Specialized programs employing different models of care delivery work collaboratively to address the health care needs of children in foster care.

Specialized knowledge and skills applicable to caring for children in foster care include guidelines developed to address this population's special health care needs, cross-system collaboration, and helping families cope with the health impacts of trauma. This paper begins with a review of the special health care needs of children in foster care and relevant guidelines. We discuss different models of health care delivery that can be employed to meet the special health care needs of children in foster care. We then provide examples of two programs employing different models of care that work collaboratively to deliver care to children in foster care in our community.

Sexual abuse and disclosure concerns of youth in foster care.

BACKGROUND: Youth in foster care have higher lifetime rates of sexual abuse victimization than their peers who are not in foster care. This sexual abuse occurs before, during, and after their placement. Yet there is a dearth of qualitative research focused on the characteristics of the abuse and the disclosure experiences of youth in foster care. OBJECTIVE: We aimed to understand potential barriers to disclosure for youth who were abused while in foster care. PARTICIPANTS & SETTING: Our study used anonymous, archival data of 143 one-on-one chat sessions on the US based National Sexual Assault Online Hotline (NSAOH) with youth currently living in foster care who sought help for sexual abuse. METHODS: Hotline staff summarized youth's disclosure experiences and barriers using an assessment that included open-ended responses. We used thematic analysis to code text segments. RESULTS: Youth in foster care most often discussed that the abuse was being perpetrated by a foster family member (66 %). Disclosure barriers included concerns for physical safety, not wanting to move placements, not trusting the system to keep them safe, and not wanting to disclose again after previously receiving a negative reaction to their disclosure. CONCLUSIONS: Youth in foster care who seek help for sexual abuse while in the foster care system have unique barriers to disclosure. This study underscores the need for more qualitative research with youth in foster care and includes safety recommendations and implications for training and education of those who work with youth in foster care.

Left behind? Educational disadvantage, child protection, and foster care.

BACKGROUND: Current educational policies for children involved with the Child Protective Services (CPS) system focus largely on the minority of children currently in or aging out of foster care, and target school stability and college access. OBJECTIVE: The present study investigates the nature of secondary (high school) education performance and attainment and post-secondary (college) enrollment among youth with prior or current CPS contact and their low-income, but not CPS-contacted, peers. METHOD: Following a cohort of over 63,000 high school students in Wisconsin, we use CPS investigation and placement records, and public school records to evaluate associations between CPS involvement and educational attainment. RESULTS: CPS-contacted youth have lower educational performance and greater academic challenges than their low-income peers. Youth aging out of care are uniquely disadvantaged with regard to on-time high school completion but complete high school and enroll in college at equal or higher rates than reunified youth. Across all groups, 55-75 % of those who graduated on time with "basic" or above English and math skills enrolled in college. Foster care experiences, such as time in care and placement instability, were not consistently associated with educational outcomes. CONCLUSION: Efforts to improve secondary education experiences are needed to bolster college and career pathways for disadvantaged youth.

Rates of out-of-home care among children in Canada: an analysis of national administrative child welfare data. / Taux de placement des enfants hors de leur foyer familial : analyse des données administratives nationales du système de protection de l'enfance au Canada.

INTRODUCTION: As a part of the public health approach to child welfare, data about children placed in out-of-home care are needed to assess population trends, understand drivers of social and health inequities, and examine outcomes for children and families. We analyzed administrative data from Canada to describe the population of children in out-of-home care, and estimate and compare rates of out-of-home care by province/territory, year, sex/gender, age group and placement type. METHODS: We conducted a cross-sectional analysis of point-in-time data from all provinces and territories for the period 2013/2014 to 2021/2022. We used frequencies and percentages to describe the population of children (and youth up to age 21 years) in out-of-home care and estimated overall and stratified rates and rate ratios. RESULTS: An estimated 61 104 children in Canada were in out-of-home care on 31 March 2022. The national rate of out-of-home care was 8.24 children per 1000 population. Rate variations by province/territory were substantial and changed over time. Rates were highest among males and children aged 1 to 3 and 16 to 17 years. Foster homes were the most common type of placement, although kinship homes accounted for an increasing share. CONCLUSION: This analysis demonstrated that administrative data can be used to generate national indicators about children involved in the child welfare system. These data can be used for tracking progress towards health and social equity for children and youth in Canada.

