Disrupted family reunification: Mental health, race, and state-level factors.

The children's mental health landscape is rapidly changing, and youth with mental health conditions (MHCs) are overrepresented in the child welfare system. Mental health is the largest unmet health need in child welfare, so MHCs may affect the likelihood of system reentry. Concerns regarding mental health contribute to calls for expanded supports, yet systems contact can also generate risk of continued child welfare involvement via surveillance. Still, we know little about how expanded supports at the state-level shape child welfare outcomes. Using the Adoption and Foster Care Analysis Reporting System (AFCARS), we examine the association between MHCs and system reentry within 36 months among youth who reunified with their families in 2016 (N = 41,860). We further examine whether this association varies across states and White, Black, and Latinx racial and ethnic groups via two- and three-way interactions. Results from multilevel models show that, net of individual and state-level factors, MHCs are associated with higher odds of reentry. This relationship is stronger for youth in states that expanded Medicaid by 2016 and with higher Medicaid/CHIP child participation rates. The results also show evidence of the moderating role of state-level factors, specifically student-to-school counselor ratio, diverging across racial and ethnic groups. Our results suggest a need for systems of care to better support youth mental health and counteract potential surveillance.

Minding the complexities of psychotropic medication management for children and youth in the foster care system: Paper 1: The facilitators and barriers to learning about trauma-informed medication management.

The phenomenon of inappropriate polypharmacy among the foster care population arises in part due to the challenges related to integrating trauma-informed principles into service delivery. It is further exacerbated by the complexity of intersecting systems in which child welfare case workers need to communicate, including foster and biological parents, social service agencies, and advocates. Yet, there is limited research about trauma-informed psychotropic medication management interventions for child welfare staff. This pilot study was conducted to evaluate a trauma-informed psychotropic medication management intervention and is reported in two manuscripts, pertaining respectively to the facilitators and barriers to learning, and perceived individual and institutional trauma responsiveness. The intervention comprised of a 2-hour-long training session for child welfare staff and a 3-month web-based curriculum for leadership personnel, aiming to increase their understanding of trauma-informed psychotropic medication management. In the first paper, we report on the facilitators and barriers to learning, grouped into three categories: teacher attributes, learner attributes, and situational factors. In the second paper, in addition to trauma responsiveness ratings, we also provide a detailed account of one participant's life experience and perceptions of the intervention provided, as an exemplar of the psychosocial facets of resilience. The ABC Medication Scale scores that measured staff knowledge, attitudes, and behaviors associated with medications used to treat mental health symptoms showed a significant change in scores following training. Based on these findings, we provide practical solutions to address situational factors that are worth considering when providing training for child welfare staff. PAPER 1 ABSTRACT: THE FACILITATORS AND BARRIERS TO LEARNING ABOUT TRAUMA-INFORMED MEDICATION MANAGEMENT: Given that foster care children experience many challenges that threaten their well-being, their physical and mental health needs tend to be greater than those of their peers who are not in foster care. However, owing to the transient nature of the foster care placements, as well as continuous changes in medical providers and counselors, the screenings, supportive interventions, and treatments they receive may be fragmented. This is particularly problematic when considering that many of these children are medicated as a means of managing their behavior. Moreover, children in foster care are also more vulnerable to having the medications and diagnoses accumulate due to frequent placement changes and lack of treatment continuity. Our research was guided by the question "What are the facilitators and barriers to learning about trauma-informed psychotropic medication management?" We developed an intervention to address the issue of inappropriate polypharmacy and examined the facilitators and barriers to learning using a mixed methods design. The facilitators to learning were instructor-specific (e.g., reputation, teaching style, capacity for selecting and implementing relevant resources), learner-specific (altruism, capacity to see personal relevance in the learning situation, desire for knowledge/competence, career advancement/recognition-seeking), and situational (immediacy/on-demand resources, reinforcement of pleasant learning experience). Barriers were largely situational (workload and family demands). Based on these findings, we provide practical strategies for addressing situational factors that are worth considering when designing training curricula aimed at child welfare staff.

