Scaling-up Child and Youth Mental Health Services: Assessing Coverage of a County-Wide Prevention and Early Intervention Initiative During One Fiscal Year.

PURPOSE: In the U.S., the percentage of youth in need of evidence-based mental health practices (EBPs) who receive them (i.e., coverage rate) is low. We know little about what influences coverage rates. In 2010, the Los Angeles County Department of Mental Health (LACDMH) launched a reimbursement-driven implementation of multiple EBPs in youth mental health care. This study examines two questions: (1) What was the coverage rate of EBPs delivered three years following initial implementation? (2) What factors are associated with the coverage rates? METHODS: To assess coverage rates of publicly insured youth, we used LACDMH administrative claims data from July 1, 2013 to June 30, 2014 and estimates of the size of the targeted eligible youth population from the 2014 American Community Survey (ACS). The unit of analysis was clinic service areas (n = 254). We used Geographic Information Systems and an OLS regression to assess community and clinic characteristics related to coverage. RESULTS: The county coverage rate was estimated at 17%, much higher than national estimates. The proportion of ethnic minorities, individuals who are foreign-born, adults with a college degree within a geographic area were negatively associated with clinic service area coverage rates. Having more therapists who speak a language other than English, providing care outside of clinics, and higher proportion of households without a car were associated with higher coverage rates. CONCLUSION: Heterogeneity in municipal mental health record type and availability makes it difficult to compare the LACDMH coverage rate with other efforts. However, the LACDMH initiative has higher coverage than published national rates. Having bilingual therapists and providing services outside the clinic was associated with higher coverage. Even with higher coverage, inequities persisted.

Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses.

Homelessness represents an enduring public health threat facing communities across the developed world. Children, families, and marginalized adults face life course implications of housing insecurity, while communities struggle to address the extensive array of needs within heterogeneous homeless populations. Trends in homelessness remain stubbornly high despite policy initiatives to end homelessness. A complex systems perspective provides insights into the dynamics underlying coordinated responses to homelessness. A constant demand for housing assistance strains service delivery, while prevention efforts remain inconsistently implemented in most countries. Feedback processes challenge efficient service delivery. A system dynamics model tests assumptions of policy interventions for ending homelessness. Simulations suggest that prevention provides a leverage point within the system; small efficiencies in keeping people housed yield disproportionately large reductions in homelessness. A need exists for policies that ensure reliable delivery of coordinated prevention efforts. A complex systems approach identifies capacities and constraints for sustainably solving homelessness.

Social Cohesion, Neighborhood Collective Efficacy, and Adolescent Subjective Well-being in Urban and Rural Taiwan.

This study investigates the association between neighborhood social cohesion, collective efficacy, and adolescent subjective well-being in a nationally representative sample of Taiwanese youth. The study represents a first to adapt and test a developmental ecological model within a Chinese cultural context. Data came from the Taiwan Youth Project, which assessed representative samples of seventh graders (n = 2,690) and ninth graders (n = 2,851) from both urban and rural counties. The analytic sample included 4,988 adolescents (M age = 14.4, SD = 1.14; 50% female) in Taiwan. A path analysis estimated the direct and indirect effects of social cohesion on adolescent well-being. The results suggest that neighbors can affect young people's well-being by reinforcing their perception of safety and enhancing their self-esteem. Comparisons between youth from urban and rural areas demonstrate a general similarity in the developmental processes, though the perception of safety is less of a concern in rural areas. Findings emphasize universal aspects of neighborhood collective efficacy and developmental-ecological models, as well as allude to culturally specific dimensions in a Chinese-based context.

Exposure to Community Violence and the Trajectory of Internalizing and Externalizing Symptoms in a Sample of Low-Income Urban Youth.

