Adults with a child maltreatment history: Narratives describing individual strengths that promote positive wellbeing.

BACKGROUND: Child maltreatment often has negative impacts, but some individuals have strengths that lead to better outcomes. OBJECTIVE: Describe the narratives of adults who experienced childhood maltreatment, all of whom had positive psychosocial wellbeing at average age 18 years. PARTICIPANTS AND SETTING: A purposive sample of 21 adults (mean age 27.8 years SD = 1.0) who were part of a longitudinal study on the effects of childhood maltreatment. The sample was self-described as 85.7 % female, 14.3 % male, 42.9 % Black, 33.3 % Latinx, 19.0 % White, and 4.8 % multiracial. METHODS: This descriptive qualitative study, which is part of a sequential mixed method study, used semi-structured interviews and a narrative analysis approach. Four coders completed: (1) initial reading of sample interviews (2) generating codes independently and discussion, (3) creating a codebook, (4) reviewing 10-11 transcripts each (5) reconvening to discuss/resolve differences in coding, (6) identifying themes. RESULTS: There were four themes. The first theme was seeing oneself in a good light, highlighting self-worth and helper roles. The second theme, moving forward, included letting go of their past and a future orientation. Coping with life, the third theme, included boundaries for people around them, routines, and self-sufficiency. Meaning making, the fourth theme, included insights on the effect of their maltreatment and foster care, and reflections on appreciating life and adapting to changing circumstances. CONCLUSIONS: Findings describe varied strengths that promote positive functioning after childhood maltreatment. Study themes highlight how these strengths allow adults to make meaning of their experiences and move forward successfully in life.

Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning.

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

Nurse and case manager views on improving access and use of healthcare for adults living in permanent supportive housing.

Housing is one of the social determinants of health, and homelessness is associated with health inequalities including increased morbidity and decreased life expectancy. Services to improve access to and use of primary healthcare are provided to formerly homeless individuals (hereafter residents) who live in permanent supportive housing (PSH). Residents do not always utilize services, nor receive adequate healthcare, and often have poor health outcomes. The study aims were to explore nurse and case manager (hereafter participants) views on the challenges of providing healthcare to residents, and strategies to address challenges. This descriptive, qualitative study used thematic analysis. Five nurses and eight case managers working with residents of PSH agencies were interviewed using semistructured interviews. Five main themes emerged. The first theme of context of healthcare use included how the residents' history of homelessness, trauma, and survival affected using services. The second theme was how aspects of relationships (communication issues and mistrust) were barriers to care. The third theme was how residents' health issues (physical chronic diseases, mental health, and substance dependency) affected care. Community level barriers (insurance, financial hardship, and transportation) was the fourth theme. The final theme highlighted recommendations to improve access and use of healthcare by building rapport, addressing mistrust, and using effective communication techniques. Participants noted that barriers to healthcare use were often influenced by residents' previous homeless experience. Nurses noted that chronic physical health issues were problematic for residents. Participants expressed the need to take time to form an authentic relationship to increase trust with residents.

Views on health activation and support services among formerly homeless adults living in Permanent Supportive Housing in the United States.

Individuals who have experienced chronic homelessness often have unmet physical and mental health needs and experiences of trauma and stigma. This study aimed to measure, for the first time, health activation (self-advocacy and empowerment) levels among formerly homeless adults living in Permanent Supportive Housing or PSH (referred to hereafter as residents). In addition, residents' experiences accessing health services, and their sense of health activation and efforts to manage their health within PSH settings, were explored. A mixed-methods study was conducted in Southern California (October 2018-June 2019) using a validated survey and interviews with a randomly selected group of residents (n = 61) from three PSH agencies. Activation levels were measured using the Patient Activation Measure. Descriptive and univariate survey analyses were conducted. Interview data was analysed using NVivo. Two coders coded all transcripts, and team meetings were held to reach consensus. Results showed most residents were female (64%), racial and ethnic minorities (66%), on average 54-year-olds, with 37 months of PSH residency, and 43% were taking some action to manage their health (intermediate activation level). Challenges accessing care were due to breakdowns in care, unpleasant experiences with providers, low health literacy and feeling overwhelmed by co-occurring chronic conditions. Health activation related to knowing when to take care of their health on their own and when to seek care. Unique challenges emerged related to PSH, such as lack of resident control within the housing setting and limited personnel responding to health emergencies. These challenges were magnified because residents live alone, per PSH requirements.