Minding the complexities of psychotropic medication management for children and youth in the foster care system: Paper 2: Levels of trauma responsiveness among child welfare staff.

BACKGROUND: Foster care children tend to have greater physical and mental health needs compared to those of their peers who are not in foster care due to many challenges that threaten their well-being. Yet, owing to frequent placement changes, their treatment may be fragmented. Moreover, if foster children are unable to provide important information about their own health status, and the same cannot be obtained from their families of origin, the resulting incomplete and/or inconsistent health history puts them at risk for unrecognized problems and conflicting diagnoses. Paradoxically, foster parents and resource providers often request psychotropic medications for children and youth in their care as a means of managing their behaviors. The phenomenon of inappropriate polypharmacy arises due in part to the difficulties related to integrating trauma-informed principles into the care process. It is further exacerbated by the complexity of intersecting systems in which child welfare case workers need to communicate including foster and biological parents, social service agencies, and advocates. In this second paper, we report on the same intervention as that discussed in the first paper, focusing on the effectiveness of the live 2-hour face-to-face training for child welfare staff and the 3-month web-based curriculum for leadership personnel in improving the participants' trauma responsiveness. RESEARCH QUESTIONS: 1. What are the child welfare staff's perceptions of their own knowledge, attitudes, and communication behaviors associated with medications used to treat mental health symptoms and monitoring for side-effects of psychotropic medication use in children? 2. What is the level of trauma responsiveness among child welfare staff? METHODOLOGY AND PARTICIPANTS: The ABC Medication Scale was employed to measure staff knowledge, attitudes, and behaviors associated with medications used to treat mental health symptoms before and after the intervention to determine if the training resulted in any improvements. Individual- and organizational-level trauma responsiveness was rated on a continuum of the Missouri Model: A Developmental Framework for Trauma-Informed Approaches. Artifacts of the web-based curriculum and qualitative interview data were analyzed by applying grounded theory methods. FINDINGS/RESULTS: There was a significant increase in The ABC Medication Scale scores following the training. The qualitative findings further revealed that majority of the participants rated themselves as "trauma aware" or "trauma responsive" on the Missouri Model, while indicating that their agencies could work harder to become more fully trauma-informed. As trauma-informed child welfare workforce that understands the complexity and advocacy requirements of psychotropic medication management is needed, further longitudinal research is required is to assess the training effects over time. In particular, the aim should be to establish (a) how knowledge and attitude shifts correlate with greater degrees of trauma responsiveness, and (b) if and how such trainings translate into improved systems of support.

A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs.

OBJECTIVE: This article employs a best-worst scaling (BWS) experiment to identify the claims-based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States. DATA SOURCES: Patients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18). STUDY DESIGN: Respondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims-based outcomes as most and least important for program evaluation. DATA ANALYSIS: Stratified by respondent group, best-worst scores were calculated to identify the relative importance of the claims-based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs. PRINCIPAL FINDINGS: Safety indicators (eg, antipsychotic co-pharmacy, cross-class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized "antipsychotic treatment reduction" and "increased psychosocial treatment." Caseworkers, prescribers, and caregivers prioritized "increased follow-up after treatment initiation." Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow-up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64). CONCLUSIONS: The BWS experiment supported rank ordering of candidate claims-based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.

Inequalities in educational outcomes in individuals with childhood experience of out-of-home care: What are driving the differences?

