Article

Mental health outcomes among child welfare investigated children: In-home versus out-of-home care

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Abstract

Background: Child welfare has increasingly focused on alternatives to out-of-home (OOH) placement. In-home services, such as parent training, have increased and more maltreated children remain in-home. Yet, little is known about the effect on mental health of maintaining vulnerable children in-home vs placement in stable OOH care. Objective: To evaluate and compare difference in mental health among children investigated by child welfare and who remained in-home vs. those who were placed in stable OOH care. Design/methods: We examined a cohort of children (aged 1.5-18. years) from a nationally representative sample of children investigated by child welfare using the National Survey of Child and Adolescent Well-Being II (NSCAW II). We compared changes in mental health functioning over 18. months for children who remained in-home with parent training versus those placed in stable OOH care. Results: Among the 749 children in our sample, baseline characteristics of children who remained in-home with parent training and those placed in stable OOH care were similar. Among school-aged children placed in stable OOH care, mental health problems decreased from 26% to 13% (. p=. .003). This differed significantly from school-aged children who remained in home, for whom mental health problems increased (50% decrease stable OOH care vs. 23% increase in home; p=. .007). Among pre-school aged children, mental health problems increased in both settings, particularly stable out-of-home care (. p=. .008). Conclusions: For school aged children with a history of maltreatment, mental health outcomes improve following stable OOH placement, yet worsen when remaining in-home with parents. Pediatricians should be watchful for mental health problems among children who remain home after maltreatment and should advocate for high-quality stable OOH care when it is necessary. Child welfare may need to monitor the outcomes of children remaining at home more closely and provide more intensive preventive and treatment services to families.

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... Nevertheless, residential care is currently an integral part of the care continuum López and del Valle 2015;Preyde et al. 2011). In addition, various published studies suggest that residential care is suitable and effective for children with certain, often severe, risks and needs (Chor et al. 2012;Conn et al. 2015;De Swart et al. 2012;Grietens et al. 2015). Moreover, the UN Guidelines for the Alternative Care of Children (henceforth "UN guidelines") state that residential care can be preferable if it is necessary and constructive in the interest of the child (United Nations 2009, December 18). ...
... These facilities vary in their size, in reason for placement (crisis, care, cure), in location (in or out of the community), and in their therapeutic components (Grietens et al. 2015;). In addition, the comparison of effectiveness is confounded by the differences in the characteristics of the target groups at admission (i.e., age, degree of behavioral problems and care history) between children in foster care, family-style group care and residential care (Leloux-Opmeer et al. 2017;Conn et al. 2015;Den Dunnen et al. 2012). These differences in treatment contexts and the differences in risks, needs and responsivity at admission, mean that the comparability of the outcomes of the existing types of care is limited Preyde et al. 2011). ...
... These differences in treatment contexts and the differences in risks, needs and responsivity at admission, mean that the comparability of the outcomes of the existing types of care is limited Preyde et al. 2011). This is why different researchers propose that a more realistic depiction of treatment effectiveness would be acquired if the outcomes in the different types of care were compared with the specific baseline situations with which the children and their families initially entered care (Conn et al. 2015;McCrae et al. 2010). ...
Article
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Similarities and differences in the (short-term) psychosocial development of children in foster care, family-style group care, and residential care were investigated in a sample of 121 Dutch children (M age = 8.78 years; SD = 2.34 years; 47% female; 59% Caucasian) one year after their initial placement. Pretest and posttest measurements were carried out at the substitute caregivers using the CBCL. The results were examined at group level and case level. At group level, the findings showed no evidence for higher effectiveness in favor to the family-oriented settings (foster care, and family-style group care), as hypothesized. By contrast, some small differences were found between foster care and family-style group care, in favor of the latter. At individual level, a more or less equal number of children (18%) with a clinical pretest score on psychosocial functioning clinically significant improved (behavioral normalization). An important concern is that a number of children without clinical psychosocial problems at the time of admission clinically significant deteriorated (behavioral aberration) in psychosocial functioning (20%). This might indicate a poor match between the risks, needs and responsivity of the child on the one hand and the chosen intervention on the other. Future research on factors that (prior and during placement) positively as well as negatively affect the child’s psychosocial development is needed to further clarify this finding.
... Nevertheless, residential care is currently an integral part of the care continuum (James, Roesch, et al., 2012;López & del Valle, 2015;Preyde et al., 2011). In addition, various published studies suggest that residential care is suitable and effective for children with certain, often severe, risks and needs (Chor et al., 2012;Conn, Szilagyi, Jee, Blumkin, & Szilagyi, 2015;De Swart et al., 2012;Whittaker et al., 2015). Moreover, the UN Guidelines for the Alternative Care of Children (henceforth "UN guidelines") state that residential care can be preferable if it is necessary and constructive in the interest of the child (United Nations, 2009, December 18). ...
... These facilities vary in their size, in reason for placement (crisis, care, cure), in location (in or out of the community), and in their therapeutic components Whittaker et al., 2015). In addition, the comparison of effectiveness is confounded by the differences in the characteristics of the target groups at admission (i.e., age, degree of behavioral problems and care history) between children in foster care, family-style group care and residential care (Butler & McPherson, 2007Conn et al., 2015;Den Dunnen et al., 2012). These differences in treatment contexts and the differences in risks, needs and responsivity at admission, mean that the comparability of the outcomes of the existing types of care is limited (James, Roesch, et al., 2012;Preyde et al., 2011). ...
... These differences in treatment contexts and the differences in risks, needs and responsivity at admission, mean that the comparability of the outcomes of the existing types of care is limited (James, Roesch, et al., 2012;Preyde et al., 2011). This is why different researchers propose that a more realistic depiction of treatment effectiveness would be acquired if the outcomes in the different types of care were compared with the specific baseline situations with which the children and their families initially entered care (Conn et al., 2015;McCrae, Lee, Barth, & Rauktis, 2010). ...
Thesis
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Linking typical baseline child and family characteristics of out-of-home placed children to children's psychosocial development in the various 24-h settings (foster, family-style group, and residential care)
... Youth receiving interventions from the child welfare system (CWS) have often experienced such adversities (Conn et al., 2015). ...
... Although not measured in the present study, it is also likely that ongoing stressors, such as poverty, poor parental mental health and inadequate parenting, continue to impact youth receiving IHS (Conn et al., 2015). ...
Article
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Youth within the child welfare system (CWS) have often experienced adverse life events, and many need support from health services. This study aimed to compare mental health problems and health service use among adolescents receiving in-home services (IHS), living in foster care (FC) and general population youth (GP). Data stem from the youth@hordaland survey, a population-based study of adolescents (N = 10,257, age 16-19) conducted in 2012 in Hordaland County, Norway. The adolescents provided self-reported data on CWS contact, health service use, adverse life events and multiple instruments assessing mental health problems. The IHS and FC groups had significantly higher symptom scores across most mental health measures than peers from the GP. Youth receiving IHS had significantly higher scores on measures of general internalizing and externalizing problems, attention deficit hyperactiv-ity disorder (ADHD) and depression compared with peers in FC. Those receiving IHS reported the highest health service use. Adverse life events accounted for a substantial part of the differences between the groups. Mental health problems are frequent among older adolescents within the CWS, especially among youth receiving IHS. Service providers and policymakers should be aware of the present and likely continued challenges faced by many of these youth.
... In Australia, residential OoHC involves the provision of care by paid staff who look after up to four YP in a residential building. It is well established that YP in residential care have often experienced trauma, are more likely to have complex needs, and are at increased risk of chronic physical and mental health conditions and associated morbidities, when compared to YP in the general population without a care experience (Baldwin et al., 2019;Conn et al., 2015;Martin et al., 2014;McDowall, 2018;Osborn & Delfabbro, 2005;Smales et al., 2020;Vinnerljung & Sallnäs, 2008;Wade & Dixon, 2006;Webster, 2016). Common health concerns experienced by YP in OoHC include overweight and obesity, disordered eating, lower levels of physical activity, poor nutrition, sexual and/or reproductive health issues, and increased participation in adverse health behaviours such as substance use (Casey et al., 2012;Cox et al., 2014;Cox et al., 2016;Cox et al., 2017;Martin et al., 2014;Norrish et al., 2019;Skouteris et al., 2011;Smales et al., 2020). ...
... Given that regular PA participation has been associated with several benefits to the wellbeing of YP living in OoHC (Conn et al., 2015;Harrison & Narayan, 2003;McDowall, 2018), supporting YP to address these individual barriers, potentially by upskilling RCS and other professional supports, could have a positive impact on the YP's participation in PA and their subsequent health and wellbeing. The authors are mindful that the individual barriers or challenges YP face are likely to be perpetuated by the barriers faced at the system and community level. ...