Effect of Caregiver Depressive Symptoms on the Concordance Between Caregiver and Youth Assessment of Youth Physical Health.

OBJECTIVES: To explore how caregivers' (birth parents, adoptive parents, relative caregivers, and unrelated caregivers) depressive symptoms moderate the concordance between their and their youth's assessment of the youth's physical health symptoms, diseases, and physical health status. METHODS: Participants included 224 youth with mean age of 18.0 years (SD = 1.3) and their caregivers. Multiple-group models were run to test whether caregiver depression status moderated the concordance between youth and caregiver report of physical health outcomes. Models compared caregivers above the mean for depression in the sample (n = 62) with caregivers below the mean for depression in this sample (n = 128). RESULTS: There was a strong correlation between youth and caregiver report of pain in the last 30 days and physical health status in the caregiver group with no/fewer depressive symptoms [r (128) = 0.29, p = 0.04; r (128) = 0.59, p < 0.01], but no significant correlation between the two in the caregiver group with higher depressive symptoms [r (62) = - 0.27, p = 0.27; r (62) = - 0.14, p = 0.57]. CONCLUSIONS FOR PRACTICE: Higher caregiver depressive symptoms was associated with worse concordance between caregiver and youth assessment of the youth's pain and physical health status. These two health issues are less visible and more subjective and communication between caregiver and youth may be affected by the caregiver's depressive symptoms. Since both caregiver and youth assessments of a youth's physical health provide the best clinical data, it may be helpful for health providers to assess caregiver's mental health status to provide a more complete picture.

Infant Deaths From Medical Causes After a Maltreatment Report.

OBJECTIVES: To examine whether postneonatal infants reported for maltreatment face a heightened risk of deaths attributable to medical causes. METHODS: Birth and death records for all children born in California between 2010 and 2016 (N = 3 455 985) were linked to administrative child protection system records. Infants were prospectively followed from birth through death or age 1 year. Reports of maltreatment and foster care placement episodes were modeled as time-varying covariates; sociodemographic characteristics at birth were modeled as baseline covariates. Stratified, multivariable competing risk models were used to estimate the adjusted relative hazard of postneonatal infant death attributed to a medical cause (n = 1051). RESULTS: After adjusting for baseline risk factors, and compared with infants never reported for maltreatment, the medical-related mortality risk was almost twice as great among infants reported once for maltreatment (hazard ratio: 1.77; 95% confidence interval: 1.36-2.30) and 3 times greater if there was >1 maltreatment report (hazard ratio: 3.27; 95% confidence interval: 2.48, 4.30). Among infants reported for maltreatment, periods of foster care placement reduced the risk of death by roughly half. CONCLUSION: Infants reported for alleged maltreatment had a higher risk of death from medical causes, with foster care emerging as protective. Targeted support services for parents and improved communication between the child protection system and the pediatric health care community is needed, especially when infants who may be medically fragile remain at home after an allegation of abuse or neglect.

Associations Between Psychosocial Functioning and Physical Health in Youth with Maltreatment Experiences.

Childhood maltreatment often results in long-term untoward outcomes, although some individuals demonstrate better psychosocial functioning. Maltreatment is linked with poor physical health outcomes but little is known about how psychosocial functioning is related to physical health. The aims of this study were to: 1) Identify heterogeneity of psychosocial functioning using a latent profile analysis. Positive functioning was measured by both fewer problematic symptoms (depressive, PTSD, anxiety, externalizing behavior, and substance abuse disorder) and the presence of the protective factor of social support; and 2) Explore the relationship between emergent classes of psychosocial functioning and physical health (self-reported illnesses, symptoms, and health status as well as measured overweight/obesity). Participants included a sample of youth with child welfare-documented maltreatment (n=219; mean age 18.3 years; range 15-23 years) at Time 4 (T4) of a longitudinal study. Mean differences or odds ratios were assessed across the health variables between classes. The three resulting classes were labeled: 1) higher support/lower symptoms (60.7%); 2) lower support/higher internalizing symptoms (29.2%); and 3) lower support/higher externalizing/substance abuse symptoms (10%). Youth in the lower/support/higher externalizing/substance abuse symptoms class had a similar high level of internalizing symptoms as the lower support/higher internalizing symptoms class. Youth in the lower support/high externalizing/substance abuse symptoms class had more colds and pain symptoms in the past month and gastrointestinal illnesses in the past year than the higher support/lower symptoms class, and more illnesses, respiratory problems, and gastrointestinal illnesses the last year than the lower support/higher internalizing symptoms class. Overall, functioning class was related to certain health problems which often have a stress component and were more prevalent for youth with more externalizing and substance abuse symptoms.

