Mental Health Problems of Children in Foster Care

We compared the rates of mental health problems in children in foster care across three counties in California. A total of 267 children, ages 0 to 17, were assessed two to four months after entry into foster care using a behavioral screening checklist, a measure of self-concept and, in one county, an adaptive behavior survey. Results confirmed previous research and indicated consistently high rates of mental health problems across the three counties. Behavior problems in the clinical or borderline range of the CBCL were observed at two and a half times the rate expected in a community population. Fewer children fell within the clinical range on the self-concept measure. No significant differences in rates between the three county foster care cohorts were observed, despite the different demographic characteristics of the counties. On the adaptive behavior scale, the mean scores for children in foster care were more than one standard deviation below the norm. Our findings suggest that the most important mental health screening issue with children in foster care is to identify what specific mental health problems need to be addressed so that the most effective treatment services can be provided.     

Foster Children Caught in Loyalty Conflicts: Implications for Mental Health Treatment Providers

Fifty-two foster parents participated in a two-hour training on the topic of children caught in loyalty conflicts. Prior to and following the training attendees completed measures including one in which they rated their foster children's exposure to 15 different family situations which research indicates are likely to induce feelings of loyalty conflict in children. Analyses of these data indicate that each of the situations was endorsed by between one fourth and one half of the sample. Three-fourths of the foster parents endorsed at least one of the situations, with the average number 5.5. Implications for clinicians working with this population are discussed.     

Linking Foster Family Characteristics and Mental Health Symptoms of Youth in Care

Youth in foster care are disproportionately at risk for developing internalizing and externalizing problems (Lawrence et al., 2006); however, a history of maltreatment prior to foster care placement does not automatically result in poor mental health outcomes. Among non-foster care youth, the quality of family interactions has been related to adjustment outcomes, such that low family cohesion and high family conflict is associated with poor mental health symptoms (Caples & Barrera, 2006). While little is known about these constructs in foster care placements, they may help explain the variance in internalizing and externalizing problems for youth in foster care. The present study aimed to examine whether characteristics of the foster care environment (i.e., conflict, cohesion) across various placement types (i.e., traditional foster homes, group-care settings) could help explain the link between previous maltreatment exposure and mental health problems. The sample included 178 youth in foster care (M_age?=?15.18, SD?=?1.76) and their foster caregivers living in the Midwest. Youth participants completed self-report measures about prior maltreatment history, current family environment characteristics, and youth internalizing symptoms. Foster caregivers completed measures on current family environment and youth externalizing symptoms. Results indicated that caregiver report, but not youth report, of family cohesion was negatively associated with youth report of internalizing problems. When examining the indirect effects, youth report of family conflict partially accounted for the link between youth self-report of maltreatment and internalizing symptoms (B?=?0.106, 95% CI?=?0.026–0.186). Caregiver report of family conflict fully accounted for the association between youth self-report of maltreatment and caregiver report of youths’ externalizing symptoms (B?=?0.108, 95% CI?=?0.005–0.211). Findings highlight the importance of utilizing multiple informants when measuring foster family environment and suggest that family conflict is particularly salient for the mental health of youth in foster care.

     

Predictors of Placement Outcomes in Treatment Foster Care: Implications for Foster Parent Selection and Service Delivery

Treatment foster care (TFC) is a normalizing environment in which to treat those children whose particular needs are not addressed in traditional foster care and for whom an institutional setting is a restrictive and unnecessary alternative. However, when the foster care placements of these emotionally and behaviorally disturbed children fail, as they often do, the children are shifted from one home to another without the opportunity to experience permanence or emotional attachment, resulting in poor adjustment to foster care. Placement stability, which depends in part upon effective matching of foster children with potential foster families, is critical for achieving positive outcomes in TFC. Yet, there is a dearth of information to guide placement agencies in making decisions about matching foster children with families. Moreover, once a successful match has been made, it is equally vital that service delivery be of high quality so that permanence is maintained. We review research on the predictors of positive outcomes in foster care, focusing on studies involving emotionally or behaviorally disturbed children, and provide recommendations for selecting foster parents and for ensuring high quality foster care services and placement stability.     

