A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system.

BACKGROUND: Among nearly 400,000 children in US foster care, an estimated 10 % are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable. OBJECTIVE: To understand how US child welfare agencies define, identify, and track CMC. PARTICIPANTS AND SETTING: Child welfare agencies across the US. METHODS: Agencies were recruited to complete a survey as part of a larger study exploring how CMC are served by the child welfare system. Survey responses related to defining, identifying, and tracking CMC were included in analysis. Descriptive statistical analysis was conducted with Stata. Qualitative content and thematic analysis were applied to free text responses. RESULTS: Surveys were completed by agencies from 28 states and 2 major cities. Nearly half of the agencies did not have a clear definition to identify CMC; those that did have a definition often lacked standardization. The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data. CONCLUSIONS: Many US child welfare agencies lack a clear definition to identify and track CMC, impacting the ability to tailor care and service delivery to meet their unique needs. To address this, a clear definition for CMC should be developed and consistently applied within child welfare data systems. Once CMC are identifiable, future research can collect population-level data and provide recommendations for best practices and policies.

Examining the effects of the Eckerd rapid safety feedback process on the occurrence of repeat maltreatment among children involved in the child welfare system.

BACKGROUND: The Eckerd Rapid Safety Feedback Process (ERSF) is an approach to child welfare practice that combines predictive risk modeling (PRM) with real-time quality assurance and staff coaching during a child protective services investigation. During the case investigation, quality assurance (QA) reviewers provide guidance to staff by assessing key dimensions of their investigative practices and providing coaching sessions as needed. OBJECTIVE: To determine to what degree ERSF reduced the incidence of children who experienced high severity physical, sexual, or neglect maltreatment (HS-CAN) among children known to a state child welfare agency, within 12 months of the agency's involvement in a previous investigation. METHODS: This multi-year quasi-experimental study evaluated the impact of the ERSF Process on risk of repeat high severity maltreatment among children and youth identified by a PRM algorithm as high risk for experiencing repeat maltreatment and receiving the additional QA intervention, compared to those receiving the usual standard of care. RESULTS: The ERSF Process did not lower the rate of HS-CAN among children identified as high risk. The joint odds ratio for receiving ERSF given being high risk was 1.05, i.e. a point estimate indicating higher probability of future HS-CAN. CONCLUSIONS: In this statewide implementation of ERSF, we did not find a positive effect of this particular PRM-based intervention. Future maltreatment, even within 12 months of a prior investigation, may be too distal an outcome for a PRM and QA process designed to produce a high-quality CPS investigation and safety plan.

Positive Indian Parenting: A Unique Collaborative Study in the Age of COVID-19.

Positive Indian Parenting (PIP) is a culturally based training developed by the National Indian Child Welfare Association in the mid-1980s that has been widely used across Indian Country. However, quantitative studies on its efficacy have not been conducted. This manuscript reports on the study design and development of an ongoing pilot study evaluating PIP and related adaptations that occurred within the context of the COVID-19 pandemic. Adaptations to the study were required to accommodate social distancing requirements, including changing to virtual platforms for curriculum delivery, fidelity monitoring, and data collection. Lessons learned include the importance of flexibility and supportive collaborations among study partners, including unique relationships with funders, that have enabled the ongoing study adaptations during the pandemic.

Intergenerational pathways leading to foster care placement of foster care alumni's children.

This study examined a path model that postulated intergenerational relationships between biological parent psychosocial functioning and foster care alumni mental health, economic status, and social support; and from these to the likelihood of children of foster care alumni being placed in foster care. The sample included 742 adults who spent time in foster care as children with a private foster care agency and who reported having at least one biological child. A full pathway was found between poorer father's functioning to greater alumni depression, which was in turn associated with negative social support, and then a greater likelihood of child out of home placement. Other parent to alumni paths were that poorer father functioning was associated with alumni anxiety and PTSD, and poorer mother's mental health was associated with PTSD; however, anxiety and PTSD were not implicated as precursors of foster care placement of the child. Findings support the need for increased practice and policy support to address the mental health needs of parents of children in or at risk of foster care, as well as the children themselves, as family history may have a lasting influence on quality of life, even when children are raised apart from biological parents.

Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma: a feasibility study.

OBJECTIVE: To assess the accuracy of an International Classification of Diseases (ICD) code-based operational case definition for abusive head trauma (AHT). METHODS: Subjects were children <5 years of age evaluated for AHT by a hospital-based Child Protection Team (CPT) at a tertiary care paediatric hospital with a completely electronic medical record (EMR) system. Subjects were designated as non-AHT traumatic brain injury (TBI) or AHT based on whether the CPT determined that the injuries were due to AHT. The sensitivity and specificity of the ICD-based definition were calculated. RESULTS: There were 223 children evaluated for AHT: 117 AHT and 106 non-AHT TBI. The sensitivity and specificity of the ICD-based operational case definition were 92% (95% CI 85.8 to 96.2) and 96% (95% CI 92.3 to 99.7), respectively. All errors in sensitivity and three of the four specificity errors were due to coder error; one specificity error was a physician error. CONCLUSIONS: In a paediatric tertiary care hospital with an EMR system, the accuracy of an ICD-based case definition for AHT was high. Additional studies are needed to assess the accuracy of this definition in all types of hospitals in which children with AHT are cared for.

