Childhood poverty and foster care placement: Implications for practice and policy.

BACKGROUND: About 6 % of US children enter foster care (FC) at some point before age 18. Children living in poverty enter more frequently than non-poor children. Still, it is less clear if specific dimensions of poverty place a child at risk of FC entry. OBJECTIVE: This study aids our understanding of the relationships between poverty and FC entry. PARTICIPANTS AND SETTING: Data were drawn from a large linked administrative data study following low-income and/or children with maltreatment reports at baseline and followed them through 2010 (n = 9382). METHODS: Separate analyses compared low-income children and children reported for maltreatment. Cox regression analyses were used to account for clustering at the tract level. Poverty was measured at birth, receipt of income maintenance (IM) during the study period, and census tract poverty at baseline. RESULTS: The results showed that within a low-income sample, both family poverty and community poverty measures were significant factors in predicting later FC entry. However, when analyses were run comparing children with maltreatment reports with and without baseline AFDC use, the various measures of poverty diminished in impact once the type of maltreatment and report dispositions were controlled. Furthermore, we found that children living in families with more spells on income maintenance were less likely to enter FC. CONCLUSIONS: Results indicate that specific dimensions of poverty during childhood are associated with later FC entry. The lowered risk associated with a number of spells suggests connections between time limits for income assistance and the risk of entering FC.

Life-course trajectories of children through the U. S foster care system.

OBJECTIVE: Foster care is surprisingly commonplace in the United States, with more than one in twenty children experiencing placement in their lifetimes. Due to the complexity of foster care (e.g. age at contact, length of stay), we still lack a clear idea of how children move through the child welfare system. We pose the question, "do distinct typologies of system trajectories exist that may be used to inform policy analyses?" METHODS: We used child maltreatment reports and foster care case records for all U.S. children born in FY2006 and placed in care between birth and age 15. Using sequence analysis, we classified child-level system trajectories into distinct clusters. Then, we employed multilevel multinomial regression to explore child and system characteristics associated with each. RESULTS: Three typologies were identified: 1) early-entry-exit, 2) school-age-entry, and 3) late-entry. Early-entry-exit cases typically entered and left foster care before turning three, were frequently adopted, and had little ongoing system contact. School-age-entry children typically entered between ages 5-10, were in care for the shortest amount of time, and mostly exited to reunification. Late-entry children typically entered between ages 9-11, entered with substantial CPS history and remained in care into mid-adolescence. CONCLUSIONS: Our findings provide the first description of foster care trajectories in the US. Both practice and policy formulation can benefit from these empirically supported descriptions. Using such trajectory typologies, researchers can now explore how trajectories may predict wellbeing outcomes. We discuss how the differences among the typologies may inform identification of service needs and outcomes.

Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children.

OBJECTIVE: This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years. METHODS: This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex. RESULTS: Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion. CONCLUSIONS: This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.

Life is a highway: Driver's license acquisition and social determinants for youth in foster care and their non-foster care peers.

BACKGROUND: Data regarding the connection between driver licensure and social determinants for youth could provide insight into the impact of driver license acquisition. These relationships are important for youth overall and particularly for foster youth given that adolescents in foster care obtain driver's licenses less often than their non-foster care peers. This integrative review explores the association between driver licensure and social determinants. METHODS: Whittemore and Knafl guidelines were used to conduct the integrative review. The articles were identified in collaboration with an expert in library science and public health. Results were organized by the Healthy People 2030 (HP 2030) Social Determinants of Health (SDOH) model. RESULTS: Six studies were included. Social and community context included social support structures helping youth get driver's licenses. Economics, including income and education, influenced license acquisition. Driver license acquisition was associated with improved well-being, security, and mental health. CONCLUSION: While fewer of those living in urban, walkable neighborhoods with access to public transportation were licensed, results from other studies suggest that car access is associated with psychological well-being. Further, licensure is disproportionately lower for populations historically marginalized from equal housing, education, and employment opportunities. Licensure plays a role in well-being.

Research Participation of Minor Adolescents in Foster Care.