Emerging Adulthood and Leaving Foster Care: Settings Associated with Mental Health

The present study examined the role of contextual support on mental health during the transition to adulthood within a vulnerable group, adolescents leaving foster care because of their age. Participants were 265 19- to 23-year-olds who retrospectively reported on 3 main contexts of emerging adulthood: housing security, educational achievement, and employment attainment in the first 2 years after leaving foster care. Mental health measured self-reported emotional distress, substance abuse, and deviancy at the time of interview. Growth Mixture Modeling empirically identified 3 latent trajectory classes. Stable-Engaged (41%) experienced secure housing and increasing connections to education and employment over time. Stable-Disengaged (30%) maintained housing but reported decreasing rates of education and small increases in employment. Instable-Disengaged (29%) experienced chronic housing instability, declined connection to education, and failed to attain employment. Stable-Engaged and Stable-Disengaged classes reported better mental health compared to the Instable-Disengaged class, indicating the importance of housing in transitioning to adulthood.     

Prereading Deficits in Children in Foster Care

Reading skills are core competencies in children's readiness to learn and may be particularly important for children in foster care, who are at risk for academic difficulties and higher rates of special education placement. In this study, prereading skills (phonological awareness, alphabetic knowledge, and oral language ability) and kindergarten performance of 63 children in foster care were examined just prior to and during the fall of kindergarten. The children exhibited prereading deficits with average prereading scores that fell at the 30(th) to 40(th) percentile. Variations in prereading skills (particularly phonological awareness) predicted kindergarten teacher ratings of early literacy skills in a multivariate path analysis. These findings highlight the need for interventions focused on prereading skills for children in foster care.     

Mental Health and Other Service Use by Youth in Therapeutic Foster Care and Group Homes

Little is known about what additional services youth receive while they reside in out-of-home treatment settings. However, such information may be crucial for explaining effectiveness and variation in outcomes for youth in such settings. Our research examines patterns of multi-sector service use for youth in two settings—Therapeutic Foster Care and group homes. Data come from in-person interviews with Treatment Foster Parents and Group Home Staff for a NC state-wide sample of youth with psychiatric disorders and aggressive behavior. Findings indicated high rates of service use by youth in both settings. Analyses indicated significant differences in service types used by youth in each setting, yet similar volume of service use between settings. Clinical and demographic factors did not significantly influence types of services received. Differences in service patterns between the two groups indicated that youth in TFC were more likely to receive community-based, individualized services while youth in group homes were more likely to receive more restrictive services.     

Cultural Mistrust of Mental Health Professionals Among Black Males Transitioning from Foster Care

We examined cultural mistrust of mental health professionals among Black males who are transitioning from the foster care system (N = 74) and its relationship to their level of satisfaction with child welfare services and the frequency of negative social contextual experiences. Results of hierarchical regression analysis showed that the level of satisfaction with child welfare services moderated the relationship between negative social contextual experiences and cultural mistrust of mental health professionals. Specifically, more frequent negative social contextual experiences were related to greater cultural mistrust of mental health professionals for Black males reporting low satisfaction with child welfare services, but not for those reporting high satisfaction with child welfare services. Implications for service delivery are discussed.     

Foster Care Placement,Poor Parenting,and Negative Outcomes Among Homeless Young Adults

Although homeless youth with and without foster care histories both face adverse life circumstances, little is known about how these two groups compare in terms of their early histories and whether they face similar outcomes. As such, we compared those with and without a history of foster care placement to determine if the associations between a history of poor parenting and negative outcomes including depression, delinquency, physical and sexual victimization, and substance use, are similar for these two groups. The sample consisted of 172 homeless young adults from the Midwestern United States. Multivariate results revealed that among those previously in foster care, a history of physical abuse and neglect were positively associated with more depressive symptoms whereas sexual abuse and neglect were related to delinquency and physical victimization. Additionally, lower caretaker monitoring was linked to greater delinquent participation. Among those without a history of foster care, physical abuse was related to more depressive symptoms whereas sexual abuse was positively correlated with delinquency, sexual victimization, and substance use. Furthermore, lower monitoring was related to more substance use. Our findings are discussed in terms of a social stress framework and we review the implications of foster care placement for homeless young adults.     

