2012; Horwitz, Hurlburt, Heneghan, et al., 2012). Estimated rates of children and youth in foster care with clinical behavioral health needs range from 23.9% to 61% depending on age range, as older youth are more likely to have identified behavioral health-related issues (Horwitz et al., 2012; Horwitz, Hurlburt, Heneghan, et al., 2012; McMillen et al., 2004; Petrenko, Culhane, Garrido, & Taussig, 2011; Shin, 2005).
Children and youth in out-of-home care have high rates of behavioral health need, and states are increasingly adopting screening protocols to identify and intervene with these youth. This study presents longitudinal analyses of the case flow of youth aged 3–17 in Washington State's foster care system, tracking rates of screening, scoring above or below clinical criteria cutoff scores, and service receipt. This study describes what variables are associated with these three decision points.
Eighty-nine percent of eligible youth were screened for behavioral health need soon after entry in to out-of-home care; most of those who were not screened were already receiving behavioral health services. Sixty-one percent scored above criteria on at least one screening measure by at least one respondent. Sixty percent of those who scored above criteria and 33% of those who scored below criteria received at least one behavioral health service within 4 months of entry to care. After controlling for all variables, screening above criteria was related to age, race/ethnicity, county rurality, abuse type, reason for out-of-home placement, past behavioral health service receipt, and type of past diagnosis. Service receipt for those scoring above criteria was related to age, race/ethnicity, county rurality, abuse type, and type of prior behavioral health diagnosis.
The role of screening in child welfare is dynamic and influenced by multiple factors. In the current study, youth screening above criteria was related to increased rates of service receipt. However, many children with behavioral health service needs did not receive services. The relatively high rates of youth scoring below criteria but receiving services may indicate a need for ongoing systematic screening in order to identify emergent needs, or additional screening measures at intake. States considering or employing the use of screening tools should weigh a variety of approaches to screening, assessment, and referral to services in order to ensure maximal benefit.
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The purpose of this systematic review is to compare the associations of kinship care and non-kinship care with children's mental health and to examine the factors associated with children's mental health in kinship care and non-kinship foster care. A comprehensive search was conducted in nine databases, and 237 articles were identified yielding eight studies that met criteria. Study designs, sample characteristics, methodologies, and results were collected and entered into data matrices and data was analyzed narratively. This review found that children in kinship care exhibited better mental health outcomes than children in non-kinship care in the univariate and bivariate comparisons. However, the associations between kinship care and children's mental health in regression models were mixed across studies. The associations depended on research designs (cross-sectional or prospective longitudinal design) and whether statistical models addressed selection bias and controlled for confounders. This review also identified that child maltreatment related factors, placement related factors, child level factors, foster caregiver level factors, foster family environmental level factors, and neighborhood level factors were associated with foster children's mental health. Some implications for practice and research were discussed.

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: This study was supported by National Institute of Mental Health (NIMH) award P30-MH074678 (J. L.).

: This article is discussed in an editorial by Dr. Gail Edelsohn on page 566.

: Data are from the National Survey of Child and Adolescent Well-Being, developed under contract with the Administration on Children, Youth, and Families (ACYF), U.S. Department of Health and Human Services (DHHS); and the National Data Archive on Child Abuse and Neglect. The findings/conclusions are those of the authors and do not necessarily reflect the opinions of the NIMH, nor indicate endorsement of its content by ACYF/DHHS.

: Disclosure: Drs. Horwitz, Hulburt, Heneghan, Landsverk, and Stein, and Ms. Zhang, Rolls-Reutz, and Fisher report no biomedical financial interests or potential conflicts of interest.

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New researchMental Health Problems in Young Children Investigated by U.S. Child Welfare Agencies

Objective

Method

Results

Conclusions

Section snippets

Design and Analytic Sample

Results

Discussion

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Child Adolesc Psychiatr Clin N Am

J Am Acad Child Adolesc Psychiatry

Child Adolesc Psychiatr Clin N Am

J Am Acad Child Adolesc Psychiatry

Child Abuse Negl

Child Abuse Negl

J Affect Disord

J Am Acad Child Adolesc Psychiatry

Infant Behav Dev

Pediatr Clin North Am

Patterns and predictors of mental health services use by children in contact with the child welfare system

Children in foster care: mental health, service use and costs

Eur Child Adolesc Psychiatry

Identification of social-emotional problems among young children in foster care

J Child Psychol Psychiatry

Mental health problems of children in foster care

Journal of Child and Family Studies

Can foster carers help children resolve their emotional and behavioural difficulties?

Clin Child Psychol Psychiatry

Social-emotional screening status in early childhood predicts elementary school outcomes

Pediatrics

Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology

J Child Psychol Psychiatry

Quality of the early caregiving environment and preschool well-being: an examination of children entering the child welfare system during infancy

New research
Mental Health Problems in Young Children Investigated by U.S. Child Welfare Agencies