This study examined trajectories of psychopathology in a sample of low-income urban youth and tested exposure to community violence as a predictor of these trajectories. Self-report and parent-report survey measures of psychological problems and exposure to community violence were collected annually over 3 years from a sample of 364 fifth- to ninth-grade low-income urban youth (64% female; 95% youth of color). Linear growth models showed that youth experienced declines in both internalizing and externalizing symptoms across adolescence. Exposure to community violence was more strongly associated with externalizing symptoms than with internalizing symptoms but predicted declines in both types of symptoms. Results also indicated that youth reported more internalizing and externalizing symptoms than their parents reported for them. Exposure to community violence may explain unique trajectories of mental health problems among low-income urban youth. In addition, youth efforts to adopt a tough façade in the face of community violence could lead to higher rates of externalizing problems relative to internalizing problems, whereas desensitization processes may better explain reductions in both types of symptoms over time. Finally, youth report may be more valid than parent report in the context of urban poverty.

Housing decisions among homeless families involved in the child welfare system.

The present study embedded a qualitative sub-study within a randomized controlled trial of housing services for child welfare-involved families to examine housing decisions made in the face of homelessness and child protection. Participants included a representative sample of caregivers (n = 19) randomized to receive the Family Unification Program - a permanent housing intervention for inadequately housed families under investigation for child abuse or neglect - or child welfare services-as-usual. Qualitative interviews 12 months after randomization assessed housing decision-making processes involved in keeping families safe and stable. Results indicated a push-pull dynamic that constrained housing choices regardless of whether permanent housing was made available. Caregiver housing decisions were constrained by time limitations, affordability, and access to services, while child and family safety was perceived as less important. Findings emphasize the need for housing informed child welfare services to ensure the long-term safety of children in families experiencing homelessness.

Permanent Housing for Child Welfare-Involved Families: Impact on Child Maltreatment Overview.

A longitudinal randomized controlled trial tested whether access to permanent housing reduces child maltreatment among inadequately housed families under investigation for child abuse and neglect. The study followed homeless and child welfare-involved families randomly assigned to receive a referral for housing subsidies plus housing case management (n = 75, 196 children) or housing case management alone (n = 75, 186 children). Latent growth models examined change in caregiver-reported frequencies of psychological aggression, physical abuse, and neglect toward children at five time points across 2.5 years. Intent-to-treat analyses suggested treatment differences for minor assault and neglect that approached significance; families randomly assigned to permanent housing plus case management exhibited marginally greater declines compared to families referred for housing case management only. Caregiver psychological aggression remained high over time, regardless of treatment condition. No evidence indicated higher risk families benefitted more from permanent housing. Results show some promise of permanent housing and highlight the complex needs of homeless families under investigation for child maltreatment. Findings emphasize the importance of continued involvement from the child welfare system to connect families with important resources.

Housing and Child Well Being: Implications for Research, Policy, and Practice.

Inadequate housing and homelessness represent significant barriers to family stability and child development. An accumulating body of evidence documents the relatively high risk of family separation among families experiencing housing instability and homelessness, the extent of housing problems experienced by families involved in the child welfare system, and the disproportionately high rates of homelessness among youth aging out of foster care. Vulnerable youth and families interact frequently with various social service programs intended to mitigate multifaceted and multilevel risks, however, systems efforts and resources are rarely coordinated and results to date are mixed. We introduce 13 papers that are part of a burgeoning, increasingly sophisticated body of scholarship that inform coordinated responses to inadequate housing experienced by families involved in child welfare and related interventions. We note emergent themes and state a pressing need for research that accounts for ecological and contextual influences, examines the differential impact of housing and service interventions, identifies critical ingredients of effective housing and service interventions, and positions for scale-up. We distill findings into a set of observations and recommendations that align with best intentions to improve quality of life and promote well being among some of society's most vulnerable individuals.

Housing and Child Welfare: Emerging Evidence and Implications for Scaling up Services.