Behavior Problems, Academic Skill Delays and School Failure Among School-Aged Children in Foster Care: Their Relationship to Placement Characteristics

We describe the level of behavior problems, academic skill delays, and school failure among school-aged children in foster care. We also examine how behavior problems are associated with academic problems, and explore how these outcomes are related to children's placement characteristics. Foster parent and child home interviews, as well as teacher telephone interviews were conducted from a randomly selected sample of 302 children aged 6 through 12 years living in out-of-home placement. Interviews included standardized screening measures. Results showed that 27% of the children scored in the clinical range for a behavior problem, and 34% were rated as having at least one behavior problem in the classroom. Twenty-three percent of the children had severe delays in reading or math, 13% had repeated a grade, and 14% had a history of school suspension and/or expulsion. Behavior problems by foster parent report were related to child suspension and/or expulsion from school, but were not associated with severe academic delays or grade retention. Placement characteristics were only sometimes related to these outcomes. Future studies examining the mental health and educational needs of this population should take into account the child's sociodemographic and placement characteristics.     

Characteristics of Children in Foster Care,Family-Style Group Care,and Residential Care: A Scoping Review

When risky child and family circumstances cannot be resolved at home, (temporary) 24-h out-of-home placement of the child may be an alternative strategy. To identify specific placement risks and needs, care professionals must have information about the child and his or her family, care history, and social-cultural characteristics at admission to out-of-home care. However, to date information on case characteristics and particular their similarities and differences across the three main types of out-of-home settings (namely foster care, family-style group care, and residential care) is largely lacking. This review compiles and compares characteristics of school-aged children of average intelligence and their families at the time of each child’s admission to one of the three care modalities. A scoping review technique that provides a broad search strategy and ensures sufficient coverage of the available literature is used. Based on the 36 studies included, there is consensus that the majority of normally intelligent children in care demonstrate severe developmental and behavioral problems. However, the severeness as well as the kinds of defining characteristics present differ among the children in foster care, family-style group care, and residential care. The review also identifies several existing knowledge gaps regarding relevant risk factors. Future research is recommended to fill these gaps and determine the developmental pathway in relation to children’s risks and needs at admission. This will contribute to the development of an evidence-based risks and needs assessment tool that will enable care professionals to make informed referrals to a specific type of out-of-home care when such a placement is required.     

A Triage Tool to Assess Unmet Health Needs for Children Entering Foster Care

Children in foster care have high levels of health care needs, many of which are unmet at foster care entry. Health care coordination (HCC) is essential to ensure unmet needs are addressed rapidly. Data is lacking about how best to triage children at foster care entry so limited HCC resources can be allocated most effectively. Therefore, we aimed to: (1) utilize a Triage Tool (TT) at foster care entry to stratify children based on unmet health care needs and (2) determine if the TT is an accurate predictor of health care utilization as indicated by cost during a child’s first few weeks in care. A TT was developed and utilized during the initial foster care health exam (IFCHE) to stratify children based on unmet needs. Medicaid records were reviewed to determine health care utilization and cost during the first 60 days post-IFCHE. Most children (61.6%) had the lowest level of unmet needs (Level 3), 29.5% had a moderate level of unmet needs (Level 2), and 9.9% had the highest level of unmet needs (Level 1). Medicaid claims review revealed that triage level did not correlate to health care utilization or costs during the first 60 days post-IFCHE. Youth placed in a group home incurred significantly higher costs than those placed in foster homes. These results suggest that the TT is useful clinically but does not predict health care utilization and costs during the first weeks in care. Group home placement incurs more cost than foster home placement, independent of triage level assigned.     

Early Developmental Screening for Children in Foster Care

Limited data exist about the ideal timing of developmental screening for young children entering foster care, and current best practice recommends screening by 1 month into care to prioritize resources for evaluation. Therefore, we aimed to: (1) compare detection rates for potential developmental delay (DD) at foster care entry before and after implementation of a developmental screen and (2) examine accuracy of developmental screening when performed at entry and 1 month into care. Charts of 124 children <6 years evaluated for an initial foster care health assessment (IFCHA) were reviewed to determine baseline detection rates for potential DD. The Parents’ Evaluation of Developmental Status (PEDS) screening tool was then prospectively administered to 167 children <6 years during their IFCHA to determine detection rates. One month following the IFCHA, caregivers were re-contacted, and the screen was re-administered. Accuracy of the initial PEDS screen was compared to the 1 month PEDS screen by calculation of sensitivity and specificity. At baseline, potential DD was detected in 34 % of children at the IFCHA compared to 46 % after implementation of the PEDS (P = 0.041). Compared to the 1 month screen, the early screen had a sensitivity of 75 % and specificity of 88 %. Use of a developmental screening tool at foster care entry increased detection of potential DD, and the results remained consistent with screening 1 month later. These results support use of a developmental screen for children in foster care and suggest that screening be performed as early as possible to expedite necessary evaluations and referrals.     