Article
Despite the clear benefits of engaging in regular physical activity (PA), research suggests that young people in Out-of-Home Care (OoHC) are less likely to achieve the recommended levels of PA than their same-aged counterparts in the general community. To date, there has been limited examination of the barriers to PA engagement specific to young people living in residential OoHC. This qualitative study aimed to better understand the barriers and/or challenges to regular PA engagement for young people in residential OoHC. The voice of young people, residential care staff, and key stakeholders in the OoHC sector were included through the use of interviews and focus groups. Three key barriers were identified including: (1) the residential OoHC setting is not conducive to PA; (2) young people require additional support to be physically active; and (3) there are community barriers which impact young people’s engagement in PA. Discussions identified a number of individual barriers or challenges faced by young people, which are impacted or exacerbated by the barriers faced at the system and community level. Findings suggest there is a need for governments, agencies involved in OoHC and community sports and recreation facilities to re-examine current practices and policies and address barriers related to workloads of residential care staff, funding, resource allocations, and capacity to support young people’s participation in PA. The need to take action is urgent and warranted. It is recommended that future intervention approaches develop innovative partnerships—that bring together research, practice, community, and policy resources—to ensure access to PA does not become an equity issue for YP living in residential OoHC.
... While little is known about the child welfare system factors that may be related to increasing the link between screening and child behavioral health services, there are existing data on the in- dividual level predictors of behavioral health service use for youth in foster care. Higher rates of externalizing behaviors, difficulty with peers and prosocial behaviors, history of sexual abuse, caregiver behavioral health concerns, and older age (due to either longer time in care or worsening clinical presentation) have been associated with higher likelihood of service receipt ( Burns et al., 2004;Clark, Yampolskaya, & Robst, 2011;Conn, Szilagyi, Jee, Blumkin, & Szilagyi, 2015;Garland, Landsverk, Hough, & EllisMacLeod, 1996;Leslie et al., 2000;Leslie et al., 2003;Shin, 2005). Children and youth in kinship care (e.g. who are placed with a relative or family friend) are less likely to receive behavioral health services than youth in other forms of out-of-home care (Coleman & Wu, 2016;Petrenko et al., 2011;Villagrana, 2010). ...
Article
Purpose: 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. Results: 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. Conclusions: 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.
... Prior work has urged pediatricians to monitor mental health for youth in out-of home care and for child welfare to provide ongoing services. (Conn et al., 2015). ...
Article
In this article, we reflect on a pilot project implementing a mindfulness-based stress reduction program among traumatized youth in foster and kinship care. We adapted a mindfulness intervention to teach self-regulation skills in a supportive, interactive, social group setting environment. Our hypothesis was that teaching mindfulness skills would enhance youth competency in stress management by giving them tools for self-regulation. In response to youth request for social groups, we adapted a mindfulness intervention aimed at stress reduction to include supervised social activities. Our program was marked by two adverse events: raising considerations regarding safety and supervision when in group settings with youth who previously experienced adverse childhood experiences and are prone to extreme reactivity and escalating behaviors. We share our experiences and recommendations for future research and practice, including recruitment considerations, opinions of group versus individual therapy, intensity of supervision of high-risk youth, training and support for graduate student volunteers working with youth in the child welfare system, and expectations for foster and adoptive family support of these youth. Our collective goal is to promote the health and wellness of these young people, equipping them with self-efficacy skills for future success, which may include mindfulness training. We realize that there is no one best approach to reaching this goal, and we need to consider safety and practicality when designing programs for youth in foster and kinship care.
... Several studies examining troubled youth have compared outcomes for youth who stay and receive services inhome with youth who receive out-of-home placements. For example, among maltreated children with similar high levels of clinical acuity, those placed in GC experienced a 50% reduction in their mental health problems, whereas children who remained at home with parent training experienced a 24% increase in their mental health problems (Conn et al., 2015). A study found that for a population of children who social workers recommended should be removed from their homes, those who were removed improved over time, while those who remained at home (in-home interventions not specified) stayed at the same low level of psychological, physical, social, and cultural quality of life (Davidson-Arad, 2005). ...
Article
It is not unusual to see research studies or published opinion pieces that claim to demonstrate that home-based interventions (HBI) are more effective than group-care (GC) programs for young people with emotional and behavioral difficulties. The claim about the comparative effectiveness of HBIs in contrast to GC programs can only be true if they serve the same population of young people by age, gender, and degree of emotional and behavioral difficulties and that the outcomes for HBIs are statistically significantly better than those for GC. There is a long-standing argument between those who think that GC programs are unnecessary in comparison to those who think a mature child welfare system will always need some GC programs, albeit for a few young people with extreme difficulties. This article explores this issue in terms of how legitimate comparisons can be made between these two forms of service and how case-mix adjustment provides an established method for doing this. The purpose is to move away from ideological posturing by advocates from either side of the argument and put the debate about these forms of service and their effectiveness onto a firmer evidence base.
... Not surprisingly, mental health seemed to be the main health concern that YP reported experiencing when reflecting on their time in care. This is not dissimilar to recent research by Conn et al. (2015) and Ford et al. (2018). When participants spoke about their mental health, they often felt that it was rarely addressed appropriately, with some YP describing it as being completely neglected and/or going unnoticed altogether. ...
Article
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Children in care (CiC) experience poorer health outcomes than their same-aged peers without an experience of care. Despite growing recognition of the importance of listening to the voices of children and young people (YP), to date, the voices of CiC are not well represented in research examining their health. This study aimed to explore the experiences and perceptions of health among YP who have previously lived in care. A co-design approach was used to inform the research methodology by engaging YP with a lived experience in cooperative discussions. Ten YP participated in one-on-one semi-structured interviews and thematic analysis was used to analyse the data. The current findings highlight that YP consistently felt their health needs were not adequately met while in care, nor did they feel listened to, understood, or educated about health-related matters. This unique insight into the challenges they experienced in care offers realistic guidance for change.
... Methodological and statistical advances have led to improved data sources and analytic approaches. Nationally representative samples (e.g., NSCAW: Berger et al., 2009;Conn, Szilagyi, Jee, Blumkin, & Szilagyi, 2005); important large longitudinal studies using linked data from Alaska (Parrish, Fleckman, Prindle, Eastman, & Weil, 2020), Wisconsin [Berger, Cancian, Han, Noyes, & Rios-Salas, 2015)], Missouri (Jonson-Reid, Kohl, 2009), California (Putnam-Hornstein, Needell, King, andJohnson-Motoyama (2013); and North Carolina (Barth, Duncan, Hodorowicz, & Kum, 2010); greater use of econometric tools (e.g, Doyle, 2013;Gross, 2020;Parrish et al., 2020); propensity score analysis (e.g., Berger et al., 2009;Berzin, 2008); and more standardized measurement of outcomes (e.g., Bald, Chyn, Hastings, & Machelett, 2019) have generated important new findings related to child wellbeing outcomes of CPS and CWS involvement. ...
Article
Current calls to end structural racism in the US include proposals to abolish or radically transform child welfare services (CWS). While substantial research finds numerous poor outcomes following maltreatment, the efficacy and acceptability of CWS, particularly for children of color, has long sparked debate. This review summarizes the state of quantitative research across seven domains for children overall and by race with varying degrees of CWS contact. Current research with adequate comparisons provides no robust evidence to support the idea that children have worse outcomes from CWS involvement, but few studies focused on Black children. Implications for research and system change are discussed.
... Previous research has focused predominately on children in out-of-home care (OHC), suggesting they are at an increased risk of a range of mental health disorders and suicide attempt compared with their general population peers whilst in care [4][5][6][7][8]. Evidence of poor outcomes across numerous domains for care experienced children has fuelled debate around the efficacy of OHC versus in-home care (IHC) [9][10][11][12][13]. As the number of children in the child welfare system has increased in many countries, it is of key policy and practice importance to examine the nature and extent to which these mental health risks persist into adulthood and to explore variation in outcomes based on the type of child welfare service received [14][15][16][17][18][19]. ...
Article
Full-text available
Purpose This is the first comprehensive review of empirical research that investigated the association between receipt of child welfare services and adult mental health outcomes. The review summarised the results of studies about mental health outcomes of adults with a history of child welfare involvement. Methods A scoping review methodology was used to search five electronic databases (MEDLINE, EMBASE, PsychINFO, IBSS, Social Policy and Practice). Studies were included if they examined any child welfare exposure (including receipt of services while remaining at home/being placed in care) and adult mental health status. Results In total 4591 records were retrieved, of which 55 met the eligibility criteria. Overall, receipt of child welfare services was associated with an increased risk of adult mental ill-health, suicide attempt and completed suicide. Results regarding potential moderating factors, such as gender and care-related experiences, were mixed. Relatively few studies investigated the reasons for requiring child welfare services, the experience of abuse or neglect or the adult outcomes of child welfare service users who remained in their own homes. Mental ill-health was defined and measured heterogeneously and details about the nature and type of welfare service utilisation were lacking. Conclusion There is a need for detailed, longitudinal studies to better understand the relative contribution of pre-existing adversity versus experiences during and after exposure to child welfare services on adult mental health outcomes. More standardised measures of mental ill-health and greater detail from authors on specific care exposure are also needed.
