Child Maltreatment, Mental Health, and Self-Reported Health Among Adolescent Girls in Child Welfare: Mediating Pathways.

Child maltreatment is common in the US and has been shown to be associated with physical and psychological health problems in adolescence and adulthood. Based on the allostatic load theory, this study examined the association between different types of child maltreatment (emotional, physical, and sexual abuse, and physical neglect) and self-rated health, and the mediating roles of post-traumatic stress and depression in these relationships. Participants were 249 girls involved in the child welfare system, ages 12-19 years, the majority of whom were African American. A one item self-reported general health measure, the Child Trauma Questionnaire-Short Form (CTQ-SF), Child PTSD Symptom Scale (CPSS) and the Child Depression Inventory (CDI) measured self-reported health, child maltreatment, and posttraumatic and depression symptoms, respectively. Higher levels of emotional, physical, and sexual abuse, and physical neglect were significantly associated with poorer ratings of health. PTSD and depression were significant mediators between histories of childhood emotional, physical, and sexual abuse and physical health. In conclusion, results indicate that the pathways from child abuse to physical health problems in adolescents are through psychological distress. Trauma focused interventions to reduce symptoms of PTSD and depression among this vulnerable group of adolescents are essential to improve health.

Exploring Bullying Perpetration and Victimization Among Adolescent Girls in the Child Welfare System: Bully-Only, Victim-Only, Bully-Victim, and Noninvolved Roles.

Childhood abuse is a common experience for youth in the child welfare system, increasing their risk of bullying perpetration and victimization. Little research exists that has examined the rates of bullying perpetration and victimization for child welfare-involved adolescent girls. The study addressed the following aims: (a) to generate frequency estimates of physical, nonphysical, and relational forms of bullying perpetration and victimization; (b) to identify the frequency of bully-only, victim-only, bully-victim, and noninvolved roles; and (c) to identify risk and protective factors that correlate with these bullying role types. Participants were 236 girls (12-19 years) in the child welfare system from a Midwestern urban area. Participants were referred to the study to join a trauma-focused group program. Seventy-five percent of the total sample were youth of color, with the remaining 25% identifying as White, non-Hispanic. Data were collected through baseline surveys that assessed childhood abuse, bullying perpetration and victimization, posttraumatic stress, substance misuse, aggression-related beliefs and self-efficacy, placement type, placement instability, and mental health service use. Child welfare-involved adolescent girls were found to assume all four major role types: bully-only (6.4%, n = 15), victim-only (20.3%, n = 48), bully-victim (44.1%, n = 104), and nonvictims (29.2%, n = 69). The bully-victim rate was approximately 7 times higher than the rate found in a nationally representative sample of non-child welfare-involved youth. The current study identified posttraumatic stress disorder (PTSD) symptoms, anger self-efficacy, and alcohol use as significant correlates of bullying roles. The identification of a substantially higher rate of bully-victims has important practice implications, suggesting child welfare and school systems adopt trauma-informed systems of care. Bully-victims are very likely traumatized children who are in need of effective trauma treatment rather than punitive sanctions.

Service Engagement and Retention: Lessons from the Early Childhood Connections Program.

The high attrition rates found in studies of early childhood home visitation create barriers to measuring the effectiveness of such programs. Most studies examine attrition at program completion. This practice may mask important differences in characteristics between families that end participation at various time points. This study helps address this gap by examining factors associated with percent attrition for early drop out (before three months) compared to the program midpoint (nine months or more) and program completion (18 months) using data from the treatment arm of a small feasibility study of enhanced referral to home visitation among child welfare-involved families (n = 64). Caregivers who identified as White tended to leave by the program midpoint and caregivers who had better social support were more likely to stay at the end of the program. This study is the only published study to date of participation in a community-based home visitation program by child welfare-involved families but several trends identified were consistent with prior studies with other populations. Given the very small sample size, both statistically significant and near significant trends are discussed in the context of existing literature. The practical variation found has implications for continuing to build knowledge of attrition in early childhood home visitation.

The role of physical activity enjoyment in the pathways from the social and physical environments to physical activity of early adolescent girls.