Inadequate housing threatens family stability in communities across the United States. This study reviews emerging evidence on housing interventions in the context of scale-up for the child welfare system. In child welfare, scale-up refers to the extent to which fully implemented interventions sustainably alleviate family separations associated with housing instability. It incorporates multiple aspects beyond traditional measures of effectiveness including costs, potential reach, local capacities for implementation, and fit within broader social services. The framework further encompasses everyday circumstances faced by service providers, program administrators, and policymakers who allocate resources under conditions of scarcity and uncertainty. The review of current housing interventions reveals a number of systemic constraints for scale-up in child welfare. Reliance on rental assistance programs limits capacity to address demand, while current practices that target the most vulnerable families may inadvertently diminish effectiveness of the intervention and increase overall demand. Alternative approaches that focus on homelessness prevention and early intervention must be tested in conjunction with community initiatives to increase accessibility of affordable housing. By examining system performance over time, the scalability framework provides an opportunity for more efficient coordination of housing services within and outside of the child welfare system.

Homelessness and Aging Out of Foster Care: A National Comparison of Child Welfare-Involved Adolescents.

The present study represents the first large-scale, prospective comparison to test whether aging out of foster care contributes to homelessness risk in emerging adulthood. A nationally representative sample of adolescents investigated by the child welfare system in 2008 to 2009 from the second cohort of the National Survey of Child and Adolescent Well-being Study (NSCAW II) reported experiences of housing problems at 18- and 36-month follow-ups. Latent class analyses identified subtypes of housing problems, including literal homelessness, housing instability, and stable housing. Regressions predicted subgroup membership based on aging out experiences, receipt of foster care services, and youth and county characteristics. Youth who reunified after out-of-home placement in adolescence exhibited the lowest probability of literal homelessness, while youth who aged out experienced similar rates of literal homelessness as youth investigated by child welfare but never placed out of home. No differences existed between groups on prevalence of unstable housing. Exposure to independent living services and extended foster care did not relate with homelessness prevention. Findings emphasize the developmental importance of families in promoting housing stability in the transition to adulthood, while questioning child welfare current focus on preparing foster youth to live.

Longitudinal Impact of a Family Critical Time Intervention on Children in High-Risk Families Experiencing Homelessness: A Randomized Trial.

A randomized trial compared effects of a Family Critical Time Intervention (FCTI) to usual care for children in 200 newly homeless families in which mothers had diagnosable mental illness or substance problems. Adapted from an evidence-based practice to prevent chronic homelessness for adults with mental illnesses, FCTI combines housing and structured, time-limited case management to connect families leaving shelter with community services. Families were followed at five time points over 24 months. Data on 311 children-99 ages 1.5-5 years, 113 ages 6-10 years, and 99 ages 11-16 years-included mother-, teacher-, and child-reports of mental health, school experiences, and psychosocial well-being. Analyses used hierarchical linear modeling to investigate intervention effects and changes in child functioning over time. Referral to FCTI reduced internalizing and externalizing problems in preschool-aged children and externalizing for adolescents 11-16. The intervention led to declines in self-reported school troubles for children 6-10 and 11-16. Both experimental and control children in all age groups showed reductions in symptoms over time. Although experimental results were scattered, they suggest that FCTI has the potential to improve mental health and school outcomes for children experiencing homelessness.

Family and housing instability: Longitudinal impact on adolescent emotional and behavioral well-being.

This study investigated the longitudinal effects of family structure changes and housing instability in adolescence on functioning in the transition to adulthood. A model examined the influence of household composition changes and mobility in context of ethnic differences and sociodemographic risks. Data from the National Longitudinal Study of Adolescent Health measured household and residential changes over a 12-month period among a nationally representative sample of adolescents. Assessments in young adulthood measured rates of depression, criminal activity, and smoking. Findings suggested housing mobility in adolescence predicted poorer functioning across outcomes in young adulthood, and youth living in multigenerational homes exhibited greater likelihood to be arrested than adolescents in single-generation homes. However, neither family structure changes nor its interaction with residential instability or ethnicity related to young adult outcomes. Findings emphasized the unique influence of housing mobility in the context of dynamic household compositions.