... As of March 2019, 6846 young people in Wales were in the care of their local authority, the majority (71%) accommodated in foster care placements [7]. While most young people in care in the UK report their experiences to be good [8], and report satisfaction with their life [9], there is clear evidence that those who have experienced care do not fare as well as the general population in relation to their physical health, cognitive and language skills [10], and mental health [11][12][13], which in turn can impact their development and journey to adulthood [14][15][16]. Studies have begun to investigate subjective wellbeing of children and young people in foster care in the UK [9], and foster and residential care internationally [17][18][19]. ...
Article
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Purpose Studying mental wellbeing requires the use of reliable, valid, and practical assessment tools, such as the Short version of the Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). Research on the mental wellbeing of children in care is sparse. The current study aims to: (1) examine the unidimensionality of SWEMWBS; (2) assess measurement invariance of SWEMWBS across children and young people in care compared to their peers not in care; and (3) investigate the latent factor mean differences between care status groups. Methods We used data from the 2017 School Health Research Network Student Health and Wellbeing (SHW) survey, completed by 103,971 students in years 7 to 11 from 193 secondary schools in Wales. The final data include a total of 2,795 participants (46% boys), which includes all children in care and a sub-sample of children not in care who completed the SWEMWBS scale fully and answered questions about their living situation. Results Confirmatory factor analysis supported the unidimensionality of SWEMWBS. The SWEMWBS is invariant across groups of young people in foster, residential and kinship care compared to children and young people not in care at configural, metric and scalar levels. Findings from latent mean comparisons showed that young people in care reported lower mental wellbeing than their peers, with those in residential care reporting the lowest scores. Conclusions Findings suggest that SWEMWBS is a valid scale for measuring differences in mental wellbeing for young people in care similar to the population.
... A further distinction is between children who have been placed in OOHC, versus those who remain in their homes despite substantiated records of maltreatment. Some have argued that a stable OOHC placement can improve mental health outcomes, whilst in-home care can worsen a child's mental health if the child remains in the traumatic home environment [26]. Conversely, others have argued that OOHC is inherently disruptive and traumatic, creating harm to children [27]. ...
Article
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Maltreated children are vulnerable to adverse mental health outcomes. Information about how children’s mental health needs vary according to different levels of child protection contact (potentially culminating in out-of-home care [OOHC]) is valuable for the effective provision of services. This study aimed to examine associations between different levels of contact with child protection services before the age of 10 years and self-reported mental health difficulties at age 11 years. Participants (n = 26,960) were drawn from the New South Wales Child Development Study, a multiagency, multigenerational, longitudinal record linkage study that combines administrative records with cross-sectional survey data. We examined associations between four levels of child protection response (non-threshold reports, unsubstantiated reports, substantiated reports, OOHC; each relative to no report) and six domains of self-reported mental health difficulties (including internalising and externalising symptoms, and psychotic-like experiences). All levels of contact with child protection services were associated with increased odds of mental health difficulties in all domains. Children who had been placed in OOHC and children with substantiated reports had the highest odds of reporting clinical levels of mental health difficulties; 48.1% of children with an OOHC placement and 45.6% of those with substantiated child protection reports showed clinical levels of mental health difficulties in at least one domain. Children with child protection reports that were unsubstantiated, or determined not to meet the threshold for risk-of-significant harm, were also at increased risk of mental health difficulties in middle childhood. These findings underscore the importance of early detection and intervention for all children at risk of maltreatment.
... Among the characteristics present in the child, behavior problems, for example, can be seen as limiting factors for resource offer in several contexts, such as within the family environment and in the school context 27,29,30 . ...
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Chapter
The child welfare system helps children experiencing abuse, neglect, and other problems experience safe and permanent living environments. Children who enter this system often present co-occurring emotional/behavioral disorders, as well as compromised learning, often associated with the experience of trauma. There are several barriers and challenges to addressing these concerns in these students, including a lack of collaboration between schools, families, service providers, and other community organizations. Increasing school and community support is vital to promoting psychosocial adjustment and placement stability for these children, especially when they are in out-of-home placements. There is also a strong connection between being involved in the child welfare system, and entering the juvenile justice system, emphasizing the critical role of cross-system collaboration and planning in developing, improving, and expanding programs to assist these youth. School behavioral health programs can provide the context and support to implement the system-wide, trauma-informed approach that will benefit children involved in, or at risk for involvement in the child welfare system.
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Previous studies have shown that mental health disorders (MHD) among parents might be an important mechanism in the intergenerational transmission of out-of-home care (OHC). The current study aimed to further study this interplay by investigating the associations between OHC and MHD within and across generations. We used prospective data from the Stockholm Birth Cohort Multigenerational Study (SBC Multigen) on 9033 cohort members (Generation 1; G1) and their 15,305 sons and daughters (Generation 2; G2). By odds ratios of generalised structural equation modelling, we investigated the intergenerational transmission of OHC and MHD, respectively, as well as the association between OHC and MHD within each generation. Second, we examined the associations between OHC and MHD across the two generations. In order to explore possible sex differences, we performed the analyses stratified by the sex of G2. The results showed an intergenerational transmission of OHC, irrespective of sex. Regarding the intergenerational transmission of MHD, it was shown for both sexes although only statistically significant among G2 males. OHC was associated with MHD within both generations; in G2, this association was stronger among the males. While we found no direct association between OHC in G1 and MHD in G2, there was a significant association between MHD in G1 and OHC in G2. The latter was more evident among G2 females than G2 males. We conclude that OHC and MHD seem to be processes intertwined both within and across generations, with some variation according to sex. Although there did not seem to be any direct influences of OHC in one generation on MHD in the next generation, there was some indication of indirect paths going via parental MHD and child OHC.
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While there are many studies that examine the adverse effects of behavior problems among children in out-of-home care, evidence to understand the cumulative evidence of factors that may change such behavioral paths is limited. Research indicates that children in out-of-home care tend to have higher levels of internalizing and externalizing symptoms, conduct disorders, depression levels, and suicidal behavior compared to children in the general population. To effectively mitigate the risk of behavioral maladjustment, it is important to determine variables that may change behavioral paths, and lead to better outcomes. To address this evidence gap, this study presents a narrative systematic review to examine the quantitative evidence on factors associated with behavioral development of children in out-of-home care. Findings from a total of 146 studies were extracted to investigate what the longitudinal trajectories of behavior problems for children in out-of-home care look like and what variables are associated with particular developmental paths. Results indicated that various individual and ecological variables significantly influence the level of problem behavior that developed over time. Evidence gaps, implications and recommendations for researchers, policy makers and practitioners are presented.
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Foster and kinship carers face unique and complex challenges in caring for Australia’s most vulnerable children. It is therefore necessary to ensure that home-based carers are adequately upskilled and supported to promote the health of children in their care. The aim of this paper was to better understand the barriers to developing healthy lifestyle behaviours (relevant to nutrition and physical activity) among children in home-based care, from the perspective of foster and kinship carers. Focus group sessions were conducted with 21 carers: eight foster carers and 13 kinship carers. Four key themes were identified: (1) Childhood experience and children’s healthy lifestyle behaviours; (2) There are personal costs of being a carer; (3) Carers require support to develop healthy lifestyle behaviours in children; and (4) Broader systemic factors impact healthy lifestyle development. Carers in the current study described their experience of key emotional, financial, and systemic barriers to facilitating healthy lifestyle behaviours among the children in their care. To address such challenges, carers recommended the development of trauma-informed support, education, and resources to prioritise and facilitate healthy lifestyle development among children in home-based care.
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There are strong imperatives for young people living in out-of-home care (OoHC) to exercise their right to participate in health-related decision making and health care practices to foster better health outcomes. This systematic review aimed to explore if and how the voices of young people in OoHC are represented in research examining their health. Studies published in the prior 15 years that examined the health needs and/or health status of young people living in OoHC were included. A total of 39 studies met the inclusion criteria. Of these, only three studies involved directly interviewing young people about their perspectives on what health means to them. The remaining studies relied on carers’ reports or self-report questionnaires that primarily examined prevalence of specific mental illnesses or other health conditions. This review showed that the voices of young people in OoHC have been underrepresented in research examining their health and health care needs. The adoption of new research designs to better incorporate young people’s perspectives of health matters appears warranted to better explore the unique health needs of this population.