Most girls experience a notable decline in physical activity (PA) in early adolescence, increasing their risk for harmful health outcomes. Enjoyment for PA (i.e., positive feelings toward PA) is a determinant of PA among girls during adolescence and sustained PA throughout adulthood. Previous studies recommended increasing girls' PA enjoyment in order to increase their PA, but did not include environmental-level strategies for how families, schools, or communities do this. To gain insight on such strategies, this study examines the role of PA enjoyment as a mediator of social and physical environments to moderate-to-vigorous intensity PA of early adolescent girls. Cross-sectional, secondary analyses, using structural equation modeling, were conducted on a U.S. national dataset of 1721 sixth grade girls from the Trial of Activity for Adolescent Girls in 2003. Mediation model fit parameters included χ2 (292, N = 1721) = 947.73 p < 0.001, CFI = 0.95, RMSEA = 0.04 (90% CI = 0.03, 0.04), and SRMR = 0.037 suggesting overall good fit. There were no indirect effects on PA through PA enjoyment from the social or physical environmental factors. To PA, there were significant direct effects only from social support from friends (ß = 0.15, CI = 0.09, 0.22). To PA enjoyment, there were significant direct effects from social support from family (ß = 0.15, CI = 0.08, 0.23), school climate (teachers ß = 0.15, CI = 0.10, 0.21 and boys ß = 0.15, CI = 0.09, 0.20), and neighborhood environment (ß = 0.10, CI = 0.04, 0.17). The findings of this study identified several direct effects of the social and physical environment on PA enjoyment that can begin to inform environmental-level strategies for increasing PA enjoyment among early adolescent girls.

A Randomized Trial of Home Visitation for CPS-Involved Families: The Moderating Impact of Maternal Depression and CPS History.

Home visitation (HV) interventions may hold promise to improve parenting and prevent child maltreatment recidivism in families reported to child protective services (CPS) with young children, but this has rarely been studied. Findings are presented from an 18-month randomized controlled trial in which intact families ( N = 122) with at least one CPS report were provided with a facilitated connection to a paraprofessional evidence-based HV program or usual care services from child protection. Results are reported for changes in maternal stress, depression, and social support outcomes and repeat reports to CPS. No significant changes were found in maternal outcomes by group. Among nondepressed mothers or families without multiple CPS reports prior to study enrollment, HV was associated with a significantly lower likelihood of CPS report recidivism. These results indicate potential for HV to prevent maltreatment recidivism but suggest that higher intensity intervention is warranted for mothers exhibiting significant depressive symptoms or families with extensive CPS histories.

Mental Health Pathways Linking Childhood Maltreatment to Interpersonal Revictimization During Adolescence for Girls in the Child Welfare System.

This study compares the association of histories of childhood emotional, physical, and sexual abuse, and physical neglect with revictimization among adolescent girls, and investigates the role of posttraumatic stress and symptoms of depression as mediators. Participants were 234 girls aged 12 to 19 years, who have been involved with the child welfare system in a Midwestern urban area. Data were collected from baseline surveys of a trauma-focused group program to which the participants were referred. The majority of participants were youths of color (75%) who were primarily African American (70%), and the remaining participants were White, non-Hispanic (25%). Data were collected through surveys that assessed histories of child abuse and neglect, symptoms of posttraumatic stress and depression, and experiences of physical, verbal, and relational revictimization in the last 3 months. All types of abuse and neglect were significantly associated with higher frequencies of revictimization and higher levels of posttraumatic stress and depressive symptoms. Parallel mediation analyses demonstrated that both posttraumatic stress and depression fully mediated the relationships between emotional abuse and revictimization, and sexual abuse and revictimization. Physical abuse was fully mediated by posttraumatic stress, but not by depression. Results also indicated that neither posttraumatic stress nor depression were mediators for the relationship between neglect and revictimization. There were similar pathways to revictimization in adolescents from emotional and sexual abuse through posttraumatic stress and depression. Evidence is mounting for the deleterious effects of emotional abuse. There is evidence that treatment of both posttraumatic stress and depression in emotionally and sexually abused adolescents involved in child welfare is warranted to prevent future revictimization.

Trying to bridge the worlds of home visitation and child welfare: Lessons learned from a formative evaluation.

Young children in families contacting the child welfare system are at high risk of recurrent maltreatment and poor developmental outcomes. Home visitation programs to support parenting may offer hope as a preventive resource but these programs are rarely linked with child welfare. This article describes findings from a formative evaluation of a program designed to connect child welfare-involved families to an existing evidence-supported home visitation program. The program, Early Childhood Connections (ECC), was developed by a field-university partnership including leaders from a public state child welfare system, regional early childhood education systems, and several local agencies providing family support services. Despite extensive and rigorous planning by the workgroup and collaborative refining of the intervention approach as agency needs changed, the continued structural and policy changes within both the home visitation agency and the child welfare agencies created significant ongoing barriers to implementation. On the other hand, child welfare-involved families were receptive to engaging with home visitation. Implications of lessons learned for ongoing program development in this area are discussed.