Residential mobility during adolescence: Do even "upward" moves predict dropout risk?

This paper uses the National Longitudinal Study of Adolescent Health to investigate the impact of housing instability in adolescence on the likelihood of subsequent graduation from high school. Combining census data, self-reports, and information about respondents' residential changes, we use the variation in households' number of moves and neighborhood quality to predict whether participants obtain a high school diploma. Controlling for major predictors of housing mobility, students experiencing at least one move over a 12-month period have a roughly 50% decreased likelihood of obtaining a high school diploma by the age of 25. These associations are identified regardless of whether students move to a poorer or less-poor neighborhood. Our results carry implications for the development of housing policies and interventions designed for disadvantaged populations.

The Family Unification Program: A Randomized-Controlled Trial of Housing Stability.

The study tests the short-term impact on housing stability of the Family Unification Program (FUP), a permanent housing program for child welfare- involved families at risk of separation from children due to inadequate housing. Families eligible for FUP (n = 150) received housing case management services as usual, and half were referred for permanent housing vouchers made available through FUP. Families referred for FUP secured more enriched home learning environments, while more precariously housed families exhibited greater housing, stability when referred for FUP. The intervention did not relate with housing affordability or improvements in neighborhood quality. Findings suggest benefits of FUP-especially for more vulnerable families--in key areas that support child developmet; however, families continue to struggle in the context of poverty.

Effects of the SAFE Children preventive intervention on developmental trajectories of attention-deficit/hyperactivity disorder symptoms.

This study examined whether a family-based preventive intervention for inner-city children entering the first grade could alter the developmental course of attention-deficit/hyperactivity disorder (ADHD) symptoms. Participants were 424 families randomly selected and randomly assigned to a control condition (n = 192) or Schools and Families Educating Children (SAFE) Children (n = 232). SAFE Children combined family-focused prevention with academic tutoring to address multiple developmental-ecological needs. A booster intervention provided in the 4th grade to randomly assigned children in the initial intervention (n =101) evaluated the potential of increasing preventive effects. Follow-up occurred over 5 years with parents and teachers reporting on attention problems. Growth mixture models identified multiple developmental trajectories of ADHD symptoms. The initial phase of intervention placed children on more positive developmental trajectories for impulsivity and hyperactivity, demonstrating the potential for ADHD prevention in at-risk youth, but the SAFE Children booster had no additional effect on trajectory or change in ADHD indicators.

Family Unification Program: Housing Services for Homeless Child Welfare-Involved Families.

The Family Unification Program-a U.S. Department of Housing and Urban Development initiative to facilitate interagency collaboration between the child welfare and public housing service systems-aims to stabilize families at risk for parent-child separation by addressing housing needs. Findings from a randomized controlled trial suggest that families referred to the program experienced lower risk for homelessness and out-of-home placement compared with child welfare services as usual. The findings suggest that housing services offer an effective alternative to foster care.

Inadequate housing among families under investigation for child abuse and neglect: prevalence from a national probability sample.

This study aimed to estimate the prevalence of inadequate housing that threaten out-of-home placement among families under investigation by child welfare. Data came from the National Survey of Child and Adolescent Well-Being, a nationally representative longitudinal survey of child welfare-involved families. Child protective services caseworkers as well as caregivers provided information on families whose child remained in the home after initial investigation (N = 3,867). Multilevel latent class analyses tested the presence of inadequately housed subgroups using 4 housing problem indicators at baseline. Logistic regressions assessed convergent and predictive validity. A two class latent solution best fit the data. Findings indicated that inadequate housing contributed to risk for out-of-home placement in approximately 16 % of intact families under investigation by child protective services. These families were 4 times more likely to need housing services 12 months later. Federal legislation emphasizes integration of social services as necessary to end homelessness. This study demonstrates overlap across public agencies. Enhanced coordination of child welfare and housing services facilitates interventions to prevent and mitigate homelessness.