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This chapter first describes how foster care, intended as a temporary but necessary solution for children who cannot safely remain at home, is increasingly described as a problem in and of itself rather than as a solution to a difficult problem. Specifically, we identify and address the primary criticisms levied against the foster care system by scholars, media, and the public, namely that (1) foster care is overused as an intervention; (2) foster care is harmful to children; and (3) racial and class bias affect decisions about the removal of children. We describe the philosophical frameworks that inform perspectives about foster care and then examine and discuss the empirical evidence pertinent to these arguments. We conclude that, although there are numerous ways in which the quality of the current foster care system could be improved, an objective review of relevant research does not validate the most critical claims about foster care.
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Objectives: To examine associations between being the subject of child protection reports in early childhood and diagnoses of mental disorders during middle childhood, by level of service response. Design, setting, participants: Retrospective analysis of linked New South Wales administrative data, 2001-2016, for a population cohort of children (mean age in 2016, 13.2 years; SD, 0.37 years) enrolled in the longitudinal NSW Child Development Study (NSW-CDS), wave 2 linkage. Main outcome measures: Associations between being the subject of a child protection report (any, and by level of child protection response) during early childhood (birth to 6 years of age) and diagnoses of mental disorders during middle childhood (6-14 years). Results: 13 796 of 74 462 children in the NSW-CDS (18.5%) had been the subjects of reports to child protection services during early childhood: 1148 children had been placed in out-of-home care at least once, and 1680 had been the subjects of substantiated risk-of-significant-harm reports but were not placed in care, while 9161 had non-substantiated reports, and 1807 had reports of facts that did not reach the threshold for significant harm. After adjusting for sex, socio-economic disadvantage, perinatal complications, and parental mental illness, early childhood contact with protection services was associated with increased frequency of being diagnosed with a mental disorder during middle childhood (adjusted odds ratio [aOR], 2.72; 95% CI, 2.51-2.95). The frequency was highest for children who had been placed in out-of-home care (aOR, 5.25; 95% CI, 4.46-6.18). Conclusion: Childhood-onset mental disorders are more frequently diagnosed in children who come to the attention of child protection services during early childhood, particularly in children placed in out-of-home care.
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Aim: Decades of research confirm that children and adolescents in out-of-home care (foster family, residential care) have much greater healthcare needs than their peers. A systematic literature review was conducted to evaluate organizational healthcare models for this vulnerable group. Methods: A systematic literature search was undertaken of the following databases: Academic Search Elite, CENTRAL, Cochrane Database of Systematic Reviews, Cinahl, DARE, ERIC, HTA, PsycInfo, Psychology and Behavioural Sciences Collection, PubMed, SocIndex. Randomized and non-randomized controlled trials were to be included. Two pairs of reviewers independently assessed abstracts of the identified published papers. Abstracts meeting the inclusion criteria were ordered in full text. Each article was reviewed independently, by pairs of reviewers. A joint assessment was made based on the inclusion criteria and relevance. Cases of disagreement were resolved by consensus discussion. Results: No study with low or medium risk of bias was identified. Conclusion: In the absence of studies of acceptable quality, it is not possible to assess the impact of organizational models intended to ensure adequate health and dental care for children and adolescents in out-of-home care. Therefore, well-designed follow-up studies should be conducted following the implementation of such models. This article is protected by copyright. All rights reserved.
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Care‐experienced young people demonstrate significantly poor physical, social and mental health outcomes during and beyond their time in care, yet they have rarely been consulted or included in research examining their health needs to date. This qualitative paper explores care‐experienced young people's perceptions of health in care, including accessing healthcare and interacting with health professionals. The research methodology was informed by a co‐design approach through consultation with care‐experienced young people. Semi‐structured interviews were conducted with 10 young people. The findings revealed that: (1) the care system does not nurture young people's health; (2) young people in care experience difficulty accessing and navigating a complex health system; and (3) young people are not given a voice when it comes to their health. The findings provide key recommendations for practice, including the empowerment of young people through positive, responsive and trusting relationships to prioritise the health of young people in care.
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Black and Latinx youth are more likely to be placed into foster care compared to non-Latinx white youth. Foster care placement can facilitate mental health service use, yet youth from marginalized and oppressed racial and ethnic groups in foster care are still less likely to receive mental health services compared to non-Latinx white youth. This study aims to examine this discrepancy Black and Latinx youth face by testing (a) whether mental health need moderates the relationship between race or ethnicity and foster care placement and (b) whether race or ethnicity moderates the relationship between foster care placement and mental health service use. Data come from the National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal national probability study of youth in contact with the child welfare system. Internalizing need was associated with a decreased likelihood of foster care placement for non-Latinx white youth compared to those with no need; findings showed the opposite for Latinx youth. Race and ethnicity did not significantly moderate the relationship between foster care placement and mental health service use, although predicted probabilities suggest that differences in mental health service use were more pronounced for Black and Latinx youth in in-home and kinship care compared to non-kinship foster care. Results suggest that despite main effects of race and ethnicity on foster care placement and mental health service use, discrepancies across these outcomes are not explained by race and ethnicity alone. Findings highlight the need to comprehensively examine predictors together, rather than separately, when assessing foster care care placement and mental health service use. A multi-pronged approach is outlined for child welfare reform.
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Despite growing evidence of links between adverse childhood experiences (ACEs) and long-term health outcomes, there has been limited longitudinal investigation of such links in youth. The purpose of these analyses was to describe the patterns of exposure to ACEs over time and their links to youth health. The current analyses used data from LONGSCAN, a prospective study of children at risk for or exposed to child maltreatment, who were followed from age 4 to age 18. The analyses focused on 802 youth with complete data. Cumulative exposure to ACEs between 4 and 16 was used to place participants in 3 trajectory-defined groups: chronic ACEs, early ACEs only, and limited ACEs. Links to self-reported health at age 18 were examined using linear mixed models after controlling for earlier health status and demographics. The chronic ACEs group had increased self-reported health concerns and use of medical care at 18 but not poorer self-rated health status. The early ACEs only group did not significantly differ from limited ACEs on outcomes. In addition to other negative outcomes, chronic ACEs appear to affect physical health in emerging adulthood. Interventions aimed at reducing exposure to ACEs and early mitigation of their effects may have lasting and widespread health benefits. Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
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Relations between maternal depression and attachment security among 50 infant–mother and 54 preschool child–mother dyads were examined using the classification system of M. D. S. Ainsworth, M. C. Blehar, E. Waters, and S. Wall (1978) and M. Main and J. Solomon (1990) for infants and the Preschool Assessment of Attachment (P. M. Crittenden; see record 1993-01051-001) for preschoolers. Attachment insecurity was significantly associated with maternal depression among infants and preschoolers. Furthermore, children without unitary, coherent attachment strategies tended to have more chronically impaired mothers than did children with coherent, organized attachment strategies. Results stress the importance of severity-chronicity of parental illness in the study of depression and early attachment relations, and that differences between children with and without coherent organized attachment strategies are as clinically informative as are differences between secure and insecure children. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This investigation examined the impact of dimensions within maltreatment such as the severity, frequency, chronicity, and subtypes of maltreatment and their relationship with child outcome. Children between the ages of 5 and 11 who participated in a summer camp program were assessed on their social competence, behavior problems, and peers ratings of cooperation, disruption, and initiation of aggression. The 235 participants were all from low-socioeconomic status families; 145 children were from families with documented histories of child maltreatment, whereas 90 of the children had no record of maltreatment. The study found that severity of the maltreatment, the frequency of Child Protective Services reports, and the interaction between severity and frequency were significant predictors of children's functioning. Additionally, the chronicity of the maltreatment in the family significantly predicted peer ratings of aggression. Subtype differences emerged as well, with children in the sexual abuse group being more socially competent than other maltreated children, and children in the physical abuse group having more behavior problems than nonmaltreated children. Regression analyses with cooccurrence of multiple subtypes of maltreatment indicated that physical neglect, physical abuse, and sexual abuse made significant unique contributions in predicting child outcomes. The advantages of exploring multiple dimensions within maltreatment, the necessity of developing better operational definitions of these dimensions, and social policy implications of the findings are discussed.
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Child welfare service agencies provide parent training as part of their legally mandated responsibility to provide ser- vices to assist families to keep their children at home or to achieve reunification. The use of parent-training programs for families in the child welfare system has undergone relatively little examination. Mental health, special education, and juvenile justice have been identifying evidence-based approaches that have demonstrated effectiveness with chil- dren and families with conduct disorders and other behavioral problems, although few of these interventions have been tested with child welfare services clientele. This article brings together evidence about the most promising pro- grams from other child service sectors with information about the current parent training approaches in child welfare and generates a range of proposals about next steps to enhance the capacity of parent training and fulfill the high expectations set in law and practice.
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The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioral screening questionnaire that can be completed in 5 minutes by the parents or teachers of children aged 4 to 16; there is a self-report version for 11- to 16-year-olds. In this study, mothers completed the SDQ and the Child Behavior Checklist (CBCL) on 132 children aged 4 through 7 and drawn from psychiatric and dental clinics. Scores from the SDQ and CBCL were highly correlated and equally able to discriminate psychiatric from dental cases. As judged against a semistructured interview, the SDQ was significantly better than the CBCL at detecting inattention and hyperactivity, and at least as good at detecting internalizing and externalizing problems. Mothers of low-risk children were twice as likely to prefer the SDQ.