The point of view of children in residential and foster care on their health: A comparative study / Le point de vue des enfants en foyer et famille d'accueil sur leur santé : étude comparative

Although it is a major issue, the health of children and adolescents in care is still mainly explored on the basis of information provided by adults in French studies. This study therefore aims to make up for the lack of studies integrating the young people's own point of view and to explore certain aspects of health, as reported by the children and adolescents themselves, by comparing the health of children in care with that of children in the general population. The sample consists of 477 children in care (versus 23,672 who are not). The data were collected through a cross-sectional survey conducted by UNICEF France between October 2020 and March 2022 among 25,300 children and adolescents aged 6 to 18 who responded to a paper or online self-administered questionnaire. The main results of this study confirm the existing findings concerning the much greater health care needs of children and adolescents placed outside their homes (foster families, children's homes) compared to their peers. In particular, they underline greater psychological suffering linked to their life histories, health risk practices, sexual violence, and suicidal risk. The discussion addresses the complexity of the issues associated with their health and underlines the importance of taking into account the child's own point of view.

Bien qu'elle constitue un enjeu majeur, la santé des enfants et adolescents pris en charge au titre de la protection de l'enfance reste majoritairement explorée à partir d'éléments renseignés par les adultes dans le cadre des études françaises. Cette étude vise ainsi à pallier le manque d'études intégrant le propre point de vue des jeunes et à explorer certains aspects liés à la santé, tels que les enfants et adolescents peuvent eux-mêmes en rendre compte, en comparant la santé d'enfants accueillis en foyer ou famille d'accueil à celle d'enfants de la population générale. L'échantillon est constitué de 477 enfants placés (versus 23 672 qui ne le sont pas). Les données ont été recueillies dans le cadre d'une enquête transversale réalisée par l'UNICEF France entre octobre 2020 et mars 2022 auprès de 25 300 enfants et adolescents de 6 à 18 ans ayant répondu à un questionnaire papier ou en ligne auto-administré. Les principaux résultats de cette étude confirment les constats existants concernant les besoins de soins de santé beaucoup plus importants des enfants et des adolescents placés hors de leur domicile (famille d'accueil, foyer) comparativement à leurs pairs. Ils soulignent notamment une plus grande souffrance psychologique liée à leurs histoires de vie, les pratiques constituant un risque pour la santé, les violences sexuelles et le risque suicidaire. La discussion aborde la complexité des enjeux associés à leur santé et souligne l'intérêt de prendre en compte le point de vue de l'enfant lui-même.

National training and development curriculum training program impact on placement, permanency, and stability.

BACKGROUND: Resource parent trainings are an important factor in caregiver readiness and retention, which can improve placement stability and permanency achievement for children and youth, especially those who are marginalized. OBJECTIVE: Resource parents need access to evidence-based training programs attentive to caring for children and youth from a variety of diverse backgrounds. This study evaluates placement, permanency, and stability outcomes of children whose resource parents were trained in one such program: the National Training and Development Curriculum (NTDC). PARTICIPANTS AND SETTING: Participants include adults who completed a resource parent training program (N = 3822) and children in their care (N = 2565) in the U.S. states of Florida, Georgia, Illinois, and Missouri. METHODS: This quasi-experimental study involved statistical testing of caregivers and children using AFCARS data. Propensity-score matching was used to control for differences in the child permanency analysis. RESULTS: With a better understanding of the realities of fostering, NTDC participants were slightly less likely to foster after training (OR = 0.6; p < .001), self-selecting out before taking a child into the home. Those who did foster were more likely to foster a child who is a teen (OR = 1.4; p = .004), Asian/Asian American (OR = 3.8; p = .02), Black/African American (OR = 1.6; p < .001), or Hispanic/Latinx (OR = 1.7; p = .002). Children of NTDC caregivers entered legal adoptions (OR = 2.0; p = .003) and guardianships (OR = 2.9; p = .03) at higher rates than children of comparison caregivers, while rates of reunification (OR = 1.3; p = .11) were not statistically different. CONCLUSIONS: Evidence points to the effectiveness of NTDC in preparing resource parents to provide care for a diverse range of children by age, race, and ethnicity, and for those children to achieve permanency.