STUDY OBJECTIVE: In this study we evaluated published studies about foster care to: (1) determine the types of data used; (2) describe the degree to which a sexual/reproductive health topic was addressed; and (3) describe the consent process. DESIGN: Analysis of published literature. SETTING: PubMed was searched using "foster care" for English articles published between January 1, 2017 and September 4, 2019. PARTICIPANTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Articles were coded into 4 data source categories: primary, secondary, peripheral, or perspective data. Articles with a primary data source were coded for participant ages: only 9 years old and younger, 10- to 17-year-olds (minor adolescents), and only 18 years old and older. Articles using a secondary data source were coded for the source of the data registry. All articles were coded for presence of a sexual/reproductive health outcome. The primary data articles that included minor adolescents were coded for the study topic and consent process. RESULTS: Of the 176 articles about foster care, 72/176 (41%) used primary data, 53/176 (30%) used secondary data, and 51/176 (29%) used peripheral/perspective data. Forty-eight of the primary data articles included minor adolescents. Secondary data sources included few national research surveys. Sexual/reproductive health outcomes were measured in 17 articles, 4 of which used primary data. The consent process for minor adolescents varied and had no consistent pattern across studies. CONCLUSION: Research on best practices for consent processes and use of registries could be developed to increase research on sexual/reproductive health outcomes among adolescents in foster care.

Developmental and behavioral profile in a domestic adoptees sample: a new challenge for the pediatrician.

BACKGROUND: The aim of this study is to investigate the changes of developmental and behavioral profile in a domestic adoptees sample. METHODS: Thirty-six domestic adoptive families were recruited, resulting in a sample of 39 children. Families were sent a general questionnaire for collecting data related to the children demographic variables, infant's background (time spent in institutional care, age at adoption), children's health status and anthropometric measures at T0, T1, T2, and T3. Moreover, the Infant Behavior Questionnaire-Revised Very Short Form and a modified version of parent-report of Child Behavior Checklist were used to assess temperament and to detect behavioral problems. RESULTS: As regards the psychopathological evaluation, behavior problems were more common in older children, especially among girls. In particular they exhibited a higher frequency of internalizing problems versus externalizing. CONCLUSIONS: Children in foster care suffer discontinuity of care that negatively affects their emotional and physical development. It is important for pediatricians to be aware of the special needs of adopted children, providing adequate support to adoptive families.

Predictors of remaining in foster care after age 18 years old.

BACKGROUND: The Fostering Connections to Success and Increasing Adoptions Act of 2008 created the option for U.S. states to extend the foster care age limit up to the 21 st birthday. The law provides foster youth extra protections while they transition to adulthood. OBJECTIVE: To inform states' efforts to better design and implement extended foster care (EFC), we examine the impact of the policy change on length of EFC stay and factors associated with youth's time in EFC. PARTICIPANTS AND SETTING: We use two samples of foster youth in California that extended the foster care age limit to 21 in 2012: 37,827 youths who turned 18 between the years 2008 and 2014 and 711 youths who participated in an interview-based panel study. METHODS: Leveraging California's child welfare administrative data and California Youth Transitions to Adulthood Study's (CalYOUTH) survey data, we investigated predictors of months youths remained in EFC with linear regression and Cox proportional hazard regression. RESULTS: Almost half of youth eligible for EFC remained in care until their 21 st birthday. These cohorts stayed in foster care up to 16 months longer (p < .001) than previous cohorts without an EFC option. Multiple individual factors were associated with youths' length of stay in EFC. However, a youth's county of placement made a greater difference on their time in EFC-up to 16 months (p < .05). CONCLUSIONS: Our findings underscore the importance that placement location has on how long youth remain in EFC, and expands our understanding of how county and state context shape EFC participation.

Moderating the Risk for Attention Deficits in Children with Pre-Adoptive Adversity: The Protective Role of Shorter Duration of out of Home Placement and Children's Enhanced Error Monitoring.

Early institutional-deprivation has been found to increase risk for inattention/hyperactivity (ADHD). Notably, studies suggest that children with a history of adversity evidencing an enhanced ERP (the error-related-negativity; ERN) may be protected against attention problems. However, such protective effects of the ERN have been studied in children whom typically experienced residential instability. It is unknown whether error-monitoring is similarly protective for children with stable post-deprivation placements. The present study examined the protective effect of the ERN in a sample of children who experienced at least 3-years of stable, relatively enriched caregiving after being internationally-adopted as infants/toddlers from institutional-care. We included two groups of children adopted internationally before age three, one group adopted from institutional-care (PI:n = 80) and one comparison group adopted from foster-care (FC;n = 44). A second comparison group consisted of non-adopted children (NA;n = 48) from demographically comparable families. At five-years of age, we assessed child ADHD symptoms (parent-report) and behavioral performance and neural correlates of error-monitoring (Go/No-Go task). PI children displayed lower Go/No-Go accuracy relative to FC children, and higher levels of ADHD symptoms relative to NA controls. In both FC and PI groups, longer duration of pre-adoptive out-of-home placement was associated with inattention, especially for children with deficits in error-monitoring. Enhancing cognitive control in the form of error monitoring might be a useful intervention target to protect children from some of the negative outcomes associated with adverse early care. Furthermore, results underscore that regardless of type of pre-adoptive care, we should aim to place children in stable/permanent homes as early as possible.