Mental Health and School Functioning for Girls in the Child Welfare System: the Mediating Role of Future Orientation and School Engagement.

This study investigated the association between mental health problems and academic and behavioral school functioning for adolescent girls in the child welfare system and determined whether school engagement and future orientation meditated the relationship. Participants were 231 girls aged between 12 and 19 who had been involved with the child welfare system. Results indicated that 39% of girls reported depressive symptoms in the clinical range and 54% reported posttraumatic symptoms in the clinical range. The most common school functioning problems reported were failing a class (41%) and physical fights with other students (35%). Participants reported a mean number of 1.7 school functioning problems. Higher levels of depression and PTSD were significantly associated with more school functioning problems. School engagement fully mediated the relationship between depression and school functioning and between PTSD and school functioning, both models controlling for age, race, and placement stability. Future orientation was not significantly associated with school functioning problems at the bivariate level. Findings suggest that school engagement is a potentially modifiable target for interventions aiming to ameliorate the negative influence of mental health problems on school functioning for adolescent girls with histories of abuse or neglect.

Adaptation and implementation of a trauma-focused cognitive behavioral intervention for girls in child welfare.

This study describes the process of adapting and implementing Girls Aspiring toward Independence (GAIN), a trauma-focused, group-based therapy adapted from Cognitive Behavioral Intervention for Trauma in Schools (CBITS) for girls in child welfare. Descriptive data were examined on 3 outcomes: posttraumatic stress disorder (PTSD), depression, and social problem-solving skills among adolescent girls in the child welfare system. Qualitative and quantitative methods were utilized to inform the adaptation of the CBITS intervention, evaluate feasibility, treatment fidelity, and acceptability, and to test the effects of the intervention. Girls ages 12 to 18 (N = 27) were randomly assigned to the experimental and usual care conditions. Participants' symptoms of PTSD and depression and social problem-solving skills were evaluated at pre, post- (3 months), and follow-up (6 months) assessments. Adaptations for GAIN were primarily related to program structure. Data indicated that the program was receptive to girls in child welfare and that it was feasible to recruit, randomize, assess outcomes, and implement with adequate fidelity. Retention was more successful among younger girls. Descriptive initial data showed greater reductions in the percentage of girls with PTSD and depression, and modest increases in social problem-solving skills in the experimental versus usual care condition. Despite the growth of knowledge in dissemination and implementation research, the application of trauma-focused empirically supported treatment to child welfare populations lags behind. A large-scale RCT is needed to determine if GAIN is effective in reducing mental health problems and social problem-solving in the child welfare population. (PsycINFO Database Record

Childhood Abuse and Aggression in Adolescent Girls Involved in Child Welfare: The Role of Depression and Posttraumatic Stress.

This study investigated the relationship between histories of childhood abuse and aggressive behaviors among adolescent girls involved in child welfare, and determined whether symptoms of post-traumatic stress and depression mediated this relationship. Participants were 237 girls ages 12-19 years. Overall, results indicated 89 % of the adolescents endorsed at least one aggressive behavior towards others. Specifically, 72.0 % engaged in physical aggression, 78.5 % engaged in non-physical aggression, and 51.5 % endorsed relational aggression. Greater severity of emotional and physical abuse were significantly associated with a higher frequency of aggressive behaviors. Sexual abuse was not significantly related to aggression. Post-traumatic stress and depression fully mediated the relationship between emotional abuse and aggression, controlling for race, service use, and living situation. The linkages between physical abuse and aggression were not mediated by either post-traumatic stress or depression. Findings suggest that among adolescent girls with histories of emotional abuse, post-traumatic stress and depression represent potential modifiable risk factors to target for reducing aggression.

Relationship between abuse and neglect in childhood and diabetes in adulthood: differential effects by sex, national longitudinal study of adolescent health.