Women,Mental Health,and Managed Care

Abstract

Managed care has changed the way that mental health care is provided. These insurers manage such factors as length and type of therapy made available, access to therapy, and level of payment for therapy. Women, as the majority of those insured by managed care and as consumers of mental healthcare, are differentially affected by these changes.     

Mental Health and Managed Care

In this essay I continue the conversation going on today on the crisis in delivering mental-health care within the realities of managed care. A guiding perspective is represented briefly in material from the writings of Edmund Pellegrino. He recommends the norm of patient-centered relationships to direct and govern managed care so cost can be controlled, but not by the sacrifice of quality of care. This emphasis must be balanced with a struggle for the greater social good and fair allocation of goods to all citizens. Definitions are offered along with a discussion of controversial issues and constructive suggestions to make possible a better future for the work of mental health in relation to managed care.     

Comparing Outcomes for Youth Served in Treatment Foster Care and Treatment Group Care

This study compared youth in the Florida Medicaid system prior to entry into treatment foster care or treatment group care, and compared outcomes in the 6 months after treatment. Florida Medicaid data from FY2003/04 through 2006/2007 along with Department of Juvenile Justice, Department of Law Enforcement, and involuntary examination data were used to examine youth receiving out-of-home treatment. Propensity score matching was used to examine the effect of out-of-home treatment on outcomes. Males, older youth, and youth with prior involuntary examinations, felony charges, misdemeanor charges, or inpatient psychiatric treatment were more likely to be placed in treatment group care. Treatment foster care placement was more likely for youth with prior treatment foster care episodes. Propensity matching results indicated that youth in treatment foster care had greater reductions in felony charges, and were less likely to return to out-of-home treatment in the following 6 months. While often placed in group care settings, youth with prior criminal justice encounters, especially for felony charges, may be better served in treatment foster care programs.     

Demographic,Clinical, and Geographic Predictors of Placement Disruption among Foster Care Youth Receiving Wraparound Services

The effective delivery of wraparound depends upon the availability of a wide range of community-based services. This study seeks to determine the impact of proximity to resources on the effectiveness of a wraparound program for stabilizing foster care placements among a sample of youth. We present a methodology for deriving proximity scores for individual clients using Geographic Information Systems technology, and incorporate this score into a model for predicting placement disruption among youth in foster care receiving services within a wraparound model aimed at preventing placement disruptions. Cox Regression is used to predict length of time until placement disruption using clinical, demographic, and service proximity measures. Risk of placement disruption is predicted by trauma experiences, risk behaviors, and age, and is reduced by the presence of child strengths and proximity to resources. The impact of proximity to resources on placement disruption varies by land use type, suggesting that proximity exerts a greater impact on youth in rural and suburban areas than in urban areas where wraparound service delivery models may be able to overcome distance and other barriers. Implications for the implementation of wraparound programs as well as service system planning are discussed.     

Patterns of Aberrant Eating Among Pre-adolescent Children in Foster Care

The paper reports epidemiological and phenomenological investigations of aberrant eating among 347 pre-adolescent children in court-ordered foster and kinship care, in New South Wales, Australia. A quarter of children displayed clinically significant aberrant eating problems, with no evidence of gender or age effects. Two distinct patterns were identified. The first is a pattern of excessive eating and food acquisition and maintenance behaviors without concurrent obesity (termed Food maintenance syndrome), resembling the behavioral correlates of Hyperphagic Short Stature (Psychosocial Dwarfism). Various data suggest this pattern is primarily triggered by acute stress, including maltreatment in care, against a background of complex psychopathology and developmental disabilities. The second is a cluster of pica-type eating behaviors that correlates with self-injurious behavior, and is closely associated with developmental disabilities. The paper includes recommendations for clinicians working with pre-adolescent children in care.