Foster Care Involvement Among Youth With Intellectual and Developmental Disabilities.

Importance: Youth with intellectual and developmental disabilities (I/DD) are more likely to be placed in foster care than other youth. Examining the clinical and sociodemographic characteristics of youth with I/DD in the foster care system is critical for identifying disparities and understanding service needs. Objective: To produce a population-level analysis of youth with I/DD in foster care that examines differences in rates of foster care involvement based on race, ethnicity, age, and sex. Design, Setting, and Participants: This cross-sectional study involved all individuals with I/DD 21 years and younger enrolled in Medicaid through foster care in 2016 via data from Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) for all 50 US states and Washington, DC. As a key insurer of I/DD services and foster care, Medicaid claims offer a timely population-level analysis. Youth with I/DD were grouped into diagnostic subgroups: autism spectrum disorder (ASD) only, intellectual disability only, or ASD and ID. The data analysis took place from July 2022 to September 2023. Exposure: TAF data contain Medicaid enrollment information by month with a binary indicator of foster care involvement, and eligibility files identify race, ethnicity, age, and sex. Main Outcomes and Measures: The period prevalence of foster care involvement was determined among I/DD youth by diagnostic subgroups using an intersectional approach across race, ethnicity, age, and sex. Logistic regression examined associations between risk for foster care involvement and race, ethnicity, age, and sex. Results: A total of 39 143 youth with I/DD had foster care involvement in 2016. Black youth (adjusted odds ratio [aOR], 1.37; 95% CI, 1.28-1.47) and females (aOR, 1.18; 95% CI, 1.1-1.27) had increased likelihood for foster care involvement. The likelihood for foster care involvement increased with age in all groups relative to the age group 0 to 5 years old. Conclusions and Relevance: This study found that among youth with I/DD, Black youth and females faced higher risk for foster care involvement, and the likelihood of foster care involvement increased with age. There is an urgent need for research that focuses on addressing system-level factors that drive increased risk. Understanding the specific health needs of Black and female youth with I/DD is critical to ensure the formation, implementation, and monitoring of equitable delivery of health services.

Systematic Review of the Evaluation of Foster Care Programs.

OBJETIVE: The aim of this study was to conduct an exhaustive synthesis to determine which instruments and variables are most appropriate to evaluate foster care programs (foster, kinship, and professional families). This evaluation includes the children, their foster families, their families of origin, professionals, and foster care technicians. METHOD: The systematic review included randomized, quasi-randomized, longitudinal, and control group studies aimed at evaluating foster care interventions. RESULTS: A total of 86 studies, 138 assessment instruments, 18 constructs, and 73 independent research teams were identified. CONCLUSIONS: (1) although the object of the evaluations was the children, the informants were usually the people in charge of their care; therefore, effort should be made to involve the children in a more participatory way; (2) psychosocial functioning, behavior, and parenting are transversal elements in most evaluations, while quality of life and coping are not sufficiently well incorporated; (3) practical instruments (brief and easy to apply and correct) that are widely used and carry scientific guarantees should be prioritized to ensure the comparability and reliability of the conclusions; and (4) progress should be made in the study of evaluation models for all forms of foster care, including foster, extended, and specialized families.

OBJETIVO: El objetivo es realizar una síntesis exhaustiva que contribuya a determinar qué instrumentos y variables son las más adecuadas para evaluar programas de acogimiento familiar (familias extensas, ajenas y profesionalizadas), incluyendo en esta evaluación a los niños, sus familias acogedoras, sus familias de origen y a los profesionales y técnicos del acogimiento familiar. Método: La revisión sistemática incluyó estudios aleatorizados, cuasialeatorizados, longitudinales y con grupo control dirigidos a evaluar intervenciones de acogimiento familiar. RESULTADOS: Se identificaron 86 estudios, 138 instrumentos de evaluación, 18 constructos y 73 equipos de investigación independientes. CONCLUSIONES: (1) aunque el objeto de las evaluaciones sean los niños, habitualmente los informantes son las personas a cargo de sus cuidados, con lo que se debe hacer un esfuerzo por involucrarlos de forma más participativa; (2) el funcionamiento psicosocial, el comportamiento o la parentalidad son elementos transversales en la mayor parte de evaluaciones, sin embargo la calidad de vida y el afrontamiento no están suficientemente bien incorporados; (3) deben priorizarse instrumentos prácticos (breves y fáciles de aplicar y corregir), de amplio uso y con garantías científicas para asegurar la comparabilidad y fiabilidad de las conclusiones; (4) debe avanzarse en la investigación de modelos de evaluación en todas las modalidades de acogimiento familiar, ya sea en familias ajenas, extensas o especializadas.