LGBT youth in foster care and the critical advocacy role of Public Health Nurses.

AIMS AND OBJECTIVES: The purpose of this study was to describe the role of public health nurses working with lesbian, gay, bisexual, and transgender (LGBT) children in foster care in the San Francisco Bay Area. BACKGROUND: LGBT youth are disproportionately represented in foster care and experience poor health and education outcomes. Foster care public health nurses (FCPHN) are in a unique position to address disparities with timely and appropriate referrals and advocate for policy changes. DESIGN: An online survey was developed to describe FCPHN responsibilities in case managing LGBT children. METHOD: In all, 39 FCPHNs completed the survey. RESULTS: Most FCPHN did not know the number of LGBT youth in their caseload and reported that there was no systematic method of collecting this data. Few FCPHN had received training in LGBT health issues. CONCLUSION: This study confirms reports from other studies regarding lack of systematic data collection to deliver appropriate services to LGBT youth. It reports FCPHN lack of training as well as their assessment of the most important needs of this population. RELEVANCE TO CLINICAL PRACTICE: FCPHNs are in a unique position to advocate by promoting gender inclusive forms in child welfare agencies and addressing disparities in access to care.

Reducing the Number of Children Entering Foster Care: Effects of State Earned Income Tax Credits.

Foster care caseloads, an indicator of child maltreatment, are increasing. Children living in poverty are significantly more likely to be reported to the child welfare system and are overrepresented in foster care. Thus, it is critical to identify prevention strategies that can stem the flow of foster care entries, particularly among populations at higher risk. We used variations in the adoption and refund status of state-level Earned Income Tax Credit (EITC), a socioeconomic policy intended to reduce poverty, to examine their effect on foster care entry rates. Fixed-effects models, accounting for year- and state-fixed effects, demonstrated that a refundable EITC was associated with an 11% decrease in foster care entries compared to states without a state-level EITC after controlling for child poverty rate, racial/ethnic composition, education, and unemployment. Policies that strengthen economic supports for families may prevent child maltreatment and reduce foster care entries and associated costs.

Health Care Utilization for Children in Foster Care.

OBJECTIVE: To utilize hospital EMR data for children placed in foster care (FC) and a matched control group to compare: 1) health care utilization rates for primary care, subspecialty care, emergency department (ED) visits, and hospitalizations; 2) overall charges per patient-year; and 3) prevalence of complex chronic conditions (CCC) and their effect on utilization. METHODS: Children ≤18 years old with a designation of FC placement and controls matched on age, race/ethnicity, gender, and zip code who had an encounter at an urban pediatric health system between 7/1/11 and 6/30/12 were identified in the EMR. Data on outpatient, ED, and inpatient encounters and charges for 7/1/12 to 6/30/13 were obtained. A general linear mixed-effects model was applied to estimate means and rates for each group. Analyses were repeated among the subpopulations of children with and without CCCs. RESULTS: A total of 1156 FC cases were matched to 4062 controls (mean = 3.5 controls/case). FC cases had significantly higher rates (per 100 patient-years) of hospitalizations (18.5 vs 12.7, P = .005), and subspecialty visits (173.3 vs 113.6; P < .001) but not ED (50.4 vs 45.2, P = .056) or primary care visits (154.6 vs 149.8; P = .50). FC cases had higher charges ($14,372 vs $7082; P < .001). Among children with CCCs, health care utilization rates and charges were higher among FC cases (all P < .001). Among children without CCC, rates and charges were similar for FC cases and controls (all P > .20). CONCLUSIONS: FC children utilized more hospitalizations and subspecialty office visits. The increased utilization rates and charges among children in FC were driven by the subset of children with CCCs.

The Cumulative Prevalence of Termination of Parental Rights for U.S. Children, 2000-2016.