Nurses' perceptions: Addressing social determinants of health to improve patient outcomes.

Nursing organizations and leaders adopted the social determinants of health (SDOH) as essential to the delivery of health care, but little is known about working registered nurses' (hereafter nurses) views on the SDOH. The purpose of this study was to (1) explore nurses' perceptions of how SDOH affect patient care and (2) describe nurses' ideas about how SDOH can be addressed to improve outcomes and services. Thirteen registered nurses with a baccalaureate in nursing beginning their online graduate advanced practice educational program were interviewed. This qualitative descriptive study used constant comparative analysis for data analysis. The analysis found two major themes: (1) SDOH are integrated into the nurses' care. The SDOH experienced by patients challenges the nurses to provide care at the patient's level and to provide usable patient education, and (2) health-care delivery change is needed to achieve equity and to provide health care to those in need. The nurses recommended more organized, seamless health-care delivery and interdisciplinary advocacy to achieve these needed changes. Nurse educators and nurse leaders can harness the frustration and ingenuity of nurses to help the nurses advocate for health-care change that integrates the SDOH.

Predictors and correlates of unstable housing experiences among a child welfare-involved sample.

The study examined whether youth demographics, family factors, and maltreatment type were related to unstable housing and whether unstable housing predicted delinquency and marijuana use. Participants included 216 child welfare-affiliated adolescents (mean age = 18.2 years). Youth with more lifetime residences were more likely to experience unstable housing although Latino youth (compared to White, Black, or multiethnic/biracial) were less likely to experience unstable housing. Unstable housing was associated with subsequent delinquency. Caregiver type (parent vs. relative/unrelated caregiver) was not related to unstable housing, thus homelessness prevention programs should include youth who remain with their parents and those with non-parent caregivers.

The Young Adolescent Project: A longitudinal study of the effects of maltreatment on adolescent development.

The Young Adolescent Project (YAP) is an ongoing longitudinal study investigating the effects of abuse and neglect on adolescent development. It is a multidisciplinary study guided by a developmental, ecological perspective, and designed to consider the physical, social, and psychological effects of childhood maltreatment through the transition from childhood to adolescence. Four waves of data collection have been completed, ranging from early (Mean age = 10.95) to late adolescence (Mean age = 18.24). Members of the maltreated group (n = 303) were selected from new cases that had been opened by the Department of Child and Family Services, whereas the comparison group (n = 151) were not involved with child welfare but lived in the same neighborhoods as the maltreated group. The study assessed a wide variety of domains including physical development (e.g., height, weight, body mass, pubertal development); physiological reactivity (e.g., cortisol); cognitive abilities; mental health (e.g., symptoms of depression, anxiety, trauma, and aggression); risk behavior (e.g., sexual activity, delinquency, or substance use); social development (e.g., self-esteem, competence, and social support); family environment; and exposure to community violence. Overall, our findings demonstrated the pervasive and persistent adverse effects of child maltreatment both within and across domains, but they also identified maltreated youth with positive functioning. Our hope is that this work will help move us toward identifying targets for intervention to cultivate resilience and positive adaptation after early maltreatment experiences.

The Moderating Role of Cortisol Reactivity on the Link Between Maltreatment and Body Mass Index Trajectory Across Adolescence.

