Children who return home from foster care: a 6-year prospective study of behavioral health outcomes in adolescence.

OBJECTIVE: Returning children to their biological families after placement in foster care (ie, reunification) has been prioritized with legislation. Comprehensive studies of child behavioral health functioning after reunification, however, have not been conducted. This study examined outcomes for youth who were reunified after placement in foster care as compared with youth who did not reunify. DESIGN: Prospective cohort. SETTING: Children who entered foster care in San Diego, California, and who remained in foster care for at least 5 months. Participants. A cohort of 149 ethnically diverse youth, 7 to 12 years old, who entered foster care between May 1990, and October 1991. Seventy-five percent of those interviewed at Time 1 were interviewed at Time 2 (6 years later). OUTCOME MEASURES: 1) Risk behaviors: delinquent, sexual, self-destructive, substance use, and total risk behaviors; 2) Life-course outcomes: pregnancy, tickets/arrests, suspensions, dropping out of school, and grades; 3) Current symptomatology: externalizing, internalizing, total behavior problems, and total competence. RESULTS: Compared with youth who were not reunified, reunified youth showed more self-destructive behavior (0.15 vs -0.11), substance use (0.16 vs -0.11), and total risk behavior problem standardized scores (0.12 vs -0.09). Reunified youth were more likely to have received a ticket or have been arrested (49.2% vs 30.2%), to have dropped out of school (20.6% vs 9.4%), and to have received lower grades (6.5 vs 7.4). Reunified youth reported more current problems in internalizing behaviors (56.6 vs 53.0), and total behavior problems (59.5 vs 55.7), and lower total competence (41.1 vs 45.0). There were no statistically significant differences between the groups on delinquency, sexual behaviors, pregnancy, suspensions, or externalizing behaviors. Reunification status was a significant predictor of negative outcomes in 8 of the 9 regression equations after controlling for Time 1 behavior problems, age, and gender. CONCLUSIONS: These findings suggest that youth who reunify with their biological families after placement in foster care have more negative outcomes than youth who do not reunify. The implications of these findings for policy and practice are discussed.

Children and youth in foster care: distangling the relationship between problem behaviors and number of placements.

OBJECTIVE: The purpose of this research was to provide a prospective look at the relationship between change in placement and problem behaviors over a 12-month period among a cohort of foster children. METHOD: The sample contained 415 youth, and was part of a larger cohort of children who entered foster care in San Diego, California and remained in placement for at least 5 months. The Child Behavior Check List was used to assess behavior problems. Every change of placement during the first 18 months after entry into the foster care system was abstracted from case records. RESULTS: The results suggest that volatile placement histories contribute negatively to both internalizing and externalizing behavior of foster children, and that children who experience numerous changes in placement may be at particularly high risk for these deleterious effects. Initial externalizing behaviors proved to be the strongest predictor of placement changes for the entire sample and for a sub-sample of those who initially evidenced problem behaviors on at least one broad-band CBCL scale. Our findings also suggest that children who initially score within normal ranges on the CBCL may be particularly vulnerable to the detrimental effects of placement breakdowns. CONCLUSIONS: On the basis of these findings we argue for an analytical approach that views behavior problems as both a cause and as a consequence of placement disruption. Children who do not evidence behavior problems may in fact constitute a neglected population that responds to multiple disruptions of their primary relationships with increasingly self-defeating behaviors.

Assessment of intimate partner violence among high-risk postpartum mothers: concordance of clinical measures.

Intimate partner violence (IPV) may be a more common problem than some conditions for which pregnant women are routinely screened and evaluated. Screening for IPV necessitates competence in assessment using reliable and valid instruments. The present study examines the concordance in the prevalence of abuse reported by 436 high-risk postpartum mothers using (1) a single item hospital screen, (2) trained paraprofessional interviewer-interview format, and (3) the Conflict Tactics Scale (CTS), a standardized research instrument. The hospital screen identified 4% of the sample as scared, threatened or hurt, the Family Stress Checklist (FSC) identified 16.9% of the fathers as having severe potential for violence, and the CTS identified 18.6% of the sample as victims of physical abuse at the hands of the baby's father. There was minimal overlap between the ratings of severe potential for violence and the occurrence of violence as assessed by the CTS. Study findings illustrate the inadequacy of current procedures for detecting IPV with high-risk populations and highlight the need to develop reliable and valid assessments that can be easily utilized in the hospital setting.