BACKGROUND: Prior research has shown that individuals with experience of out-of-home care (foster family care or residential care) in childhood are educationally disadvantaged compared to their peers. In order to be better equipped to design interventions aimed at improving the educational outcomes of children for whom society has assumed responsibility, this study seeks to further our understanding about which factors that contribute to the educational disparities throughout the life course. METHODS: Using longitudinal data from a cohort of more than 13,000 Swedes, of which around 7% have childhood experience of out-of-home care, Peters-Belson decomposition is utilized to quantify the extent to which the gap in educational achievement in school (age 16) and midlife educational attainment (age 50) captures differences in the prevalence of factors influencing educational outcomes, and differences in the impacts between these factors. RESULTS: We find that the achievement and the attainment gap was around 13% and 9% respectively. These gaps were to a large extent explained by differences in the distribution of predictors. The major explanatory factor for placed children's lower achievement was a lower average cognitive ability. Yet there were some evidence that the rewards of cognitive ability in these children differed across the life course. While the lower returns of cognitive ability suggest that they were underperforming in compulsory school, the higher returns of cognitive ability on midlife attainment indicate that-given previous underperformance-their attainment at age 50 reflects their cognitive capacity more accurately than their achievement at age 16 do. CONCLUSION: The large influence of the unequal distribution of predictors suggests that policy efforts are needed to promote equity in the distribution of factors contributing to educational achievement and attainment. Since cognitive ability was found to be an important contributory factor, such efforts may include promoting cognitive and intellectual development among children in out-of-home care, preferably starting at a young age.

Interventions and practice models for improving health and psychosocial outcomes of children and young people in out-of-home care: protocol for a systematic review.

INTRODUCTION: Children and young people placed in out-of-home care (OoHC) are often affected by a history of trauma and adverse childhood experiences. Trauma in early childhood can impact on children's health and psychosocial development, whereas early interventions can improve children's development and placement stability. Although several interventions and practice models have been developed to improve health and psychosocial outcomes for children and young people in OoHC, there remains a lack of rigorous research examining the impact of these interventions in OoHC settings, as there are no systematic reviews examining the impact these interventions and practice models have on the children and young people they serve. We aim to conduct a comprehensive systematic review to examine the effectiveness of interventions and practice models for improving health and psychosocial outcomes in children and young people living in OoHC and to identify relevant knowledge gaps. METHODS AND ANALYSIS: Major electronic databases including Medline, Medline in-process and other non-indexed citations, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Sociological Abstracts and all Evidence-Based Medicine Reviews incorporating: Cochrane Database of Systematic Reviews, American College of PhysiciansJournal Club, Database of Abstracts of Reviews of Effects,Cochrane Central Register of Controlled Trials, CochraneMethodology Register, Health Technology Assessment and National Health Service Economic Evaluation Database, will be systematically searched for any studies published between 2008 and 2018 of interventions and practice models developed to improve health and psychosocial outcomes for children and young people in OoHC. Two independent reviewers will assess titles and abstracts for eligibility according to prespecified selection criteria and will perform data extraction and quality appraisal. Meta-analyses and/or metaregression will be conducted where appropriate. ETHICS AND DISSEMINATION: This study will not collect primary data and formal ethical approval is therefore not required. Findings from this systematic review will be disseminated in a peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42019115082.

Background, experience of abuse, and mental health among adolescents in out-of-home care: a cross-sectional study of a Swedish high school national sample.

PURPOSE: To compare experiences for adverse events, especially sexual abuse, and mental health in a group of high school students in out-of-home care with a representative sample of peers of the same age and similar educational attainment living with their parents. MATERIALS AND METHODS: A sample of 5839 students in the third year of Swedish high school, corresponding to a response rate of 59.7%, answered a study specific questionnaire. Data from 41 students living in out-of-home care were compared with data from peers not in out-of-home care in a cross-sectional analyze. RESULTS: Students in out-of-home care had more often an immigrant background and a non-heterosexual orientation, had more often experienced physical and penetrative sexual abuse, and more often sought healthcare for mental problems. Disclosure of sexual abuse was less common, and acts of persuasion or adults' use of their social position was more common among students in out-of-home care. CONCLUSIONS: Even where the protective factor 'senior educational attainment' is present, risks for abuse and poor mental health are evident for adolescents in out-of-home care. Disclosure of adversity, when it has occurred, ought to be higher among these adolescents with regular contact with social services, but our findings indicate tendencies for the opposite. We therefore suggest routines to be established to screen for adverse life events and mental health actively, along with general and systematic assessments of adversity and mental health during care.