Community- and data-driven homelessness prevention and service delivery: optimizing for equity.

OBJECTIVE: The study tests a community- and data-driven approach to homelessness prevention. Federal policies call for efficient and equitable local responses to homelessness. However, the overwhelming demand for limited homeless assistance is challenging without empirically supported decision-making tools and raises questions of whom to serve with scarce resources. MATERIALS AND METHODS: System-wide administrative records capture the delivery of an array of homeless services (prevention, shelter, short-term housing, supportive housing) and whether households reenter the system within 2 years. Counterfactual machine learning identifies which service most likely prevents reentry for each household. Based on community input, predictions are aggregated for subpopulations of interest (race/ethnicity, gender, families, youth, and health conditions) to generate transparent prioritization rules for whom to serve first. Simulations of households entering the system during the study period evaluate whether reallocating services based on prioritization rules compared with services-as-usual. RESULTS: Homelessness prevention benefited households who could access it, while differential effects exist for homeless households that partially align with community interests. Households with comorbid health conditions avoid homelessness most when provided longer-term supportive housing, and families with children fare best in short-term rentals. No additional differential effects existed for intersectional subgroups. Prioritization rules reduce community-wide homelessness in simulations. Moreover, prioritization mitigated observed reentry disparities for female and unaccompanied youth without excluding Black and families with children. DISCUSSION: Leveraging administrative records with machine learning supplements local decision-making and enables ongoing evaluation of data- and equity-driven homeless services. CONCLUSIONS: Community- and data-driven prioritization rules more equitably target scarce homeless resources.

Meeting housing needs of child welfare-involved families: Policy insights from simulation modeling.

BACKGROUND: Inadequate housing contributes to the risk of family separation in nearly one-quarter of child maltreatment investigations. Child welfare struggles to identify and address the demand for housing assistance. A range of housing interventions shows promise for stabilizing families. Still, aid remains difficult to access, and little evidence exists for prioritizing households to interventions. Inefficient decisions about who to serve with scarce housing resources threaten to diminish resources and unintentionally place children at greater risk. OBJECTIVE: The present study leverages computational modeling to simulate the complex dynamics of coordinated child welfare response to inadequate housing. Simulations address the lack of microdata on current service delivery to inform policy-making that protects children from family insecurity. PARTICIPANTS AND SETTINGS: A series of simulated policy experiments test strategies for maximizing access to appropriate housing assistance and minimizing system-wide family separations using US estimates of housing insecurity and child welfare involvement. Models incorporate the feedback loops involved in seeking and waiting for needed services, using information on national rates of housing insecurity among child welfare-involved families. RESULTS: Results demonstrate population-level improvements in family stability from enhanced targeting of housing assistance to families most likely to benefit, plus expanded access to housing interventions. Neither improved screening procedures nor more housing supports alone improve child welfare outcomes. CONCLUSIONS: Findings emphasize the importance of data-driven upstream policies for protecting inadequately housed children at risk of maltreatment.

Emerging adulthood and leaving foster care: settings associated with mental health.

The present study examined the role of contextual support on mental health during the transition to adulthood within a vulnerable group, adolescents leaving foster care because of their age. Participants were 265 19- to 23-year-olds who retrospectively reported on 3 main contexts of emerging adulthood: housing security, educational achievement, and employment attainment in the first 2 years after leaving foster care. Mental health measured self-reported emotional distress, substance abuse, and deviancy at the time of interview. Growth Mixture Modeling empirically identified 3 latent trajectory classes. Stable-Engaged (41%) experienced secure housing and increasing connections to education and employment over time. Stable-Disengaged (30%) maintained housing but reported decreasing rates of education and small increases in employment. Instable-Disengaged (29%) experienced chronic housing instability, declined connection to education, and failed to attain employment. Stable-Engaged and Stable-Disengaged classes reported better mental health compared to the Instable-Disengaged class, indicating the importance of housing in transitioning to adulthood.