INTRODUCTION: Few studies have investigated links between child abuse and neglect and diabetes mellitus in nationally representative samples, and none have explored the role of obesity in the relationship. We sought to determine whether child abuse and neglect were associated with diabetes and if so, whether obesity mediated this relationship in a population-representative sample of young adults. METHODS: We used data from 14,493 participants aged 24 to 34 years from Wave IV of the National Longitudinal Study of Adolescent Health to study associations between self-reported child abuse (sexual, physical, or emotional abuse) and neglect as children and diabetes or prediabetes in young adulthood. We conducted sex-stratified logistic regression analyses to evaluate associations in models before and after the addition of body mass index (BMI) as a covariate. RESULTS: Although the prevalence of diabetes was similar for men and women (7.0% vs 6.7%), men were more likely than women to have prediabetes (36.3% vs 24.6%; omnibus P < .001). Among men, recurrent sexual abuse (≥3 lifetime incidents) was significantly associated with diabetes (OR, 3.66; 95% CI, 1.31-10.24), but not with prediabetes. There was no evidence of mediation by BMI. No forms of child abuse or neglect were associated with diabetes or prediabetes among women. CONCLUSIONS: Recurrent sexual abuse is robustly associated with diabetes in young adult men, independently of other forms of child abuse or neglect and BMI. Future research should explore other potential mechanisms for this association to identify avenues for prevention of diabetes among men who have experienced sexual abuse.

A preliminary examination of child well-being of physically abused and neglected children compared to a normative pediatric population.

Federal mandates require state child welfare systems to monitor and improve outcomes for children in three areas: safety, permanency, and well-being. Research across separate domains of child well-being indicates maltreated children may experience lower pediatric health-related quality of life (HRQL). This study assessed well-being in maltreated children using the Pediatric Quality of Life Inventory (PedsQL 4.0), a widely used measure of pediatric HRQL. The PedsQL 4.0 was used to assess well-being in a sample of children (N = 129) receiving child welfare services following reports of alleged physical abuse or neglect. We compared total scores and domain scores for this maltreated sample to those of a published normative sample. Within the maltreated sample, we also compared well-being by child and family demographic characteristics. As compared with a normative pediatric population, maltreated children reported significantly lower total, physical, and psychosocial health. We found no significant differences in total and domain scores based on child and parent demographics within the maltreated sample. This preliminary exploration indicates children receiving child welfare services have significantly lower well-being status than the general child population and have considerable deficits in social and emotional functioning. These findings support continued investment in maltreatment prevention and services to improve the well-being of victims of maltreatment.

The Moderating Effect of Marijuana Use on the Relationship between Delinquent Behavior and HIV Risk among Adolescents in Foster Care.

Adolescents in foster care experience mental health and substance use problems that place them at risk for HIV, yet the exact nature of the relationship remains unclear. This study examined the co-occurring influences of mental health problems and substance use on HIV risk and determined whether substance use moderated the effect of mental health problems on HIV risk behaviors among adolescents in foster care. Regression analyses of cross-sectional data collected through structured interviews with 334 adolescents, aged 15-18 years, determined which mental health problems and substances increased HIV risk behaviors. Adolescents with delinquency and anxiety/depression engaged in significantly more HIV risk behaviors than their counterparts, controlling for race, gender, and type of childhood abuse. Further, any marijuana use significantly moderated the effects of delinquent behaviors on HIV risk, differentially increasing HIV risk among those who engaged in delinquent behaviors.

Individual-level predictors of nonparticipation and dropout in a life-skills HIV prevention program for adolescents in foster care.

The purpose of this study is to identify individual-level characteristics of foster care adolescents who are more likely to not participate in, and drop out of, a life-skills HIV prevention program delivered over 8 months. Structured interviews were conducted with 320 foster care adolescents (15-18 years). Logistic regression and survival analyses (Cox Proportional Hazards Regression) determined the influence of demographics, HIV sexual risk behaviors, substance use, mental health problems, and other individual-level risk factors on nonparticipation and dropout. Older age and having vaginal intercourse without a condom were significant predictors of nonparticipation. Older age and marijuana use significantly increased the hazard of dropping out of the program. Foster care adolescents at increased risk for HIV infection were more likely to never participate in and drop out of the program. To improve initial and ongoing participation, HIV prevention efforts for adolescents in foster care should be tailored to individual-level HIV risk behaviors and incorporate early and ongoing engagement and retention strategies.

Substance use and mental health problems as predictors of HIV sexual risk behaviors among adolescents in foster care.

This study examined the relationship between substance use, mental health problems, and HIV sexual risk behaviors among a sample of foster care adolescents. Data were collected through structured baseline interviews with 320 adolescents (ages 15 to 18 years) who resided in foster care placements and participated in a larger evaluation study of an HIV prevention program. Final logistic regression models indicated that delinquent behavior and marijuana use were the most significant predictors of engaging in any one HIV risk behavior. Adolescents who reported delinquent behaviors, alcohol use, and marijuana use and who were female were more likely than their counterparts to engage in vaginal sex without using a condom. Future research is needed to further identify risk and protective factors for substance use, mental health problems, and HIV sexual risk behaviors among adolescents in foster care. HIV prevention efforts for these vulnerable adolescents should target those with substance use and delinquent behaviors.