The unanticipated side effects of an attachment intervention: Parents ask higher quality questions.

Research suggests foster children are at risk for poor language skills. One intervention, attachment and biobehavioral catch-up (ABC), was shown to successfully improve not only young foster children's attachment to their parents, but also their receptive vocabulary skills (Bernard et al., 2017; Raby et al., 2019). Given that language acquisition is intricately linked to parents' sensitive interactions with their children, we ask whether the ABC intervention also improves the quality of parents' talk addressed to children. We test whether the ABC intervention results in more conversational turns between parents and their children. Crucially, we also look within these conversational turns, assessing the number and types of questions that parents ask children. Results suggest that parents who received the ABC intervention do not have more conversational turns or ask higher numbers of questions, compared to parents who received the control intervention. Rather, parents in the ABC group ask a higher proportion of child-led and restatement questions, and a lower proportion of parent-led and pedagogical questions, compared to the control. Additionally, the higher proportion of child-led questions were related to higher parental sensitivity scores. Together, these results suggest that an intervention originally designed to improve children's socioemotional outcomes had positive benefits for the quality of conversations between parents and children. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cardiovascular Disease and Risk Factors in Individuals With a History of Out-of-home Care.

BACKGROUND: Exposure to childhood out-of-home care (foster family and residential care) is associated with an increased risk of ill-health and disability in adulthood, but the risk for cardiovascular disease has not previously been studied longitudinally. METHODS: This was a national cohort study generated from linkage of a range of population-based registers, resulting in a national cohort of 881 731 of whom 26 310 (3.0%) had a history of out-of-home care. The study population, born 1972 to 1981, was followed from age 18 to age 39 to 48 years for hospitalizations and death. RESULTS: After adjusting for year of birth and maternal education, individuals with a history of childhood out-of-home-care experienced a doubling of the risk for coronary disease (hazard ratio; 95% confidence interval: 2.05; 1.74-2.41) and stroke (hazard ratio 1.85; 1.59-2.15), compared with the general population, with similar estimates for men and women. Women with a history of out-of-home care had a more than doubled risk for cigarette smoking in early pregnancy, with a relative risk of 2.26; (2.18-2.34) and a moderately increased risk for gestational diabetes relative risk 1.49 (1.19-1.86). There was marked attenuation (40% to 90%) in effect estimates for disease and risk factors after further control for cohort members educational achievement at age 15-16 years. CONCLUSIONS: A history of childhood out-of-home care was associated with a doubled risk of early cardiovascular disease events. Cigarette smoking and educational underachievement were the main identified risk factors.

Does a child maltreatment report source predict differences in immediate and subsequent report outcomes?

BACKGROUND: Mandated reporting policies, a core response to the identification of child maltreatment, are widely debated. Currently, there are calls to abolish or scale back these policies to include only certain professionals. These calls warrant evaluation of whether there are any differences in child welfare outcomes based on report source. OBJECTIVE: To determine if the initial report source predicts immediate and long-term risk of re-referral, substantiation, and placement. PARTICIPANTS AND SETTING: We used yearly National Child Abuse and Neglect Data System (NCANDS) hotline report and placement data. Children (0-14y) with a first ever hotline report in 2012-2014 were followed for three years. The final sample included 2,101,397 children from 32 states. METHODS: We use descriptive and bivariate statistics to show initial report outcomes by reporter source type and logistic regression models to evaluate the effect of report source on immediate and subsequent report outcomes. RESULTS: Professional sources varied in levels of substantiation and placement, with law enforcement, medical, and social service sources showing much higher rates. Reports from professional sources have higher odds of initial report substantiation and foster care entry, and slightly lower odds of later re-report than nonprofessional sources. We found no differences between professional and nonprofessional sources in subsequent foster care entry. CONCLUSIONS: Reports from professional, nonprofessional, and unclassified sources have varying levels of risk in some of their short- and long-term outcomes. To the degree that child protective services embrace a long-term preventative role, reports by nonprofessional report sources may provide opportunities for prevention.