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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.
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The concordance between parent reports of children's mental health services and medical and administrative service records were assessed in a field test of the Services Assessment for Children and Adolescents (SACA) interview instrument. Service use reports from primary caregivers, usually mothers, for their child's emotional or behavioral problems were compared against inpatient, outpatient, and school records in St. Louis, one of the pilot sites for the Multi-Site Study of Service Use, Need, Outcomes and Costs in Child and Adolescent Populations (UNOCCAP). A global any use service variable, comprised of inpatient, outpatient, and school reports, yielded an overall service use concordance kappa of .76 between parent reports and records. Parent reports of inpatient hospitalization services using the SACA yielded the highest agreement with medical records, with kappa statistics of 1.00 for use of any inpatient hospital care and for medication use. Parent reports of specific inpatient services concurred with medical records more moderately, yielding kappas from .50 to .66. Reports of any outpatient mental health services yielded variable rates of agreement, with kappas ranging from .67 for any use of outpatient care, to .66 for medication use, to negligible kappas for specific treatments. Parent reports of school services were weakly related to records for most services, except for moderate agreement (.48) on placement in special classrooms for emotional or behavioral problems. Family burden or impact discriminated more powerfully than other variables between respondents who concurred with records and those who did not.
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To assess the effectiveness of social-emotional screening in the primary care setting for youths in foster care. The setting was a primary care practice for all youth in home-based foster care in 1 county. Subjects were youths, aged 11 to 17 years, and their foster parents; both completed a Strengths and Difficulties Questionnaire at well-child visits. The Strengths and Difficulties Questionnaire is a previously validated 25-item tool that has 5 domains: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems; and prosocial behaviors and an overall total difficulties score. We first compared youth versus parent Strengths and Difficulties Questionnaire scores and then assessed the accuracy of these Strengths and Difficulties Questionnaire scores by comparing them in a subsample of youths (n = 50) with results of home-based structured clinical interviews using the Children's Interview for Psychiatric Syndromes. Of 138 subjects with both youth and parent reports, 78% had prosocial behaviors (strengths), and 70% had 1 or more social-emotional problems. Parents reported significantly more conduct problems (38% vs 16%; P < .0001) and total difficulties (30% vs 16%; P = .002) than did youth. The Strengths and Difficulties Questionnaire had better agreement with the Children's Interview for Psychiatric Syndromes (n = 50) for any Strengths and Difficulties Questionnaire-identified problem for combined youth and foster-parent reports (93%), compared with youth report alone (54%) or parent report alone (71%). Although most youths in foster care have social-emotional problems, most have strengths as well. Youth and foster-parent perspectives on these problems differ. Systematic social-emotional screening in primary care that includes both youth and parent reports can identify youths who may benefit from services.
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A mental health team for looked after children, and the evaluation of its first phase are presented. The team combines primary mental health worker, psychology and psychiatry skills. It offers telephone and face-to-face consultation to local authority staff, assessment, treatment and training. Forty-five children and their carers, who consecutively attended the service, were independently assessed by a researcher at the time of referral and at five-month follow-up. Outcome measures included the Strengths and Difficulties Questionnaire (SDQ), the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) and a service satisfaction questionnaire. At 5 months, children had significantly improved on a number of HoNOSCA scales, and on the emotional SDQ scales. Carers perceived the interventions as targeting different aspects of the child’s functioning, but wished they were more involved in decision-making. Carers and children were generally positive about their clinical contact. The findings are discussed in the context of developing mental health services for vulnerable children and young people, and interagency partnership.
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Using three waves of data from the National Survey of Child and Adolescent Well-Being, this study examines differences in cognitive, academic, and affective well-being of youth first placed in nonkinship foster care (N = 259) and youth first placed in group care (N = 89). To compare nonrandomized groups, propensity score matching was used. Results from hierarchical linear modeling suggest that both groups of youth show improved behavior and below-average academics over time.
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To examine differences in waking to bedtime cortisol production between children who remained with birth parents vs children placed in foster care following involvement of Child Protective Services (CPS). Between-subject comparison of cortisol patterns among 2 groups of children. Children referred from the child welfare system. Three hundred thirty-nine children aged 2.9 to 31.4 months who were living with birth parents (n = 155) or placed in foster care (n = 184) following CPS involvement as well as 96 unmatched children from low-risk environments. Main Exposures Involvement by CPS and foster care. Main Outcome Measure Salivary cortisol samples obtained at waking and bedtime for children on 2 days. Child Protective Services-involved children who continued to live with birth parents and CPS-involved children placed in foster care differed in cortisol production, with children living with their birth parents showing flatter slopes in waking to bedtime values. Continuing to live with birth parents following involvement of CPS is associated with greater perturbation to the diurnal pattern of cortisol production than living with foster parents. Foster care may have a regulating influence on children's cortisol among children who have experienced maltreatment.
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Our goal was to determine if systematic use of a validated developmental screening instrument is feasible and improves the detection of developmental delay (DD) in a pediatric medical home for children in foster care. This study had a pre-post study design, following a practice intervention to screen all children in foster care for DD by using the Ages and Stages Questionnaire (ASQ). The baseline detection rate was determined by medical chart review for all children aged 4 to 61 months who were new to foster care (NFC) during a 2-year period. After implementation of systematic screening, caregivers of young children who were NFC or already in foster care (IFC) completed the ASQ at preventive health care visits. We assessed the feasibility of systematic screening (the percentage of ASQs completed among the NFC and IFC groups). We compared the detection of DD among the baseline NFC group and the screening-NFC group by using bivariate and multivariable logistic regression. Of 261 visits that occurred after initiation of screening, 251 (96%) visits had a completed ASQ form in the medical chart, demonstrating high feasibility. Among children who were NFC, the detection of DD was higher in the screening than baseline period for the entire population (58% vs 29%; P < .001), for each age group (infants: 37% vs 14%; toddlers: 89% vs 42%; preschool: 82% vs 44%; all P < or = .01), and for all developmental domains. On adjusted analyses, the detection of potential DD in toddler and preschool children was higher among the NFC screening group than the NFC baseline group. Systematic screening for DD using the ASQ was feasible and seemed to double the detection of DDs.
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Strategies that children use for coping with stressors are known to be related to emotional adjustment, but not enough is understood about specific links with social anxiety and depression. The present investigation tested differentiated associations of social anxiety and depression with specific types of coping strategies, and evaluated the direction of these associations over time. In Study 1, 404 children aged 8-13 years completed a coping scale modified from Kochendefer-Ladd and Skinner (Developmental Psychology 38:267-278, 2002) in order to evaluate factor structure and subscale internal consistency. In Study 2, 270 8-11-year-old children completed depression and social anxiety scales, a sociometric survey, and the coping scale from Study 1, with a follow-up timepoint 9 months later. In Study 1, factor analysis revealed six internally consistent coping subscales. In Study 2, social anxiety and depression were found to have distinctive longitudinal associations with subsequent coping strategies. Decreased problem-solving, social support-seeking, and distraction were uniquely predicted by depression but not by social anxiety. Internalising coping was a stronger outcome of social anxiety, and increased externalising was uniquely predicted by depression. There was also some evidence for a moderating role of peer relations. However, none of the coping strategies predicted changes in depression or social anxiety over the two timepoints. These results highlight the impact that emotional adjustment may have on children's coping strategies, and clarify important distinctions between social anxiety and depression in relation to coping.
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This study examined the factor structure of the parent and teacher versions of the Strengths and Difficulties Questionnaire (SDQ; R. Goodman, 1997) with a sample of first-grade children at risk for educational failure. The 5-factor model previously found in studies using exploratory factor analysis was fit to the data for both parent and teacher questionnaires. Fit indices for both versions were marginally adequate. Model fit was comparable across gender and ethnic groups. Factor fit for the parent questionnaire was invariant across parent educational level. The examination of convergent and discriminant validity included peer evaluations of each SDQ construct. Thus, each of the five constructs was evaluated by three sources (parent, teacher, and child). On the basis of D. T. Campbell and D. W. Fiske's (1959) multitrait-multimethod approach as well as a confirmatory factor analysis using the correlated uniqueness model, the SDQ has good convergent validity but relatively poor discriminant validity.