Empirically-guided assessment of complex trauma for children in foster care: A focus on appropriate diagnosis of attachment concerns.

Complex trauma is defined as repeated or prolonged exposure to traumatic events perpetrated within the caregiving relationship during early childhood. Diagnostic decision making is challenging for this vulnerable population, given the widespread impact of these experiences across domains of developmental, social, emotional, and behavioral functioning. One domain, attachment, receives considerable attention for youth within the child welfare system, leading to frequent diagnosis of attachment disorders (i.e., reactive attachment disorder and disinhibited social engagement disorder). This is concerning, given the rarity, level of misunderstanding, associated stigma, and lack of psychometrically sound measures to assess attachment disorders. This article provides an overview of complex trauma and its effects, with a focus on attachment concerns. It subsequently describes one statewide assessment program for youth in the child welfare system with a history of experiencing complex trauma, elaborating on strengths and areas of future growth. A case study demonstrates the program's adherence to established guidelines and the resulting diagnoses and recommendations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Receptive Vocabulary Development of Children Placed in Foster Care and Children Who Remained With Birth Parents After Involvement With Child Protective Services.

Children who experience maltreatment are more likely than nonmaltreated children to demonstrate deficits in early receptive language skills that negatively impact their later academic achievement, social competence, and behavioral adjustment. It remains unclear whether placement in foster care affects children's early receptive language skills. In the current study, we examined whether children with Child Protective Services (CPS) involvement who were in foster care ( n = 176) had more advanced receptive vocabulary than children with CPS involvement who resided with their birth parents ( n = 144). Results demonstrated that children in foster care had higher receptive vocabulary scores at ages 36 and 48 months than children who stayed with their birth parents. Group differences were not significant after controlling for caregiver education level, marital status, and household income. These findings suggest that placement in foster care may be associated with meaningful improvements in children's receptive vocabulary among children with experiences of CPS involvement, and birth parents might benefit from increased supports to promote parent-child interactions that facilitate language development.

Children's behavioral health needs and satisfaction and commitment of foster and adoptive parents: Do trauma-informed services make a difference?

OBJECTIVE: Caring for children in foster or adoptive care with behavioral health needs can severely stress parents, contributing to adverse outcomes for children and families. Trauma-informed services from the child welfare and mental health sectors may help prevent poor outcomes by helping children and parents identify and understand trauma and its impact on children's behavioral health and receive effective treatment. To help understand the role of trauma-informed services for the child welfare population, we examined whether trauma-informed child welfare and mental health services moderated the relationship between children's behavioral health needs and parent satisfaction and commitment. METHOD: The researchers analyzed data from a cross-sectional statewide survey of foster and adoptive parents (n = 512 respondents, 42% of 1,206 contacted) from one state. RESULTS: Foster (but not adoptive) parent ratings of trauma-informed mental health services significantly moderated the relationship between children's behavioral health needs and foster and adoptive parent satisfaction and commitment. As ratings of trauma-informed mental health services increased, the association between child behavioral health needs and parent satisfaction and commitment became nonsignificant, suggesting a buffering effect. Trauma-informed child welfare services did not moderate the relationship for foster or adoptive parents. CONCLUSIONS: Leaders and policymakers are urged to promote trauma-informed mental health services for children involved with child welfare to potentially buffer foster parents against lower parenting satisfaction and commitment. More research is needed to replicate and expand on these findings and to examine the effectiveness of trauma-informed services on other relevant child and family outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Neglected children with severe obesity have a right to health: Is foster home an alternative?-A qualitative study.