PURPOSE: Child maltreatment increases risk for obesity, yet differential effects of maltreatment type remain unclear. Cortisol reactivity may help clarify these effects, given links among cortisol reactivity, maltreatment, and obesity. We examined these associations in boys and girls across adolescence. METHODS: We collected data from 454 adolescents (212 girls) across four waves (aged 8-13 years at Time 1), including 303 maltreated youth. We modeled body mass index (BMI) percentile trajectories arrayed by age separately for boys and girls and tested whether cortisol reactivity at Time 1 moderated the association between maltreatment type and BMI growth. RESULTS: In girls, cortisol reactivity moderated the association between maltreatment type and quadratic change in BMI. At low levels of cortisol, sexually abused girls had a steeper quadratic increase in BMI compared with comparison (-.65, 95% confidence interval [CI] -1.09 to -.22) and physically abused (-.76, 95% CI -1.29, -.24) girls. At high levels of cortisol, sexually abused girls did not differ from comparison (.15, 95% CI -.40 to .70) or physically abused (.21, 95% CI -.38 to .80) girls in quadratic change in BMI. In boys, cortisol reactivity did not moderate the association between maltreatment type and BMI growth. CONCLUSIONS: The combination of lower cortisol reactivity and sexual abuse may put girls at risk for BMI increase during later adolescence. Given the negative consequences of high BMI, identifying and intervening with these girls could lead to better health and well-being among this group. Cortisol reactivity may not play the same role among boys.

Pilot Evaluation of a Conservation Corps Program for Young Adults.

Education and employment programs may be effective at reducing problem behaviors among at-risk young adults. This pilot study evaluated whether participants in a Conservation Corps program (N = 100) showed changes in antisocial behavior, gang membership, and substance use during the program. Participants were young adults between 18 and 24 years who were predominantly male (60%) and ethnic minority (62% Latino; 31% African American). Over the course of the 22-week program, participants showed significant decreases in self-reported antisocial behavior and gang involvement, and approximately 28% earned a high school diploma. However, only 61% completed the program, and subgroup analyses suggested that decreased gang membership and antisocial behaviors were mostly driven by program completers. These limited pilot results suggest that the Conservation Corps offers vulnerable young adults opportunities for education advancement and a possible pathway to criminal desistance. However, education and employment programs should make retention a priority.

Longitudinal Relationship Between Mental Health Symptoms and Sleep Disturbances and Duration in Maltreated and Comparison Adolescents.

PURPOSE: To examine the longitudinal relationships between mental health symptoms and sleep for male and female maltreated and comparison adolescents. METHODS: Participants were from a longitudinal study of child maltreatment (maltreated n = 247; comparison n = 138). The current analyses used data from Time 3 (T3; average age 13.7 years) and Time 4 (T4; average age 18.2 years). Path models tested cross-lagged effects between mental health symptoms (depression and Post Traumatic Stress Disorder [PTSD]) and sleep (disturbances and duration) and main effects of maltreatment on Time 4 variables, stratified by sex. RESULTS: Reciprocal relationships between depressive and PTSD symptoms and sleep disturbances were found only for females. Specifically, depressive and PTSD symptoms at T3 predicted sleep disturbances at T4 and sleep disturbances at T3 also predicted depressive and PTSD symptoms at T4. Regarding sleep duration, PTSD symptoms at T3 predicted shorter sleep duration at T4 among females but not for males. There was no effect of maltreatment status on mental health symptoms or sleep disturbance, but maltreated adolescents reported longer sleep duration at T4 than comparison adolescents. CONCLUSIONS: The reciprocal nature of the relationship between mental health symptoms and sleep disturbances in females highlights the need to treat both mental health symptoms as well as sleep problems in female adolescents to improve mental and physical health. The absence of a negative effect of maltreatment on sleep may be due to the fact that the maltreated youth and comparison youth lived in the same low-income urban communities and were exposed to the same nocturnal environmental irritants.

Longitudinal associations of maternal depression and adolescents' depression and behaviors: Moderation by maltreatment and sex.