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This article presents a pilot project implementing a mindfulness-based stress reduction program among traumatized youth in foster and kinship care over 10 weeks. Forty-two youth participated in this randomized controlled trial that used a mixed-methods (quantitative, qualitative, and physiologic) evaluation. Youth self-report measuring mental health problems, mindfulness, and stress were lower than anticipated, and the relatively short time-frame to teach these skills to traumatized youth may not have been sufficient to capture significant changes in stress as measured by electrocardiograms. Main themes from qualitative data included expressed competence in managing ongoing stress, enhanced self-awareness, and new strategies to manage stress. We share our experiences and recommendations for future research and practice, including focusing efforts on younger youth, and using community-based participatory research principles to promote engagement and co-learning. CLINICALTRIALS.GOV: Protocol Registration System ID NCT01708291. Copyright © 2015 Elsevier Ltd. All rights reserved.
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Despite growing attention to antecedents and consequences of trauma symptoms in children, there are gaps in knowledge. Although nearly half of all children enter the child welfare system between ages 0-5, few studies have focused on the mental health of very young children. The current study examined trauma symptomology in preschool-aged children involved in the child welfare system across an entire state (n = 100). Child, maternal, and maltreatment characteristics and their relationship to child trauma symptoms were explored. Results showed that more than a quarter of children exhibited trauma symptomology. Trauma symptoms were more likely to be present when children were biracial, referred for neglect, and in homes with intimate partner violence. When mothers had their own childhood history of child welfare involvement, children were less likely to have trauma symptoms. Implications for practice with these families are discussed.
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To document the persistence and predictors of mental health problems in children aged 12 to 18 months investigated for alleged maltreatment. Data came from the second National Survey of Child and Adolescent Well-being (NSCAW II), a longitudinal study of youth 0 to 17.5 years referred to US child welfare agencies. These analyses involved children 12 to 18 months. Baseline sociodemographic, social services, developmental data, and health data were collected on children and caregivers. Potential social-emotional problems at baseline were assessed with the Brief Infant-Toddler Social and Emotional (BITSEA) scales. Outcomes were scores over the clinical cutoff on the Child Behavior Checklist (CBCL) 1.5-5 assessed at 18 months after study entry. The multivariable analyses showed that an elevated BITSEA score at baseline (odds ratio 9.18, 95% confidence interval 1.49, 56.64; P = .018) and living with a depressed caregiver (odds ratio 13.54, 95% confidence interval 2.50, 73.46; P = .003) were associated with CBCL scores in the clinical range at the 18-month follow-up. For children who scored both positive on the BITSEA and lived with a depressed caregiver, 62.5% scored positive on the CBCL compared to 10.7% of the children with one risk factor and 3.8% of the children with neither risk factor. Only 23.9% of children and/or their caregivers received any service. Data show considerable persistence of mental health problems in very young children that 2 factors could identify. Lack of services to these children is a tremendous missed opportunity for identification and treatment that could potentially prevent more serious mental health problems.
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Thirteen-month-old maltreated infants (n = 137) and their mothers were randomly assigned to one of three conditions: child-parent psychotherapy (CPP), psychoeducational parenting intervention (PPI), or community standard (CS). A fourth group of nonmaltreated infants (n = 52) and their mothers served as a nonmaltreated comparison (NC) group. A prior investigation found that the CPP and the PPI groups demonstrated substantial increases in secure attachment at postintervention, whereas this change was not found in the CS and the NC groups. The current investigation involved the analysis of data obtained at a follow-up assessment that occurred 12 months after the completion of treatment. At follow-up, children in the CPP group had higher rates of secure and lower rates of disorganized attachment than did children in the PPI or the CS group. Rates of disorganized attachment did not differ between the CPP and the NC groups. Intention to treat analyses also showed higher rates of secure attachment at follow-up in the CPP group relative to the PPI and the CS groups. However, groups did not differ on disorganized attachment. Both primary and intention to treat analyses demonstrated that maternal-reported child behavior problems did not differ among the four groups at the follow-up assessment. This is the first investigation to demonstrate sustained attachment security in maltreated children 12 months after the completion of an attachment theory informed intervention. The findings also suggest that, although effective in the short term, parenting interventions alone may not be effective in maintaining secure attachment in children over time.
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We explored and compared rates of youth diagnosed with oppositional defiant disorder (ODD) at entry into three broad program types, home-based care, foster care, and residential care. We also explored factors other than an ODD diagnosis that could be associated with program placement, and compared the presence of these factors in youth with and without an ODD diagnosis. Analyses were conducted using data from an ongoing, private-agency led, outcome measurement project. Programs were grouped into low (home-based), moderate (foster), or high (residential) categories, based upon levels of supervision and structure provided. A sample of 9,564 youth admitted into care between years 2005 and 2007 was used. Results suggested the following rates of ODD: 14.2 % overall; 7.9 % for low level programs; 5.3 % for moderate level programs; 21.1 % for high level programs. Rates were significantly different by program level (p ≤ 0.001). Sixty of 65 additional risk factors were also significantly associated with placement by level of program. No risk factors were unique to youth with ODD. Of the significant factors for youth with ODD, 4 were particularly strong: Classification as a child in need of services (CHINS), history of neglect, verbal aggression, and truancy. Youth classified as CHINS and with substantiated or suspected neglect were more likely placed into a moderate level program. Youth with verbal aggression or truancy were more likely placed into a high level program. Results suggested many factors are considered at program entry. Given the potential for poor prognosis and social costs of ODD, results support an individualized approach to placement determinations, with increased attention to symptoms of ODD and associated features at program entry.
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Young children involved in the child welfare system are susceptible to behavioral and physiological dysregulation. These children need nurturing care to develop organized attachments to caregivers; they need synchronous care to support their physiological and behavioral regulation; and they need stable caregivers who can commit to them, supporting their sense of self and behavioral regulation. Without intervention at the level of the parent and the system, most children involved with the child welfare system are unlikely to have these needs met. We present two models of intervention designed to enhance parents' synchrony and nurturance, and highlight aspects of the system that can enhance the stability and commitment of caregivers.
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Background: Over the past decades, increased knowledge about childhood abuse and trauma have prompted changes in child welfare policy, and practice that may have affected the out-of-home (OOH) care population. However, little is known about recent national trends in child maltreatment, OOH placement, or characteristics of children in OOH care. The objective of this study was to examine trends in child maltreatment and characteristics of children in OOH care. Methods: We analyzed 2 federal administrative databases to identify and characterize US children who were maltreated (National Child Abuse and Neglect Data System) or in OOH care (Adoption and Foster Care Analysis and Reporting System). We assessed trends between 2000 and 2010. Results: The number of suspected maltreatment cases increased 17% from 2000 to 2010, yet the number of substantiated cases decreased 7% and the number of children in OOH care decreased 25%. Despite the decrease in OOH placements, we found a 19% increase in the number of children who entered OOH care because of maltreatment (vs other causes), a 36% increase in the number of children with multiple (vs single) types of maltreatment, and a 60% increase in the number of children in OOH care identified as emotionally disturbed. Conclusions: From 2000 to 2010, fewer suspected cases of maltreatment were substantiated, despite increased investigations, and fewer maltreated children were placed in OOH care. These changes may have led to a smaller but more complex OOH care population with substantial previous trauma and emotional problems.
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Research has shown that adverse childhood experiences (ACEs) increase the risk of poor health-related outcomes in later life. Less is known about the consequences of ACEs in early adulthood or among diverse samples. Therefore, we investigated the impacts of differential exposure to ACEs on an urban, minority sample of young adults. Health, mental health, and substance use outcomes were examined alone and in aggregate. Potential moderating effects of sex were also explored. Data were derived from the Chicago Longitudinal Study, a panel investigation of individuals who were born in 1979 or 1980. Main-effect analyses were conducted with multivariate logistic and OLS regression. Sex differences were explored with stratified analysis, followed by tests of interaction effects with the full sample. Results confirmed that there was a robust association between ACEs and poor outcomes in early adulthood. Greater levels of adversity were associated with poorer self-rated health and life satisfaction, as well as more frequent depressive symptoms, anxiety, tobacco use, alcohol use, and marijuana use. Cumulative adversity also was associated with cumulative effects across domains. For instance, compared to individuals without an ACE, individuals exposed to multiple ACEs were more likely to have three or more poor outcomes (OR range=2.75-10.15) and four or more poor outcomes (OR range=3.93-15.18). No significant differences between males and females were detected. Given that the consequences of ACEs in early adulthood may lead to later morbidity and mortality, increased investment in programs and policies that prevent ACEs and ameliorate their impacts is warranted.