Children in foster care: factors influencing outpatient mental health service use.

OBJECTIVE: To determine factors influencing outpatient mental health service use by children in foster care. METHOD: Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL). RESULTS: Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60. CONCLUSIONS: Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.

The heterogeneity of children and their experiences in kinship care.

Increasingly, children in need of out-of-home care are being placed in kinship care, yet few studies have followed their placement histories longitudinally to determine if these children constitute a homogeneous group or heterogeneous subgroups. This study of 484 children in kinship care in San Diego County, California, indicates that children in kinship care have markedly different sociodemographic and maltreatment histories, as well as heterogeneous placement experiences.

Caregiver substance abuse among maltreated children placed in out-of-home care.

Child protective services (CPS) case records of 639 children placed in out-of-home care due to maltreatment were reviewed, and substance abuse by the child's caregiver prior to the child's placement was evaluated systematically. Based on several different sources of information, 79% of the caregivers were found to meet the criteria for caregiver substance abuse (CSA). Children with and without evidence of CSA differed on age, ethnicity, family composition, and type of maltreatment. The importance of operational specificity in defining CSA and implications for policy and service delivery are discussed.

Abnormal involuntary movements in neuroleptic-naive children and adolescents.

OBJECTIVE: To determine the prevalence of and identify risk factors for abnormal involuntary movements in a well-characterized community sample of neuroleptic-naive children and adolescents. METHOD: The Abnormal Involuntary Movement Scale (AIMS) was administered to 390 subjects aged 3-17 years who were in foster care. Additional instruments were used to assess intellect and behaviour problems. RESULTS: A total 12.6% of subjects had at least 1 rating of "mild" movements on AIMS; these included 4.1% with at least 2 ratings of "mild" or 2 of "moderate" severity. Significant risk factors for movement disorder were younger age, lower IQ, and more severe behaviour problems. The abnormal movements were usually orofacial, and the affected subjects were generally unaware of these movements. CONCLUSION: The base prevalence of abnormal involuntary movements must be considered in children and adolescents assessed for medication in order to determine the true rate of motor side effects.

Social information-processing patterns as predictors of social adaptation and behavior problems among maltreated children in foster care.

OBJECTIVE: The goal of this investigation was to determine if social information-processing patterns were predictive of later social adaptation and behavior problems within a group of maltreated children in foster care. METHOD: A longitudinal design was used to address the study hypotheses. The sample consisted of 124 maltreated children ages 5 to 10 who had been placed into foster care. Twelve months following entrance into foster care, children were presented with age-relevant hypothetical vignettes to assess the quality of the way in which they process social information. Six to 8 months following this assessment, caregivers completed the Vineland Adaptive Scales and the Child Behavior Checklist. RESULTS: Measures reflecting unbiased and competent processing were predictive of social adaptation, whereas measures reflecting biased and incompetent processing were predictive of behavior problems. In aggregate, processing measures accounted for a significant proportion of the variance in the outcome measures. CONCLUSIONS: The findings suggest that the manner in which maltreated children process social information has a bearing on their later social adaptation and behavioral adjustment. Therefore, maltreated children in foster care may benefit from interventions that target the manner in which they process social information.

Minority populations in the child welfare system: the visibility hypothesis reexamined.

This study tests the "visibility hypothesis," which suggests that there is a higher probability for minority children to be placed in foster care when living in geographic locations where their proportions in the population are relatively low, compared to areas where their proportions are high. Results support the hypothesis for African-American youth only. Explanations of the findings, and their implications for research and practice, are discussed.

Children who prosper in unfavorable environments: the relationship to social capital.