Recent research has used synthetic cohort life tables to show that having a Child Protective Services investigation, experiencing confirmed maltreatment, and being placed in foster care are more common for American children than would be expected based on daily or annual rates for these events. In this article, we extend this literature by using synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System to generate the first cumulative prevalence estimates of termination of parental rights. The results provide support for four conclusions. First, according to the 2016 estimate, 1 in 100 U.S. children will experience the termination of parental rights by age 18. Second, the risk of experiencing this event is highest in the first few years of life. Third, risks are highest for Native American and African American children. Nearly 3.0% of Native American children and around 1.5% of African American children will ever experience this event. Finally, there is dramatic variation across states in the risk of experiencing this event and in racial/ethnic inequality in this risk. Taken together, these findings suggest that parental rights termination, which involves the permanent loss of access to children for parents, is far more common than often thought.

Milking the System: A Case Study of Donor Milk for a Child in Foster Care.

INTRODUCTION: Use of pasteurized donor milk is recommended in many situations when own mother's milk is not available. One existing knowledge gap is access to donor milk for infants in government custody (foster care). MAIN ISSUE: The focus of this case study is an infant born at 41 weeks who was discharged from the hospital into foster care. The infant soon developed failure to thrive due to formula intolerance. MANAGEMENT: After trying multiple formulas, which included elemental formulas, and hospitalization, the infant began pasteurized donor milk. Within 24 hr, the infant began gaining weight. Medicaid denied two authorization requests for payment, and the state's Department of Human Services ultimately agreed to cover the discounted donor milk fees until the infant reached 1 year of age. CONCLUSION: This foster child suffered through months of failure to thrive and hospitalization before receiving human milk feedings. This care violated ethical principles of beneficence, autonomy, and justice. State officials should review their policies and regulations for providing human milk to children in their care and facilitate access to that milk when needed.

Avaliação do perfil das crianças e adolescentes institucionalizados em Porto Alegre/RS / Profile evaluation of institutionalized children and adolescents in Porto Alegre / RS

Este trabalho tem por objetivo analisar o perfil das crianças e adolescentes institucionalizados no município de Porto Alegre/RS, no período de janeiro a julho de 2019. Trata-se de uma análise documental do último Relatório de Inspeção Periódicas dos Serviços de Acolhimento Institucional para crianças e adolescentes, onde foram avaliados dados sobre: idade de entrada na Instituição, tempo de permanência, idade atual, sexo, raça, motivo do acolhimento, grau de escolaridade, deficiência física, mental ou sensorial, acesso a profissionalização, destituição do poder familiar, manutenção dos vínculos familiares, acesso ao direito de adoção e no caso de violência sexual, qual sexo mais atingido. Trata-se de um estudo descritivo, quantitativo com método transversal. Os dados coletados foram inseridos em uma base de dados processada no Software Excel, sendo posteriormente analisados no Software R, versão 3.4.1. A análise dos dados visou traçar o perfil das crianças e adolescentes e para tanto utilizou-se de avaliações estatísticas descritivas, com a exploração dos dados e sua apresentação em tabelas. Foram utilizadas a média, o desvio padrão, a frequência absoluta e a frequência relativa. Para investigar a associação entre sexo e ocorrência de violência sexual foi utilizado o teste QuiQuadrado a 5% de significância. Este trabalho recebeu aprovação do Comitê de Ética CEP/CONEP, CAEE 16519619.0.00005312. Os dados levantados e analisados mostraram que a maioria dos acolhidos era do sexo masculino, faixa etária entre 11 e 18 anos, da cor negra. Sessenta por cento das crianças e adolescentes permaneceram em acolhimento institucional por um período inferior há um ano e apresentaram algum déficit escolar. Mais da metade sofreu destituição do poder familiar e mantém vínculo com suas famílias através das visitas. Um baixo número de adolescentes acolhidos estão se profissionalizando indicando a forte necessidade de desenvolver políticas públicas com este objetivo. A negligência associada às diferentes modalidades de violência e o alto índice do uso de substâncias químicas pelos pais e/ou responsáveis foram as principais causas de acolhimento Institucional em Porto Alegre/RS demonstrando dificuldades dos pais em exercer as funções familiares básicas.

Early Childbirth Among Foster Youth: A Latent Class Analysis to Determine Subgroups at Increased Risk.