"We are not our case files": A qualitative analysis of child welfare professionals' relationships with young adults with foster care experience.

BACKGROUND: Young adults of color with foster care experience are disproportionately represented in foster care in the United States. Developing meaningful connections with child welfare professionals can help young adults develop healthy relationships in emerging adulthood. OBJECTIVE: This exploratory qualitative study addressed how young adults with foster care experience described their relationships with child welfare professionals and the impact of these relationships on their overall mental health and well-being in young adulthood. PARTICIPANTS AND SETTING: A sample of young adults of color, (ages 18-29) with lived experience in foster care from a performing arts program in New York City. METHODS: Reflexive thematic analysis was conducted on 14 semi-structured interviews with young adults of color with prior or ongoing foster care experience. RESULTS: The following themes were identified: safe space to be myself, listen to more than words, and understand my trauma. Child welfare professionals were dropped from support networks if they were disingenuous or did not attend to their own self-care needs. CONCLUSIONS: The study underscores the importance of promoting positive mental health outcomes for young adults through building stronger connections with child welfare professionals. Future research should explore the incorporation of individualized approaches to better serve this population of young adults.

Do Peers, Neighborhood Disorder, Religiosity, Spirituality, and Family Support Influence Polysubstance Use Among Older Youth Transitioning from Foster Care?

PURPOSE: Few studies have explored polysubstance use among youths aging out of foster care, despite higher rates of substance misuse for youths exiting foster care than those in the general population. Polysubstance use has been linked to substance use disorders, health problems, cognitive impairment, suicide, and overdose. METHOD: This study investigates understudied risk and protective factors associated with polysubstance use with data from 384 youth who turned 17 years old between December 1, 2001, and June 30, 2003, and were transitioning out of foster care from the Missouri Children's Division. We conducted bivariate analyses with chi-square tests for categorical variables and Analysis of Variance with continuous independent variables. Then we conducted a multinomial logistic regression to explore differences between individuals who used 1 or no substances, individuals who used only alcohol and marijuana, and individuals who used 2 or more substances. RESULTS: Bivariate analyses found that being white, having deviant peers, and living in a more disordered neighborhood were risk factors for polysubstance use. Multinomial logistic regression results found that being white (RR = 6.89, p < .001), having deviant peers (RR = 1.15, p < .001), and living in a more disordered neighborhood (RR = 1.13, p < .05), increased the risk engaging in polysubstance use. DISCUSSION: Similar to findings in other studies, we found that deviant peers and neighborhood disorder increase the risk of polysubstance use, but family support, church attendance, and spirituality were not protective against polysubstance use. CONCLUSION: Interventions should work to reduce deviant peer relationships among foster youth.

The hole in my heart is closing: Indigenous relative reunification identity verification.

OBJECTIVE: The current study explored the experience of reunification as place identity verification for Indigenous individuals who were fostered/adopted as youth. BACKGROUND: Research on reunification tends to focus on disproportionality in child welfare and the factors associated with reunification. Few studies focus on experiences of reunification among Indigenous individuals including their perceptions and comprehensions about the reunification experience. METHOD: Data from 70 fostered/adopted Indigenous individuals that reunified during adulthood were analyzed from the Experiences of Adopted and Fostered Individuals Project. Inductive thematic analysis was used to examine open-ended survey data about experience of reunification. RESULTS: Three themes inductively emerged including: (1) relative reunification, (2) perceptions about reunification, and (3) comprehensions about reunification. During relative reunification, participants reunified with parent(s), extended caregiver(s), grandparent(s), sibling(s), cousin(s), niece(s)/nephew(s), and tribe. Participant's perceptions about reunification included happiness, relief, anger, mourning, and anxiety/excitement. Participant's comprehensions about reunification related to belonging, sense of place, history/heritage, healing, and resemblance. All five functions of place identity verification were met in reunification according to the Indigenous participant's voices. CONCLUSIONS: This study explored the experience of relative reunification of Indigenous individuals who were separated from their families of origin during childhood by foster care and adoption.

Longing to belong: The ambiguous loss of Indigenous fostered/adopted individuals.