Psychosocial resources and barriers to self-management in African American adolescents with type 2 diabetes: a qualitative analysis.

PURPOSE: The purpose of this qualitative study was to identify psychosocial resources and barriers to self-management among African American adolescents with type 2 diabetes and their mothers. METHODS: African American adolescents (n = 10) aged 14 to 19 years old with type 2 diabetes for >1 year and their mothers (n = 10) were recruited from the pediatric diabetes clinic of a large medical center practice. Participants were independently interviewed and responded to a series of open-ended questions concerning illness experiences and resources and barriers to diabetes self-management. This study used a modified grounded theory approach to data coding and analysis. RESULTS: Adolescents and mothers shared similar perceptions of resources and barriers to self-management. Resources included mother's role as the primary support person, emergence of greater self-efficacy and coping over time, family recognition of the seriousness of diabetes, and the presence of supportive peers. Barriers included comorbidity, dietary and other regimen challenges, negative peer influences, and financial problems. CONCLUSIONS: Resources and barriers identified in this study represent the multiple contexts that influence type 2 diabetes (eg, individual, family, peer, economic, and cultural).

Risk factors for alcohol and marijuana use among adolescents in foster care.

This study examined the influences of individual and social risk factors on alcohol and marijuana use among a sample of foster care adolescents. Data were collected through baseline structured interviews with 320 adolescents (aged 15-18 years) who resided in foster care placements and participated in a larger evaluation study of an independent living program. Approximately 40% of the adolescents reported alcohol use, 36% reported marijuana use, and 25% reported both alcohol and marijuana use during the 6 months prior to the interview. Final logistic regression models indicated that having friends who used marijuana and other substances and having skipped school remained most predictive of using alcohol, marijuana, or both alcohol and marijuana. Recommendations for substance abuse prevention and treatment for these vulnerable adolescents are proposed.

Signs of resilience in sexually abused adolescent girls in the foster care system.

In a sample of 99 sexually abused adolescent girls in the foster care system (64% in congregate living situations and 36% in family/foster care homes), nearly half were psychologically functioning well despite having experienced moderate-to-severe emotional, physical, and sexual abuse. It was hypothesized that these girls with resilient trajectories would differ from the currently symptomatic girls on several protective factors: education, future orientation, family support, peer influence, and religion. The results revealed that the girls with resilient trajectories were significantly more certain of their educational plans and optimistic about their future and had more positive peer influences.

Cultural relevancy of a diabetes prevention nutrition program for African American women.

Diabetes among African American women is a pressing health concern, yet there are few evaluated culturally relevant prevention programs for this population. This article describes a case study of the Eat Well Live Well Nutrition Program, a community-based, culturally specific diabetes prevention nutrition program for African American women. The stages of change theory and principles from community organization guided the development of the program. Health education strategies, including participatory development and program delivery by peer educators, were applied to promote cultural relevance. Results indicated that overall participants (90%) believed the program to be culturally relevant and were very satisfied with the program (82%). Cultural relevancy was significantly associated with greater program satisfaction and changes in dietary patterns when controlling for the number of sessions attended. Conclusions suggest that participatory strategies can be effective in designing culturally specific prevention programs for African American women.

Prevalence of psychiatric disorders among older youths in the foster care system.

OBJECTIVE: To estimate the lifetime and past year prevalence rates of major psychiatric disorders in a sample of older youths in the foster care system, to examine the timing of disorder onset and system entry, and to explore variations in past year prevalence rates. METHOD: Using the Diagnostic Interview Schedule for DSM-IV, interviews were conducted with 373 17-year-old youths (90% of those eligible) in one state's foster care system between December 2001 and June 2003. RESULTS: : Sixty-one percent of the youths qualified as having at least one psychiatric disorder during their lifetime; of these youths, 62% reported onset of their earliest disorder before entering the foster care system. In addition, 37% of youths met criteria for a psychiatric disorder in the past year. The number of types of maltreatment experienced was the most robust predictor of psychiatric disorder among several maltreatment variables. There were no differences in prevalence rates for youths in kinship care and those in nonkin foster families. CONCLUSIONS: Older youths in the foster care system have disproportionately high rates of lifetime and past year psychiatric disorders. Results support recommendations for initial and periodic mental health assessments for these youths and mechanisms to continue mental health services for young adults transitioning out of the foster care system.