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In the light of continuing debate over the applications of significance testing in psychology journals and following the publication of J. Cohen's (1994) article, the Board of Scientific Affairs (BSA) of the American Psychological Association (APA) convened a committee called the Task Force on Statistical Interference (TFSI) whose charge was "to elucidate some of the controversial issues surrounding applications of statistics including significance testing and its alternatives; alternative underlying models and data transformation; and newer methods made possible by powerful computers" (BSA, personal communication, February 28, 1996). After extensive discussion, the BSA recommended that publishing an article in American Psychologist, as a way to initiate discussion in the field about changes in current practices of data analysis and reporting may be appropriate. This report follows that request. Following each guideline are comments, explanations, or elaborations assembled by L. Wilkinson for the task force and under its review. The report is concerned with the use of statistical methods only and is not meant as an assessment of research methods in general. The title and format of the report are adapted from an article by J. C. Bailar and F. Mosteller (1988). (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Objective: To evaluate whether automated e-mails promoting effective self-help strategies for depressive symptoms were effective in changing self-help behavior, and whether this improved depression outcomes. Method: 568 adults with sub-threshold depression participated in a randomized controlled trial and provided complete data. A series of 12 e-mails promoting the use of evidence-based self-help strategies was compared with e-mails providing non-directive depression information. Depression symptoms were assessed with the Patient Health Questionnaire depression scale (PHQ-9) and use of self-help strategies was assessed at baseline and post-intervention. We hypothesized that those receiving the self-help e-mails would increase their use of evidence-based self-help and this would be associated with improvements in depression. Mediation analyses were conducted using a non-parametric bootstrapping procedure. Results: Total use of the self-help strategies promoted in the e-mails significantly mediated the effect of the intervention on depressive symptoms (B = -0.75, SE = 0.16, 95% CI: -1.06 to -0.48). The direct effect of the intervention on depressive symptoms was much smaller and not significant when the mediation path was included. The majority of the individual strategies also had a significant indirect effect on depressive symptoms. Conclusions: In adults with sub-threshold depression, automated e-mails based on behavior change principles can successfully increase use of self-help strategies, leading to a reduction in depressive symptoms.
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We investigated the relationships between child, familial, and case characteristics and mental health and medical health care service utilization by physically abused children. Participants included 26 parents or caregivers of 37 Medicaid-eligible children who had substantiated cases of physical abuse. Children whose female caregivers reported a greater number of stressors were more likely to receive mental health care. Furthermore, children not living with the maltreating caregiver were more likely to receive medical health care services. Results are discussed in terms of factors that may account for these links, and the similarities of these findings with those of service utilization in general and clinical child samples.
Article
Parents' ability to make reliable and valid reports about health service utilization is a key research design consideration for studies about the unmet needs of children and adolescents with emotional or behavioral problems. This research report addresses the validity of parents' reports, in particular, parents' rates of false-negative reporting about their children's mental health service use. Our findings show that only a few parents of known service users fail to report that their child or adolescent has received services for an emotional or behavioral problem. However, when parents are asked to report about their child's service use with specific providers or in specific service settings, the rate of false-negative reporting tends to increase, and in some circumstances this increase is dramatic. Logistic regression results indicate that false-negative reporting is more likely to occur among parents whose children are male, less frequent service users, or service users whose use is less recent. After controlling for these factors, we did not find a significant difference in the rate of false-negative reporting for parents of Anglo and Latino children. Implications for research designs and survey instruments are discussed.
Article
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. 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. 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. 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.
Article
Although foster youth are at increased risk of mental illness, little is known about need for and actual use of mental health services by adolescents in the child welfare system. Analyzing a random sample of 113 foster youth in a large Midwest state, the author found that foster youth experienced severe mental health problems such as depression, anxiety and loss of behavioral/emotional control. In this study, need for services, as measured by the presence of a mental health problem, was only partially related to mental health services received. Logistic regression analyses indicated that four factors including anxiety, child abuse history, poor psychological well-being, and time in care were significantly related to mental health service use.
Article
Abusive and neglectful parenting is an established determinant of adult mental illness, but longitudinal studies of the impact of less severe problems with parenting have yielded inconsistent findings. In the face of growing interest in mental health promotion, it is important to establish the impact of this potentially remediable risk factor. Participants: 8,405 participants in the 1958 UK birth cohort study, and 5,058 in the 1970 birth cohort study Exposures: questionnaires relating to the quality of relationships with parents completed at age 16 years. Outcomes: 12-item General Health Questionnaire and the Malaise Inventory collected at age 42 years (1958 cohort) and 30 years (1970 cohort). Statistical methodology: logistic regression analyses adjusting for sex, social class and teenage mental health problems. 1958 cohort: relationships with both mother and father predicted mental health problems in adulthood; increasingly poor relationships were associated with increasing mental health problems at age 42 years. 1970 cohort: positive items derived from the Parental Bonding Instrument predicted reduced risk of mental health problems; negative aspects predicted increased risk at age 30 years. Odds of mental health problems were increased between 20 and 80% in fully adjusted models. Results support the hypothesis that problems with parent-child relationships that fall short of abuse and neglect play a part in determining adult mental health and suggest that interventions to support parenting now being implemented in many parts of the Western world may reduce the prevalence of mental illness in adulthood.
Article
Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental psychology, epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. This converging, multidisciplinary science of human development has profound implications for our ability to enhance the life prospects of children and to strengthen the social and economic fabric of society. Drawing on these multiple streams of investigation, this report presents an ecobiodevelopmental framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress, offering intriguing insights into causal mechanisms that link early adversity to later impairments in learning, behavior, and both physical and mental well-being. The implications of this framework for the practice of medicine, in general, and pediatrics, specifically, are potentially transformational. They suggest that many adult diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood. An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. It calls for pediatricians to serve as both front-line guardians of healthy child development and strategically positioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and lifelong health.
Article
The purpose of this study is to examine the association of child mental health conditions and parent mental health status. This study used data from the 2007 National Survey of Children's Health on 80,982 children ages 2-17. The presence of a child mental health condition was defined as a parent-reported diagnosis of at least one of seven child mental health conditions. Parent mental health was assessed via a 5-point scale. Logistic regression was used to assess the association of child mental health conditions and parent mental health status, while examining socioeconomic, parent, family, and community factors as potential effect modifiers and confounders of the association. 11.1% of children had a mental health condition (95% CI = 10.5-11.6). The prevalence of child mental health conditions increased as parent mental health status worsened. Race/ethnicity was the only significant effect modifier of the child-parent mental health association. After adjustment for confounders, the stratum-specific adjusted odds ratios (95% CI) of child mental health conditions related to a one-level decline in parent mental health were: 1.44 (1.35-1.55) for non-Hispanic whites, 1.24 (1.06-1.46) for non-Hispanic blacks, 1.04 (0.81-1.32) for Hispanics from non-immigrant families, 1.21 (0.96-1.93) for Hispanics from immigrant families, and 1.43 (1.21-1.70) for non-Hispanic other race children. The effect of parent mental health status on child mental health conditions was significant only among non-Hispanic children. Parent-focused interventions to prevent or improve child mental health conditions may be best targeted to the sub-populations for whom parent and child mental health are most strongly associated.
Article
To determine whether systematic use of a validated social-emotional screening instrument in a primary care setting is feasible and improves detection of social-emotional problems among youth in foster care. Before-and-after study design, following a practice intervention to screen all youth in foster care for psychosocial problems using the Strengths and Difficulties Questionnaire (SDQ), a validated instrument with 5 subdomains. After implementation of systematic screening, youth aged 11 to 17 years and their foster parents completed the SDQ at routine health maintenance visits. We assessed feasibility of screening by measuring the completion rates of SDQ by youth and foster parents. We compared the detection of psychosocial problems during a 2-year period before systematic screening to the detection after implementation of systematic screening with the SDQ. We used chart reviews to assess detection at baseline and after implementing systematic screening. Altogether, 92% of 212 youth with routine visits that occurred after initiation of screening had a completed SDQ in the medical record, demonstrating high feasibility of systematic screening. Detection of a potential mental health problem was higher in the screening period than baseline period for the entire population (54% vs 27%, P < .001). More than one-fourth of youth had 2 or more significant social-emotional problem domains on the SDQ. Systematic screening for potential social-emotional problems among youth in foster care was feasible within a primary care setting and doubled the detection rate of potential psychosocial problems.
Article
Science has an important role to play in advising policymakers on crafting effective responses to social problems that affect the development of children. This article describes lessons learned from a multiyear, working collaboration among neuroscientists, developmental psychologists, pediatricians, economists, and communications researchers who are engaged in the iterative construction of a core story of development, using simplifying models (i.e., metaphors) such as "brain architecture,"toxic stress," and "serve and return" to explain complex scientific concepts to nonscientists. The aim of this article is to stimulate more systematic, empirical approaches to the task of knowledge transfer and to underscore the need to view the translation of science into policy and practice as an important academic endeavor in its own right.
This paper describes caregiver-reported patterns of mental health service use for 347 pre-adolescent children in foster and kinship care in New South Wales (NSW), Australia. Children's mean time in care and mean time with their present caregivers were 4.3 and 3.3 years respectively. Forty-four percent of children received individual therapy or counselling, 45% received interventions in the form of clinical guidance for their caregivers, and 31% received both forms of service. Among children scoring in the clinical range on any CBCL sub-scale (N = 191), equivalent rates of mental health service use were 60%, 55% and 41% respectively. Although not directly comparable, these findings describe a higher rate of service use than that reported for children in care elsewhere. While children with more complex and severe difficulties had higher rates of service use, there was no evidence of variable access for treatment of different types of disorder. Predictors of service use are reported and contrasted with previous findings. The paper considers several features of the NSW child welfare, health and education systems that may account for the relatively high rate of service use.