OBJECTIVE: Social capital describes the benefits that are derived from personal social relationships (within families and communities) and social affiliations. This investigation examined the extent to which social capital is associated with positive developmental and behavioral outcomes in high-risk preschool children. DESIGN: A cross-sectional case-control analysis of young children "doing well" and "not doing well" at baseline in four coordinated longitudinal studies. PARTICIPANTS: A total of 667 2- to 5-year-old children (mean age, 4.4 years) and their maternal caregivers who are participating in the Longitudinal Studies of Child Abuse and Neglect Consortium. At recruitment, all children were characterized by unfavorable social or economic circumstances that contributed to the identification of the children as high risk. MEASURES: Social capital was defined as benefits that accrue from social relationships within communities and families. A social capital index was created by assigning one point to each of the following indicators: 1) two parents or parent-figures in the home; 2) social support of the maternal caregiver; 3) no more than two children in the family; 4) neighborhood support; and 5) regular church attendance. Outcomes were measured with the Child Behavior Checklist, a widely used measure of behavioral/emotional problems, and with the Battelle Developmental Inventory Screening Test, a standardized test that identifies developmental deficits. Children were classified as doing well if their scores on these instruments indicated neither behavioral nor developmental problems. RESULTS: Only 13% of the children were classified as doing well. The individual indicators that best discriminated between levels of child functioning were the most direct measures of social capital-church affiliation, perception of personal social support, and support within the neighborhood. The social capital index was strongly associated with child well-being, more so than any single indicator. The presence of any social capital indicator increased the odds of doing well by 29%; adding any two increased the odds of doing well by 66%. CONCLUSIONS: Our findings suggest that social capital may have an impact on children's well-being as early as the preschool years. In these years it seems to be the parents' social capital that confers benefits on their offspring, just as children benefit from their parents' financial and human capital. Social capital may be most crucial for families who have fewer financial and educational resources. Our findings suggest that those interested in the healthy development of children, particularly children most at risk for poor developmental outcomes, must search for new and creative ways of supporting interpersonal relationships and strengthening the communities in which families carry out the daily activities of their lives.

Type of maltreatment as a predictor of mental health service use for children in foster care.

This study examined predictors of utilization of mental health services among children and adolescents in foster care. Of particular interest was whether the type of maltreatment was related to utilization of services. Subjects were 662 children ages 2-17 who were in foster care for at least 5 months. Service utilization, demographic, and behavioral data were collected through interviews with the subjects' caretakers. Type of maltreatment data were collected from Child Welfare case records. Fifty-six percent of the subjects had received mental health services. Children removed from their homes due to sexual and/or physical abuse were more likely to receive services than were those who were removed due to neglect and caretaker absence. Clinically significant behavior problems were associated with greater likelihood of receiving services, except for the sexually abused group who were very likely to receive services regardless of their behavior problem score. Sexually abused youth also received a higher number of outpatient visits than did neglected youth. In sum, youth who have experienced "active" types of maltreatment are more likely to receive mental health services than are those with "passive" types of maltreatment, even when the effect of severity of mental health problems is controlled.

The costs of a pediatric hospice program.

The recent literature on economic issues of hospice care leaves several questions unanswered. The most important issue concerns how this type of care can be made financially attractive to patients and families for whom it is a medical option. A major study of a home-based pediatric hospice program permitted a more careful analysis than was previously feasible of the charges for hospice care and how those charges are paid. Data on provider utilization and duration in the program were obtained retrospectively on 177 patients. Costs of incidental expenditures and indirect costs were obtained prospectively from the families of 27 patients. A cost model was developed which is general enough to be used by other hospitals that might contemplate establishing a similar hospice program. Our findings are that insurance coverage, especially for publicly funded patients, is likely to be a major impediment for families deciding whether or not to use a hospice program at home.

Educational, occupational, and insurance status of childhood cancer survivors in their fourth and fifth decades of life.