CONTEXT: Research has documented elevated rates of early childbirth among adolescents who have spent time in foster care, and a better understanding is needed of the characteristics of vulnerable individuals and the circumstances of their time in care. METHODS: California birth records for 1999-2010 were probabilistically linked to state child welfare service records spanning the same date range to identify females aged 12-19 who had spent time in foster care and had had a first birth before age 20. Latent class analysis was used to identify subgroups based on age at most recent entry into care, length of this stay and three indicators of placement instability. The probability of a first birth being related to class membership was assessed as a distal outcome, and differences across classes were assessed using chi-square tests. RESULTS: Four distinct classes of foster youth were identified: Later Entry/High Instability (20% of individuals), Later Entry/Low Instability (43%), Earlier Entry/High Instability (12%) and Earlier Entry/Low Instability (25%). The probability of a first childbirth ranged from 31% (class 1) to 15% (class 4); classes 2 and 3 experienced moderate risk (23% and 24%, respectively). Two groups were further characterized by high rates of reentry into care, with 56% of class 1 and 41% of class 3 individuals experiencing more than one episode in care. CONCLUSIONS: Identifiable subgroups of female foster youth are at heightened risk of early childbirth and may benefit from early intervention, enhanced support and access to reliable, ongoing sexual and reproductive health care.

Characterization of Chronic Multiclass Psychotropic Polypharmacy and Psychotherapy in Foster Care Youth in a State Medicaid Population.

BACKGROUND: Foster youth have higher rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy compared with nonfoster youth. However, less is known about the extent of multiclass psychotropic polypharmacy after adjusting for patient factors associated with psychotropic medication use OBJECTIVES: To (a) compare psychotropic medication use and psychotherapy use by youth in foster care to those not in foster care in the Oklahoma Medicaid population across various sociodemographic and clinical factors, and (b) determine if patient-related characteristics are associated with high levels of concurrent multiclass psychotropic polypharmacy. METHODS: This cross-sectional, retrospective analysis was conducted using paid prescription, outpatient, and inpatient Oklahoma Medicaid administrative claims from calendar year 2016. Foster youth and adolescents aged 20 years or younger were identified (n = 9,325) and compared with the general Oklahoma Medicaid population of the same age (n = 639,868). Descriptive statistics highlight baseline demographic and clinical differences between the 2 groups. Multivariable logistic regression was used to determine if covariates were associated with concurrent multiclass psychotropic polypharmacy. A subgroup analysis of foster youth taking at least 1 psychotropic medication was also performed to determine factors associated with the highest level of concurrent multiclass psychotropic polypharmacy. RESULTS: Foster care was associated with higher odds of concurrent multiclass psychotropic polypharmacy regardless of presence of psychotherapy. Among the subgroup of foster youth taking at least 1 psychotropic medication, attention deficit hyperactivity disorder medications were the most commonly prescribed medication class, followed by antidepressants and anxiolytics when use was not chronic. However, at the highest level of chronic multiclass psychotropic polypharmacy (4-5 chronic concurrent medications), antipsychotics rose to the top, and anxiolytics were the least likely to be prescribed. Overall, the foster care population had the highest proportion of individuals with concurrent multiclass psychotropic polypharmacy (9.2% vs. 1.9%, P < 0.0001). The highest level of chronic multiclass psychotropic polypharmacy was more likely to occur in males (OR = 1.66, 95% CI = 1.40-1.96) and patients living in group homes (OR = 4.13, 95% CI = 2.02-8.44) or foster homes (OR = 1.66, 95% CI = 1.25-2.19). Being overweight or obese was associated with an 83% higher odds of being at the highest level of concurrent multiclass psychotropic polypharmacy (95% CI = 1.27-2.64). CONCLUSIONS: Despite higher psychotherapy use, high rates of psychotropic medication use and concurrent multiclass psychotropic polypharmacy in foster youth remain a concern for policymakers. Patterns observed at different levels of concurrent multiclass psychotropic polypharmacy may be key to identifying youth who require additional monitoring. Future research exploring factors associated with higher levels of psychotropic concurrent multiclass psychotropic polypharmacy in foster youth can lead to actionable interventions and important policy changes. DISCLOSURES: This project was funded through the CHIP Health Services Initiative. Keast, Tidmore, and Lambert report contractual employment for the Oklahoma Health Care Authority. Nesser is an employee of the Oklahoma Health Care Authority, and Shropshire is an employee of the Oklahoma Department of Human Services. Keast discloses unrelated research grant funding from AbbVie, Amgen, Otsuka, and Purdue Pharma. Tidmore discloses unrelated research grant funding from Amgen and Otsuka. The remaining authors have no relevant disclosures or conflicts of interest to declare. Posters based on this study were presented at AMCP Nexus 2017; October 16-19, 2017; Grapevine, TX, and at the AMCP Annual Meeting 2018; April 23-26, 2018; Boston, MA.