This study explored the longitudinal relationships among maternal depressive symptoms, children's depressive symptoms, aggression, and rule breaking and tested the moderating effects of maltreatment and child sex. A sample of 175 biological mother-child dyads (86 maltreated and 89 comparison) were seen at three time points, beginning at an average child age of 10.87 years. Results from cross-lagged models showed maternal depressive symptoms were related to higher levels of children's depressive symptoms but not children's aggression or rule breaking. Rule breaking predicted maternal depressive symptoms only in the comparison group. Child sex moderated some relationships. Boys' depression predicted maternal depressive symptoms, whereas maternal depressive symptoms predicted aggression among girls. There was no evidence in this sample that child maltreatment increased the effects of maternal depressive symptoms on child outcomes. These results suggest that attention in clinical practice to the importance of addressing maternal depression as well as addressing children's functioning should continue into adolescence. (PsycINFO Database Record

Qualitative Study of Foster Caregivers' Views on Adherence to Pediatric Appointments.

The current study is a qualitative investigation of how foster caregivers, primarily Latinos, view adherence to pediatric appointments. Our purpose was to identify how the child welfare system, pediatric clinics, and pediatric health providers serving foster children might promote appointment attendance. Participants in the study had a return appointment at an outpatient pediatric clinic that served only children in the child welfare system. Twenty-eight caregivers (13 related and 15 unrelated) participated in telephone interviews after the date of their scheduled pediatric appointment; 32% missed their return appointment. Semistructured interview guides included general questions about what promotes attending the pediatric appointment, what makes it difficult to attend the pediatric appointment, and how pediatric care affects the foster child. Analysis of qualitative data using content analysis identified three themes: (a) Multiple Methods to Attend Appointments, which included caregivers' organizational and problem-solving skills; (b) Positive Health Care Experiences, which consisted of caregivers' personal relationships with providers and staff members and clinic organization; and (c) Necessity of Pediatric Care, which included recognition of the need for health care, especially timely immunizations. All caregivers also reported that appointment reminders would be helpful. Unrelated caregivers said more often than related caregivers that appointment attendance was facilitated by clinic organization. Nonadherent caregivers more than attenders mentioned their need to solve problems to attend appointments or reschedule appointments. In summary, caregivers said they valued regular pediatric health care to treat their children's chronic conditions and prevent illnesses, but they acknowledged that their home lives were hectic and that attending scheduled appointments was sometimes difficult. Foster caregivers in this study identified the ideal pediatric clinic environment that encourages adherence to health care appointments. This environment is an organized clinic with easy access including parking, engaged pediatric health providers, ability to reschedule appointments when necessary, and an individualized and consistent appointment reminder system.

Concordance Between Self-Reported Childhood Maltreatment Versus Case Record Reviews for Child Welfare-Affiliated Adolescents.

The present study used data from an ongoing longitudinal study of the effects of maltreatment on adolescent development to (1) describe rates of maltreatment experiences obtained from retrospective self-report versus case record review for adolescents with child welfare-documented maltreatment histories, (2) examine self-reported versus child welfare-identified maltreatment in relation to mental health and risk behavior outcomes by maltreatment type, and (3) examine the association between the number of different types of maltreatment and mental health and risk behavior outcomes. Maltreatment was coded from case records using the Maltreatment Case Record Abstraction Instrument (MCRAI) and participants were asked at mean age = 18.49 about childhood maltreatment experiences using the Comprehensive Trauma Interview (CTI). Results showed that an average of 48% of maltreatment found by the MCRAI for each type of maltreatment were unique cases not captured by the CTI, whereas an average of 40% self-reported maltreatment (CTI) was not indicated by the MCRAI. Analyses with outcomes showed generally, self-reported maltreatment, regardless of concordance with MCRAI, was related to the poorest outcomes. The difference in associations with the outcomes indicates both self-report and case record review data may have utility depending on the outcomes being assessed.

Preliminary Validation of a Parent-Child Relational Framework for Teaching Developmental Assessment to Pediatric Residents.

OBJECTIVE: A parent-child relational framework was used as a method to train pediatric residents in basic knowledge and observation skills for the assessment of child development. Components of the training framework and its preliminary validation as an alternative to milestone-based approaches are described. METHODS: Pediatric residents were trained during a 4-week clinical rotation to use a semistructured interview and observe parent-child behavior during health visits using clinical criteria for historical information and observed behavior that reflect developmental change in the parent-child relationship. Clinical impressions of concern versus no concern for developmental delay were derived from parent-child relational criteria and the physical examination. A chart review yielded 330 preterm infants evaluated using this methodology at 4 and 15 months corrected age who also had standardized developmental testing at 6 and 18 months corrected age. Sensitivities and specificities were computed to examine the validity of the clinical assessment compared with standardized testing. A subset of residents who completed 50 or more assessments during the rotation was timed at the end of 4 weeks. RESULTS: Parent-child behavioral markers elicited from the history and/or observed during the health visit correlated highly with standardized developmental assessment. Sensitivities and specificities were 0.72/0.98 and 0.87/0.96 at 4 to 6 and 15 to 18 months, respectively. Residents completed their assessments <1 minute on average if they had completed at least 50 supervised assessments. CONCLUSIONS: A parent-child relational framework is a potentially efficient and effective approach to training residents in the clinical knowledge and skills of child development assessment.