PURPOSE: Survivors of childhood cancer who are now greater than or equal to 30 years of age are available for study in significant numbers for the first time. An evaluation of their educational achievement, current employment status, frequency of problems in the work-place, and ability to obtain affordable health and life insurance was the aim of this study. PATIENTS AND METHODS: This was a case-control study of 219 childhood cancer survivors with individually matched controls from two tertiary-care pediatric centers. Telephone interviews were used and drew on a 356-item basic instrument for both subjects and controls. Medical (including intensity of therapy), marital, and psychosocial areas were included in the survey, but statistical comparisons concentrated on educational and economic issues. RESULTS: The overall current status of survivors and controls in the relevant areas, ie, education, employment, and insurance, was similar. A history of employment discrimination for entry into the uniformed services and in other special situations, and life insurance discrimination during the initial years after the completion of therapy was noted. Survivors experienced few problems in the work-place. Survivors of CNS tumors were unique, with problems in many of the areas studied, although there were notable individual exceptions. CONCLUSION: With the exception of those individuals with CNS tumor histories, survivors who were treated in the era of 1945 to 1975 had few economic sequelae of cancer or its therapy that extended beyond the first decades after treatment.

Deaths from falls in children: how far is fatal?

The outcome of injury was determined in 317 children who were brought to a children's trauma center with a history from the caretaker that the child had fallen. Cases in which the clinicians' judgment was that an incorrect history had been given were included along with cases in which the history was not questioned. Seven deaths occurred in 100 children who fell 4 feet or less. One death occurred in 117 children who fell 10 feet to 45 feet. The 7 children who died in short falls all had other factors in their cases which suggested false histories. When children incur fatal injuries in falls of less than 4 feet, the history is incorrect. Long falls with an outdoor component are likely to be reliable data points for studies of children's injuribility.

Help seeking and satisfaction with care in 641 women with eating disorders. I. Patterns of utilization, attributed change, and perceived efficacy of treatment.

Help-seeking patterns and satisfaction with care were described by 641 women with eating disorders participating in a national magazine survey. Between 60.6% and 92.9% of respondents in three diagnostic groups sought professional treatment. Professional treatments most often entered were individual psychotherapy (52.9%), behavioral therapy (28.0%), group therapy (24.6%), and nutritional therapy (18.6%). Treatments were generally seen as helping "a little." Only bulimic anorexia nervosa respondents perceived any interventions to be more harmful than helpful, specifically Overeaters Anonymous and self-help groups, both nonprofessional interventions. Caregivers selected as "experts" regarding eating disorders were rated as more efficacious than others, helping "a little" to "somewhat."

Long-term effects of testicular cancer on sexual functioning in married couples.

Long-term sequelae of testicular cancer have not been reported from the perspective of patient and spouse. As part of a larger study, both members of 34 married couples were interviewed individually, almost 4 years after treatment ended. Spouse and patient responses were compared for concordance (agreement) regarding psychosexual functioning and fertility issues. Wives perceived fewer long-term problems than husbands and were extremely supportive throughout their husbands' illnesses. At interview, whereas 23.5% of patients still felt less attractive as a result of treatment, no spouses shared this perception. Patients were more likely to report decreased, and wives increased sexual satisfaction compared to before cancer. However, both patients and spouses were more likely to report decreased frequency of intercourse than increased. In other areas as well, concordance was generally high. Few couples reported that infertility would pose a problem, but 53% were parents; men who banked sperm were less likely to already have children.

Behavioral distress in pediatric patients with cancer receiving chemotherapy.

The purpose of this study was to assess prospectively the behavioral effects of chemotherapy in children and adolescents with cancer. A total of 94 patients, with a range of malignancies and chemotherapy protocols, were evaluated 1, 4, and 7 months after treatment initiation. Assessments focused on behavioral distress symptoms and nausea/vomiting experienced in anticipation of chemotherapy and following its administration. Significant disturbances were described in a variety of domains, with adolescents exhibiting consistently higher levels of behavioral symptoms and nausea/vomiting than younger children. Behavioral distress tended to decrease and stabilize throughout time for children and to increase throughout time for adolescents. Age differences in behavioral distress were independent of the emetogenicity of therapy given to younger and older patients. The interaction of biologic and psychosocial factors in determining treatment-related distress is discussed, along with implications for future predictive and intervention studies.