BACKGROUND: Indigenous fostered/adopted individuals report high levels of grief because of their foster care/adoption. Little has been done, however, to explore how grief is experienced and the factors that contribute to said grief for fostered/adopted Indigenous individuals. OBJECTIVE: This study examined the experiences of loss and grief of Indigenous individuals fostered/adopted during childhood. PARTICIPANTS AND SETTING: Participants were 102 Indigenous fostered/adopted individuals who described the experiences of loss and grief related to adoption. METHODS: This study utilized secondary data from the Fostered and Adopted Individuals Project. Inductive thematic analysis was conducted on open-ended survey data. RESULTS: Two themes emerged: (1) ambiguous loss as a result of foster care and adoption and (2) the effects of the ambiguous loss that stem from foster care and adoption. Indigenous fostered/adopted persons experienced ambiguous loss in foster care and adoption. Their loss remained unresolved due to a loss of access to information about their family and tribe of origin. Although family of origin, tribal community, and culture were not physically present due to separation by foster care/adoption, they remained psychologically present. As a result of ambiguous loss, participants experienced disenfranchised grief, wondering and longing to belong, and mental health and substance abuse. CONCLUSION: This study is the first of its kind to explore the loss and grief experiences of fostered/adopted Indigenous individuals using ambiguous loss theory. Ambiguous loss theory offers a framework for contextualizing the loss and grief that begins at separation and is present in adulthood.

Rates of Emotional Disturbance Among Children in Foster Care: Comparing Federal Child Welfare Data and Medicaid Records in Two States.

The purpose of this study is to estimate the rate of emotional disturbance (ED) among children in foster care and assess the validity of the national foster care census data (AFCARS) measure of ED. This study used linked child protection and Medicaid records from 2014 and 2015, for the states of California and Wisconsin, as well as data from AFCARS, a federal population census of children in foster care which states are mandated to contribute to. ED is defined by AFCARS and includes an array of mental and behavioral health diagnoses. According to AFCARS, 13% of CA children in foster care and 15% of WI children in foster care had an ED, whereas Medicaid claims produce rates of 45% and 48%, respectively. Rates of ED among children in congregate care were underestimated by 43-46 percentage points, with substantial proportions having diagnoses of disruptive behavioral disorders. Despite the AFCARS ED measure being cited in congressional testimonies and its wide use in research, results from this study suggest that the AFCARS ED estimates are an unreliable metric for use in research, policy, or practice.

Are Home Evictions Associated with Child Welfare System Involvement? Empirical Evidence from National Eviction Records and Child Protective Services Data.

This study aimed to understand the relationship between home eviction and child welfare system involvement at the county level. Using administrative data, we examined associations of home eviction and eviction filing rates with child abuse and neglect (CAN) reports and foster care entries. We found one additional eviction per 100 renter-occupied homes in a county was associated with a 1.3% increase in the rate of CAN reports and a 1.6% increase in foster care entries. The association between eviction and foster care entries was strongest among Hispanic children with an 8.1% increase. Assisting parents in providing stable housing may reduce the risk of child welfare system involvement, including out-of-home child placement. Primary and secondary prevention strategies could include housing assistance, increasing access to affordable and safe housing, as well as providing economic support for families (e.g., tax credits, childcare subsidies) that reduce parental financial burden to access stable housing.

Impact of Safe@Home on Placement and Permanency Outcomes: Results of a Quasi-Experimental Study.

This study assessed the effectiveness of Safe@Home, an in-home intervention to (1) prevent out-of-home placement for children at imminent risk of placement, and (2) minimize time in out-of-home care for children already in foster care. Using Coarsened Exact Matching, children who received Safe@Home were matched to a comparison group of children served before Safe@Home was available in their community. All children were determined by the child welfare agency to be unsafe and in need of immediate intervention. The matched samples (Safe@Home n = 510, Comparison n = 851) showed strong baseline equivalence on child age, race/ethnicity, previous history of child welfare involvement, and safety threats. Children who received Safe@Home experienced lower rate of out-of-home placements, higher rate of permanency with a parent (sustained for 12 months after the end of Safe@Home), fewer days in out-of-home care, and shorter time to case closure relative to children who received treatment as usual. There was no effect of Safe@Home on post-permanency outcomes of maltreatment and entry or re-entry after case closure.

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.