Self-Report of Health Problems and Health Care Use among Maltreated and Comparison Adolescents.

The study aims were to compare maltreated and comparison adolescents' health problems and to identify how individual, family and home characteristics and maltreatment status affect adolescents' self-report of health status and health care use. The sample was 224 maltreated adolescents (mean age = 18.3 years) and 128 comparison adolescents (mean age = 18.15 years). Comparison adolescents reported more cold and pain symptoms during the previous 30 days but no differences in other physical health problems, self-assessment of their physical and mental health or health care use compared to maltreated adolescents. Girls were more likely to have had a dental checkup, to have seen a psychological counselor, and to self-identify their physical health as poor compared to boys. Older adolescents were less likely to have had a medical checkup or seen a psychological counselor than younger adolescents. A history of maltreatment was not related to health or health care disparities for adolescents growing up in the same low-income environment as adolescents without a maltreatment report. The environmental context and geographical location in which these adolescents grew up may be the primary driver in their health behaviors and health problems and not the experience of maltreatment.

Maltreated and comparison adolescents' recollections of lifetime residences: Relationship to delinquency and marijuana use.

Both childhood maltreatment and frequent childhood residence changes are associated with poor behavioral outcomes including drug use and delinquency. It is not clear whether a higher number of residences results in poorer outcomes for maltreated adolescents compared to adolescents living in the same community but without child welfare-documented maltreatment. Our study of child welfare-affiliated maltreated youth (n=216) and comparison youth (n=128) from the same community (age M = 18.21, SD = 1.42) examined: 1. whether child/caregiver characteristics and maltreatment status were associated with lifetime number of residences and 2. whether child/caregiver characteristics, residences, and maltreatment status were associated with delinquency and marijuana use. The outcomes of this study, number of residences, delinquency, and marijuana use, were all skewed, and consequently negative binomial regressions were used. Maltreatment status, ever living with a non-parent caregiver, and being older are associated with more residence changes during childhood. More residences and male sex are associated with person offense delinquency and marijuana use. In lower income neighborhoods, such as where the adolescents in this study lived, residence changes are not unusual, but in this study maltreated youth moved more often than youth from the same community. It is important to help caregivers who live in disadvantaged neighborhoods, especially families with child welfare involvement, understand the behavioral consequences of residence changes and provide support for stable long-term housing.

Pediatric Return Appointment Adherence for Child Welfare-Involved Children in Los Angeles California.

OBJECTIVES: This study of primarily Latino caregivers and Latino child welfare-involved children had the following aims: (1) explore the return appointment adherence patterns at a pediatric medical clinic; and (2) determine the relationship of adherence to return appointments and caregiver, child, and clinic variables. METHODS: The sample consisted of caregivers of child welfare-involved children who were asked to make a pediatric outpatient clinic return appointment (N = 87). Predictors included caregiver demographics, child medical diagnoses and age, and clinic/convenience factors including distance from the clinic to caregiver's home, days until the return appointment, reminder telephone call, Latino provider, and additional specialty appointment. Predictors were examined using χ(2) and t tests of significance. RESULTS: Thirty-nine percent of all caregivers were nonadherent in returning for pediatric appointments. When return appointments were scheduled longer after the initial appointment, caregivers were less likely to bring children back for medical care. CONCLUSIONS: The 39 % missed return appointment rate in this study is higher than other similar pediatric populations. Better coordination between pediatricians and caregivers in partnership with child welfare case workers is needed to ensure consistent follow-up regarding health problems, especially when appointments are not scheduled soon after the initial appointment.