OBJECTIVE: To explore key person's perspectives of foster home placement or notification of risk of harm to Social Services of children with severe obesity. METHODS: This case study research was performed in the southwest of Sweden and based on interviews with nine informants: a foster home youth, two foster parents, a social worker, two hospital social workers, a pediatric physician, a pediatric nurse, and a psychologist. Content analysis was used for narrative evaluations, within- and cross case analyses and displays. RESULTS: Positive health outcomes of the foster home placement were described as a healthy and normalized weight status, a physically and socially active life, and an optimistic outlook on the future. The foster parents made no major changes in their family routines, but applied an authoritative parenting style regarding limit setting about sweets and food portions and supporting physical activity. The professionals described children with severe obesity as having suffered parental as well as societal neglect. Their biological parents lacked the ability to undertake necessary lifestyle changes. Neglected investigations into learning disabilities and neuropsychiatric disorders were seen in the school and healthcare sector, and better collaboration with the Social Services after a report of harm might be a potential for future improvements. Rival discourses were underlying the (in) decision regarding foster home placement. CONCLUSION: A child's right to health was a strong discourse for acting when a child was at risk for harm, but parental rights are strong when relocation to a foster home is judged to be necessary.

The impact of a statewide trauma-informed child welfare initiative on children's permanency and maltreatment outcomes.

This article presents findings of a state-wide trauma informed child-welfare initiative with the goal of improving well-being, permanency and maltreatment outcomes for traumatized children. The Massachuetts Child Trauma Project (MCTP), funded by the Administration of Children and Families, Children's Bureau was a multi-year project implementing trauma-informed care into child welfare service delivery. The project's implementation design included training and consultation for mental health providers in three evidence-based treatments and training of the child-welfare workforce in trauma-informed case work practice. The learning was integrated between child-welfare and mental health with Trauma Informed Leadership Teams which included leaders from both systems and the greater community. These teams developed incremental steps toward trauma-informed system improvement. This study evaluated whether MCTP was associated with reductions in child abuse and neglect, improvements in placement stability, and higher rates of permanency during the first year of implementation. Children in the intervention group had fewer total substantiated reports of maltreatment, including less physical abuse and neglect than the comparison group by the end of the intervention year. However, children in the intervention group had more maltreatment reports (substantiated or not) and total out-of-home placements than did their counterparts in the comparison group. Assignment to MCTP, however, was not associated with an increase in kinship care or adoption. Overall, the results are promising in reinforcing the importance of mobilizing communities toward improvements in child-welfare service delivery.

Protocol for the economic evaluation of a complex intervention to improve the mental health of maltreated infants and children in foster care in the UK (The BeST? services trial).

INTRODUCTION: Children who have experienced abuse and neglect are at increased risk of mental and physical health problems throughout life. This places an enormous burden on individuals, families and society in terms of health services, education, social care and judiciary sectors. Evidence suggests that early intervention can mitigate the negative consequences of child maltreatment, exerting long-term positive effects on the health of maltreated children entering foster care. However, evidence on cost-effectiveness of such complex interventions is limited. This protocol describes the first economic evaluation of its kind in the UK. METHODS AND ANALYSIS: An economic evaluation alongside the Best Services Trial (BeST?) has been prospectively designed to identify, measure and value key resource and outcome impacts arising from the New Orleans intervention model (NIM) (an infant mental health service) compared with case management (CM) (enhanced social work services as usual). A within-trial economic evaluation and long-term model from a National Health Service/Personal Social Service and a broader societal perspective will be undertaken alongside the National Institute for Health Research (NIHR)-Public Health Research Unit (PHRU)-funded randomised multicentre BeST?. BeST? aims to evaluate NIM compared with CM for maltreated children entering foster care in a UK context. Collection of Paediatric Quality of Life Inventory (PedsQL) and the recent mapping of PedsQL to EuroQol-5-Dimensions (EQ-5D) will facilitate the estimation of quality-adjusted life years specific to the infant population for a cost-utility analysis. Other effectiveness outcomes will be incorporated into a cost-effectiveness analysis (CEA) and cost-consequences analysis (CCA). A long-term economic model and multiple economic evaluation frameworks will provide decision-makers with a comprehensive, multiperspective guide regarding cost-effectiveness of NIM. The long-term population health economic model will be developed to synthesise trial data with routine linked data and key government sector parameters informed by literature. Methods guidance for population health economic evaluation will be adopted (lifetime horizon, 1.5% discount rate for costs and benefits, CCA framework, multisector perspective). ETHICS AND DISSEMINATION: Ethics approval was obtained by the West of Scotland Ethics Committee. Results of the main trial and economic evaluation will be submitted for publication in a peer-reviewed journal as well as published in the peer-reviewed NIHR journals library (Public Health Research Programme). TRIAL REGISTRATION NUMBER: NCT02653716; Pre-results.