Safety and risk assessment frameworks: overview and implications for child maltreatment fatalities.

This article highlights current models used in child protection to assess safety and risk, and discusses implications for child maltreatment fatalities. The authors advance that current risk and safety practice approaches were not designed to accurately estimate the likelihood of low base-rate phenomena and have not been empirically tested in their ability to predict or prevent severe or fatal child maltreatment. They advance that, regardless of the ultimate effectiveness of safety and risk tools, competent assessment and decision-making in child protection depend on sound professional judgment and a comprehensive systemic approach that transcends the use of specific tools.

Institutional predictors of developmental outcomes among racially diverse foster care alumni.

Child welfare practitioners are confronted with the responsibility of relying on best practice to ensure children in foster care transition successfully into adulthood after leaving the foster care system. Yet, despite recent reforms and efforts to address their needs, research clearly shows that foster care alumni are still more likely to experience negative developmental outcomes compared to adults in the general population. The purpose of this study was to better understand how child-serving systems of care adequately prepare racially diverse foster care alumni to thrive. Controlling for gender, age, placement instability, and circumstances of exit from foster care, study findings highlighted salient racial and ethnic differences relative to which factors predicted the odds of mental health, education, and employment outcomes. Implications for developing and implementing culturally sensitive, evidence-based prevention and intervention programs to promote positive developmental outcomes among racially diverse foster care alumni are discussed.

Family Group Decision Making (FGDM) with Lakota families in two tribal communities: tools to facilitate FGDM implementation and evaluation.

This article describes an adapted Family Group Decision Making (FGDM) practice model for Native American communities, the FGDM family and community engagement process, and FGDM evaluation tools as one example for other native communities. Challenges and successes associated with the implementation and evaluation of these meetings are also described in the context of key historical and cultural factors, such as intergenerational grief and trauma, as well as past misuse of data in native communities.

Strengthening families and communities to prevent child abuse and neglect: lessons from the Los Angeles Prevention Initiative Demonstration Project.

The Prevention Initiative Demonstration Project, funded by the Los Angeles County Department of Children and Family Services (DCFS), is a community-specific strategy delivered through eight regional networks designed to address the full spectrum of community-based prevention. This article summarizes a strong and meaningful pattern of improvements found in the second year evaluation for three groups of families--those living in high-risk communities but not involved with DCFS, those being investigated by DCFS for possible child maltreatment, and those with open DCFS cases.

Toolkit for Adapting Cognitive Behavioral Intervention for Trauma in Schools (CBITS) or Supporting Students Exposed to Trauma (SSET) for Implementation with Youth in Foster Care.

Cognitive Behavioral Intervention for Trauma in Schools (CBITS) was developed for use by school-based mental health professionals for any student with symptoms of distress following exposure to trauma. Supporting Students Exposed to Trauma (SSET) was adapted from CBITS for use by any school personnel with the time and interest to work with students affected by trauma. The purpose of this toolkit is to assist school-based mental health professionals, school personnel, and child welfare social workers in adapting these interventions for use with youth aged 10-15 who are in foster care. The authors note that delivering a school-based mental health program to youth in foster care has many challenges, including collaboration between the child welfare and education systems, confidentiality and information sharing policies regarding youth in foster care, and identification of these youth. The toolkit was designed to help understand these challenges and provide strategies for addressing them.

Context matters: real-world and utilization-focused evaluation strategies to support change and improvement in child welfare.

This article examines the importance of context in evaluative inquiry. Following guidelines from real-world and utilization-focused evaluation frameworks, four projects are described to illustrate one foundation's pragmatic approach to evaluation that values collaboration, methodological appropriateness, and utilization. The authors contend that such an approach helps to ensure meaningful and actionable results in child welfare because it is responsive to local agency information and capacity needs while simultaneously contributing to the knowledge base of the field.

Posttraumatic stress disorder among foster care alumni: the role of race, gender, and foster care context.

Little is known about the prevalence of posttraumatic stress disorder (PTSD) in adult alumni of foster care and its demographic and contextual correlates. This is one of the first studies to report on racial/ethnic and gender differences and the influence of foster care experiences (i.e., revictimization during foster care, placement change rate, and placement in kinship care) on past year PTSD. Findings revealed significant gender disparities and a moderating influence of kinship care on the relationship between gender and PTSD, as well as increased risk associated with a history of emotional and sexual abuse. Recommendations are made for clinical and systemic intervention.