Article
Despite known high rates of mental health problems among children in foster care, these problems are often not identified promptly by primary care or other systems. A novel delivery system is a centralized primary care practice for foster care. The purpose of this study was to examine the identification of mental health within two pediatric medical homes for foster care. We conducted a retrospective medical chart review of all children, aged 6-18Â years, newly entering foster care, in two foster care clinics serving two county-wide populations. Our sample of 242 children describes demographics, rates for mental health problem identification, and length of time after entering foster care that mental health needs were identified. We used logistic regression analyses to examine variables associated with identification of mental health needs. Both centralized foster care medical homes had high rates for identification of mental health problems (>Â 70% in both sites), timely identification (the majority identified within two months after entry into care), and high mental health referral rates for children entering foster care (>Â 70%). Our findings suggest that attention to mental health needs for children in foster care within their primary care setting can impact identification rates and management of mental health.
Article
Background: Little is known about how best to implement behavioral screening recommendations in practice, especially for children in foster care, who are at risk for having social-emotional problems. Two validated screening tools are recommended for use with young children: the Ages and Stages Questionnaire: Social Emotional (ASQ-SE) identifies emotional problems, and the Ages and Stages Questionnaire (ASQ) identifies general developmental delays in five domains, including personal-social problems. The current study examined: (1) whether systematic use of a social-emotional screening tool improves the detection rate of social-emotional problems, compared to reliance on clinical judgment; (2) the relative effectiveness of two validated instruments to screen for social-emotional problems; and (3) the patterns of social-emotional problems among children in foster care. Methods: We used retrospective chart review of children in foster care ages 6 months to 5.5 years: 192 children before and 159 after screening implementation, to measure detection rates for social-emotional problems among children. The ASQ-SE and the ASQ were used in multivariable logistic regression analyses to examine associations between children with social-emotional problems. Results: Use of the screening tool identified 24% of the children as having a social-emotional problem, while provider surveillance detected 4%. We identified significantly more children with social-emotional problems using the ASQ-SE than using the ASQ, and agreement between the instruments ranged from 56% to 75%, when data were stratified by age group. Multivariable modeling showed that preschool children were more likely to have a social-emotional problem than toddlers and infants (aOR = 3.4, 95% CI = 1.1-10.8). Conclusions: Systematic screening using the ASQ-SE increased the detection rate for social-emotional problems among young children in foster care, compared to provider surveillance and the ASQ. A specific social-emotional screening tool appears to detect children with psychosocial concerns who would not be detected with a broader developmental screening tool.
Article
There is ongoing debate regarding the impact of youth behavior problems on placement change in child welfare compared to the impact of placement change on behavior problems. Existing studies provide support for both perspectives. The purpose of this study was to prospectively examine the relations of behavior problems and placement change in a nationally representative sample of youths in the National Survey of Child and Adolescent Well-Being. The sample consisted of 500 youths in the child welfare system with out-of-home placements over the course of the National Survey of Child and Adolescent Well-Being study. We used a prospective cross-lag design and path analysis to examine reciprocal effects of behavior problems and placement change, testing an overall model and models examining effects of age and gender. In the overall model, out of a total of eight path coefficients, behavior problems significantly predicted placement changes for three paths and placement change predicted behavior problems for one path. Internalizing and externalizing behavior problems at baseline predicted placement change between baseline and 18 months. Behavior problems at an older age and externalizing behavior at 18 months appear to confer an increased risk of placement change. Of note, among female subjects, placement changes later in the study predicted subsequent internalizing and externalizing behavior problems. In keeping with recommendations from a number of professional bodies, we suggest that initial and ongoing screening for internalizing and externalizing behavior problems be instituted as part of standard practice for youths entering or transitioning in the child welfare system.
Article
This study used data on 2,453 children aged 4-17 from the National Survey of Child and Adolescent Well-Being and 5 analytic methods that adjust for selection factors to estimate the impact of out-of-home placement on children's cognitive skills and behavior problems. Methods included ordinary least squares (OLS) regressions and residualized change, simple change, difference-in-difference, and fixed effects models. Models were estimated using the full sample and a matched sample generated by propensity scoring. Although results from the unmatched OLS and residualized change models suggested that out-of-home placement is associated with increased child behavior problems, estimates from models that more rigorously adjust for selection bias indicated that placement has little effect on children's cognitive skills or behavior problems.
Article
The present project examined the relationships among early maternal maltreatment risk, children's self-regulation, and later development. It was expected that early maltreatment risk would impact children's emerging self-regulation which in turn, would foster pre-academic delays and behavioral problems. The project used structural equation modeling to examine the relationship between early maltreatment risk in 169 primiparous adolescent mothers and the subsequent development of their children in pre-academic and behavioral domains at 5 years of age. Maltreatment risk was assessed by two evaluation tools: (1) a multi-measure index of parenting attitudes, abuse potential, and knowledge and expectations about child development, and (2) an abbreviated version of the multi-measure index consisting of only 12 items. In addition, cognitive and emotional regulation at age 3, as assessed by maternal reports of regulatory behaviors and a newly created observational measure, was evaluated as a potential mediator of development at 5. Findings revealed that maternal maltreatment risk was associated with lower levels of children's regulation, which in turn significantly predicted pre-academic skills and behavior problems. Incorporating direct paths from maltreatment risk to each of the children's outcomes did not significantly improve model fit indices. Results suggest that self-regulation was a key process variable in the relationship between maltreatment risk and children's development. The findings support targeting self-regulatory abilities to halt the progression of developmental difficulties often found in maltreated children. The present study identified self-regulation as a mechanism for transmitting the effects of maltreatment risk to multiple domains of children's functioning; these findings have important implications for intervention programs. Intervention programs that focus on fostering self-regulation in home and preschool settings should enhance developmental outcomes. Previous research has shown the utility of targeting self-regulation in reducing the frequency and intensity of students' anger (Beck, R., & Fernandez, E. (1998). Cognitive-behavioral self-regulation of the frequency, duration, and intensity of anger. Journal of Psychopathology and Behavioral Assessment, 20, 217-229.). Within the context of maltreatment intervention, these programs have considerable utility. By tailoring programs to strengthen dysfunctional regulation processes common to maltreated children, cognitive and behavioral functioning should be enhanced.
Article
Hypotheses involving mediation are common in the behavioral sciences. Mediation exists when a predictor affects a dependent variable indirectly through at least one intervening variable, or mediator. Methods to assess mediation involving multiple simultaneous mediators have received little attention in the methodological literature despite a clear need. We provide an overview of simple and multiple mediation and explore three approaches that can be used to investigate indirect processes, as well as methods for contrasting two or more mediators within a single model. We present an illustrative example, assessing and contrasting potential mediators of the relationship between the helpfulness of socialization agents and job satisfaction. We also provide SAS and SPSS macros, as well as Mplus and LISREL syntax, to facilitate the use of these methods in applications.
Article
One hundred significantly overweight patients sequentially applying to a very low calorie diet (VLCD) program were interviewed to learn how the onset of obesity correlated with other life events. By comparison with a control group of 100 always-slender adults, the obese applicants were found to be different at a highly significant level in the prevalence of childhood sexual abuse, nonsexual childhood abuse, early parental loss, parental alcoholism, chronic depression, and marital family dysfunction in their own adult lives. The obese patients commonly reported using obesity as a sexually protective device; many reported overeating to cope with emotional distress. Inquiry into depression, past sexual abuse, and past or present dysfunctional family life should be added to the current medical evaluation of all obese patients. The resultant findings are likely to be relevant to their treatment, whether for obesity or for other medical conditions.
Article
This study examined predictors of utilization of mental health services among children and adolescents in foster care. Of particular interest was whether the type of maltreatment was related to utilization of services. Subjects were 662 children ages 2-17 who were in foster care for at least 5 months. Service utilization, demographic, and behavioral data were collected through interviews with the subjects' caretakers. Type of maltreatment data were collected from Child Welfare case records. Fifty-six percent of the subjects had received mental health services. Children removed from their homes due to sexual and/or physical abuse were more likely to receive services than were those who were removed due to neglect and caretaker absence. Clinically significant behavior problems were associated with greater likelihood of receiving services, except for the sexually abused group who were very likely to receive services regardless of their behavior problem score. Sexually abused youth also received a higher number of outpatient visits than did neglected youth. In sum, youth who have experienced "active" types of maltreatment are more likely to receive mental health services than are those with "passive" types of maltreatment, even when the effect of severity of mental health problems is controlled.