Psychosocial screening and monitoring for children in foster care: Psychometric properties of the Brief Assessment Checklist in a Dutch population study.

Children in foster care experience higher levels and rates of psychosocial difficulties than children from the general population. Governments and child welfare services have a responsibility to identify those children in care who have need for therapeutic services. This can be achieved through systematic screening and monitoring of psychosocial difficulties among all children in foster care. However, general screening and assessment measures such as the Strengths and Difficulties Questionnaire (SDQ) and Child Behavior Checklist (CBCL) might not adequately screen for the range of difficulties experienced by foster children. The Brief Assessment Checklists for Children (BAC-C) and Brief Assessment Checklists for Adolescents (BAC-A) are measures designed to screen for and monitor attachment- and trauma-related difficulties among child welfare populations. This article reports psychometric properties of the BAC-C and BAC-A, estimated in a population study of 219 Dutch foster children. The results suggest the BAC-C and BAC-A perform both screening and monitoring functions well. Their screening accuracy, internal reliability and concurrent validity are comparable to those estimated for the SDQ within the same child and adolescent sample. Future research is needed to assess the value of the Brief Assessment Checklists (BAC) compared to other measures and to validate cut-points for the BAC. This study further establishes the BAC-A and BAC-C as valid and useful mental health screening and monitoring measures for use with children and adolescents in foster care.

Addressing the mental health needs of looked after children in foster care: the experiences of foster carers.

WHAT IS KNOWN ON THE SUBJECT?: In the UK and internationally, the number of looked after children is increasing year on year. Mental health problems among looked after children are significantly higher than in the general population, and the uptake of mental health services for these children is low. There is a poor prognosis for children with untreated mental health problems; this is further compounded if the child is within the care system. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This study adds to our understanding of foster carers' experiences of the mental health needs of looked after children and demonstrates some of the challenges associated with accessing appropriate and timely mental health services. New knowledge derived from this research is that the barriers to accessing Child and Adolescent Mental Health Services (CAMHS) are not at the time of initial referral as previously reported, but later, once within the mental health system with long waiting times experienced particularly for specialist services. This study provides new insights into the experience of being a foster carer and the levels of support and resources needed that directly relate to the viability of the placement. The majority of the foster carers interviewed were from a Black and Minority Ethnic (BME) background, previously under-represented in this research area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A number of areas in current CAMHS provision need addressing with a focus on accessibility, consultation and support for foster carers. Waiting times need to be addressed, and improved communication with other agencies is also highlighted. CAMHS nurses are well placed to develop and deliver a comprehensive care package to foster carers, offering more tailored support to them whilst enabling the children and young people in their care to access and engage more effectively with mental health services. ABSTRACT: Introduction Despite well-documented vulnerabilities to mental health problems among the increasing population of looked after children, there continues to be poor uptake and utilization of Child and Adolescent Mental Health Services (CAMHS). Aim To elicit views of foster carers regarding the mental health needs of children and adolescents in their care and their experiences of accessing mental health services. Methods A grounded theory approach and semistructured interviews with ten foster carers. Results The experience of being a foster carer was the core category, with three major themes: (1) foster carers' psychological understanding of challenging behaviour; (2) barriers to accessing CAMHS; (3) the importance of support. Discussion A key finding of this research is that barriers to accessing CAMHS were not experienced at the point of referral, but once within the mental health system. The foster carers demonstrated a proactive approach to accessing services but expressed a need for more support structures related directly to the viability of the placement. Implications for practice Mental health nurses have a pivotal role in providing a more responsive and needs-led service for this population; professional support to foster carers to include facilitating peer support; and clinical interventions for the looked after children.