Why current and former recipients of foster care need high quality mental health services.

This commentary presents data about the emotional, behavioral, and substance abuse disorders of youth in foster care and former recipients of foster care ("alumni") in the United States to underscore the reasons why high quality mental health services are essential.

Exploring spirituality among youth in foster care: findings from the Casey Field Office Mental Health Study.

This study examined spiritual coping mechanisms, beliefs about spirituality and participation in spiritual activities and in other positive activities among adolescents in foster care. A multidimensional measure of spirituality was developed for face-to-face interviews with 188 youth (ages 14-17) from diverse racial/ethnic backgrounds in the United States. Findings revealed 95% of youth believe in God, over 70% believe God is 'creator' and God is 'love', and 79% considered prayer a spiritual practice. Most youth said love and forgiveness help them heal. Two-thirds (67%) reported responding to 'bad or tragic things happening' by spending time alone, and over half responded by praying (59%) or sharing the problem with someone else (56%). Youth's top three spiritual goals were to follow God's plan for them, become a better person, and know their purpose in life. Based on the value youth ascribed to spiritual coping mechanisms, recommendations for policy and practice focus on the integration of spirituality into practice and caregiving for youth in foster care.

Mental health services for children placed in foster care: an overview of current challenges.

Given the evidence from studies indicating that children in care have significant developmental, behavioral, and emotional problems, services for these children are an essential societal investment. Youth in foster care and adults who formerly were placed in care (foster care alumni) have disproportionately high rates of emotional and behavioral disorders. Among the areas of concern has been the lack of comprehensive mental health screening of all children entering out-of-home care, the need for more thorough identification of youth with emotional and behavioral disorders, and insufficient youth access to high-quality mental health services. In 2001, the American Academy of Child and Adolescent Psychiatry (AACAP) and the Child Welfare League of America (CWLA) formed a foster care mental health values subcommittee to establish guidelines on improving policy and practices in the various systems that serve foster care children (AACAP and CWLA, 2002). Because of the excellent quality and comprehensiveness of these statements, the Casey Clinical Foster Care Research and Development Project undertook consensus development work to enhance and build upon these statements. This article presents an overview of mental health functioning of youth and alumni of foster care, and outlines a project that developed consensus guidelines.

Best practices for mental health in child welfare: screening, assessment, and treatment guidelines.

The Best Practices for Mental Health in Child Welfare Consensus Conference focused on developing guidelines in five key areas (screening and assessment, psychosocial interventions, psychopharmacologic treatment, parent engagement, and youth empowerment) related to children's mental health. This paper provides an overview of issues related to the first three areas, presents the guidelines developed in these areas, and discusses the implications these guidelines have for the field of child welfare.

Best practices for mental health in child welfare: parent support and youth empowerment guidelines.

This paper, the second in a series of two guideline papers emerging from the 2007 Best Practices for Mental Health in Child Welfare Consensus Conference, provides an overview of the key issues related to parent support and youth empowerment in child welfare and presents consensus guidelines in these important areas. The paper also discusses some of the implications these guidelines have for the child welfare field.

Effects of enhanced foster care on the long-term physical and mental health of foster care alumni.

CONTEXT: Child maltreatment is a significant risk factor for adult mental disorders and physical illnesses. Although the child welfare system routinely places severely abused and/or neglected children in foster care, no controlled studies exist to determine the effectiveness of this intervention in improving the long-term health of maltreated youth. OBJECTIVE: To present results of the first quasi-experimental study, to our knowledge, to evaluate the effects of expanded foster care treatment on the mental and physical health of adult foster care alumni. DESIGN: We used a quasi-experimental design to compare adult outcomes of alumni of a model private foster care program and 2 public programs. The latter alumni were eligible for but not selected by the private program because of limited openings. Propensity score weights based on intake records were adjusted for preplacement between-sample differences. Personal interviews administered 1 to 13 years after leaving foster care assessed the mental and physical health of alumni. SETTING/ PARTICIPANTS: A representative sample of 479 adult foster care alumni who were placed in foster care as adolescents (14-18 years of age) between January 1, 1989, and September 30, 1998, in private (n = 111) or public (n = 368) foster care programs in Oregon and Washington. More than 80% of alumni were traced, and 92.2% of those traced were interviewed. INTERVENTION: Caseworkers in the model program had higher levels of education and salaries, lower caseloads, and access to a wider range of ancillary services (eg, mental health counseling, tutoring, and summer camps) than caseworkers in the public programs. Youth in the model program were in foster care more than 2 years longer than those in the public programs. RESULTS: Private program alumni had significantly fewer mental disorders (major depression, anxiety disorders, and substance use disorders), ulcers, and cardiometabolic disorders, but more respiratory disorders, than did public program alumni. CONCLUSION: Public sector investment in higher-quality foster care services could substantially improve the long-term mental and physical health of foster care alumni.