Adverse childhood experiences among children placed in and adopted from foster care: Evidence from a nationally representative survey.

Despite good reason to believe that children in foster care are disproportionately exposed to adverse childhood experiences (ACEs), relatively little research considers exposure to ACEs among this group of vulnerable children. In this article, we use data from the 2011-2012 National Survey of Children's Health (NSCH), a nationally representative sample of non-institutionalized children ages 0-17 in the United States, to estimate the association between foster care placement and exposure to an array of ACEs. In adjusted logistic regression models, we find that children placed in foster care or adopted from foster care, compared to their counterparts, were more likely to experience parental divorce or separation, parental death, parental incarceration, parental abuse, violence exposure, household member mental illness, and household member substance abuse. These children were also more likely to experience ACEs than children across different thresholds of socioeconomic disadvantage (e.g., children in households with incomes below the poverty line) and across different family structures (e.g., children in single-mother families). These results advance our understanding of how children in foster care, an already vulnerable population, are disproportionately exposed to ACEs. This exposure, given the link between ACEs and health, may have implications for children's health and wellbeing throughout the life course.

Mental and Physical Health of Children in Foster Care.

BACKGROUND AND OBJECTIVES: Each year, nearly 1% of US children spend time in foster care, with 6% of US children placed in foster care at least once between their birth and 18th birthday. Although a large literature considers the consequences of foster care placement for children's wellbeing, no study has used a nationally representative sample of US children to compare the mental and physical health of children placed in foster care to the health of children not placed in foster care. METHODS: We used data from the 2011-2012 National Survey of Children's Health, a nationally representative sample of noninstitutionalized children in the United States, and logistic regression models to compare parent-reported mental and physical health outcomes of children placed in foster care to outcomes of children not placed in foster care, children adopted from foster care, children across specific family types (eg, single-mother households), and children in economically disadvantaged families. RESULTS: We find that children in foster care are in poor mental and physical health relative to children in the general population, children across specific family types, and children in economically disadvantaged families. Some differences are explained by adjusting for children's demographic characteristics, and nearly all differences are explained by also adjusting for the current home environment. Additionally, children adopted from foster care, compared with children in foster care, have significantly higher odds of having some health problems. CONCLUSIONS: Children in foster care are a vulnerable population in poor health, partially as a result of their early life circumstances.

Mental Health Issues in Foster Care.

Children in foster care have exceptional needs due to their histories of abuse, neglect, and increased exposure to violence. The rates of psychiatric symptoms and disorders, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and reactive attachment disorder, are much higher in children in foster care; furthermore, the rate of these children receiving psychotropic medications is 3 times that of children who are not in foster care. Pediatricians, in their role of providing a medical home, play a central role in safeguarding the physical and mental health of these children. By taking a trauma-informed approach to understanding the unique needs and gaps in their health care, pediatricians can improve the mental health and maximize outcome for children in foster care. [Pediatr Ann. 2016;45(10):e342-e348.].

Falling off the ladder: Using focal theory to understand and improve the educational experiences of young people in transition from public care.

Coleman's focal theory, developed in relation to adolescents in the general population, appears to offer some explanation for the poor educational achievement and social exclusion of care leavers, but has been little tested empirically. This paper revisits data from two studies of care-experienced young people aged 18-25, drawing on qualitative interviews in the UK and four other European countries, to see if focal theory would have helped to predict their educational progression or otherwise. The lives of research participants were found to be characterised by disruptions and uncertainty, with multiple challenges confronting them in quick succession, making it hard for them to pace their transitions as, according to focal theory, other young people do. Findings suggest that the theory could be used to inform policy designed to improve educational outcomes and should be incorporated into training for those responsible for supporting care leavers through their transition to adulthood.