Early Childhood Development & Related Policy Implications: Young Children in Child Welfare

1. Early Childhood Development & Related Policy Implications: Young Children in Child Welfare Laurel K. Leslie, MD, MPH Institute for Clinical Research and Health Policy Studies Tufts-New England Medical Center Presentation for the 12th National Conference on Children and the Law

2. Disclosures • The speaker does not have any financial ties to disclose • These materials contain informational slides that will not be discussed during the presentation

3. Goal of this Presentation • Review what we know regarding • The Problem: Developmental & behavioral problems in young children in child welfare • Current service/treatment use • Information presented draws heavily on the NSCAW study (see next 5 slides) • Present a framework to guide development of community-based initiatives to improve outcomes

4. Background: National Survey of Child and Adolescent Well-being (NSCAW) • Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Title V, Section 429A (PL 104-193) • Congressional mandate to the Secretary to conduct a “national random sample study of child welfare” • www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw (No prior child welfare study has ever attempted anything remotely this ambitious)

5. Partners • Extended Research Team includes: • Research Triangle Institute • University of North Carolina • Caliber Associates • San Diego Children’s Hospital • CSRD, Pittsburgh Medical Center • Duke Medical Center • U.C. Berkeley • National Data Archive on Child Abuse and Neglect, Cornell • 92 Local Child Welfare Agencies • Children, Caregivers, and Teachers • Administration For Children and Families

6. Total 6,231 Long-term foster care 727 Enter through investigation 5,504 Other gateways 600 No services 1,725 Ongoing services 3,779 In home 2,312 Out-of-home 1467 NSCAW Cohort

7. Data Collection Timeline Wave 1: Baseline Nov, 1999 – Apr, 2001 Target population: Children involved in investigations closed between October 1, 1999 and December 31, 2000 Wave 2: 12 Month Follow-up Oct , 2000 – Apr, 2002 Wave 3: 18 Month Follow-up Apr, 2001 – Sept, 2002 Wave 4: 36 Month Follow-up Oct, 2002 – Apr 30, 2004 1999 ‘ 2000 ‘ ‘ ‘ ‘ 2001 ‘ ‘ ‘ ‘ 2002 ‘ ‘ ‘ ‘ 2003 ‘ ‘ ‘ ‘ 2004

8. Data Sources • Children • Assessments by Field Representatives • Interviews (children 7 and older) • Caregiver (parent) interviews • Caseworker interviews • Teacher questionnaires • Agency administrators

9. Defining the “Problem” • Young children make up a substantial proportion of children in child welfare • 28% of children in out-of-home care in 2002 were age 5 or younger • Many children experiencing abuse &/or neglect during early years of life when neurological development is most active & vulnerable • Some experience out-of-home placement which may positively or negatively affect a child’s neurological development

10. Are These Children at Risk? • Children with disabilities more vulnerable to maltreatment • Possible genetic predisposition • Many of these children display environmental risk factors for developmental & behavioral problems • Abuse/neglect/poverty/violence • Inadequate preventive health care so problems not prevented or identified (e.g. prenatal infections, lead exposure) • Parents with mental illness &/or substance abuse • Parenting practices (harsh, inconsistent discipline; lack of supervision; limited reinforcement of appropriate prosocial skills)

11. Is there a Reason to Worry? Rates • For young children in child welfare, high rates of problems in multiple studies • Developmental problems: as high as 60% compared to 4-10% in general population • Behavioral problems: as high as 40% compared to 3-6% in general population

12. NSCAW: Other Disabilities in Young Children?(Stahmer et al., 2005; percentages indicate scores < 2 SD from the mean)

13. Developmental/Behavioral Measures: 0-5 years • Developmental • Neurodevelopmental • Bayley Infant Neurodevelopmental Screener (13-24 months) • Cognition • Battelle Developmental Inventory (ages 0-4 years) • Kaufman Brief Intelligence Test (ages 4-5 years) • Speech/Language • Preschool Language Scale (ages 0-6 years) • Behavioral • Child Behavior Checklist (ages 18 months-5 years) • Social Skills Rating Scale: Prosocial Scale (ages 3-5 years) • Vineland Adaptive Behavior Scales (all ages)

14. Mental Health/Developmental Overlap in Young Children (Stahmer et al., 2005; percentages indicate scores < 2 SD from the mean) • Next steps • Define specific subgroups of need • Examine how need changes over time • Examine if service use has any impact on need

15. Is There a Reason to Worry? Placement Patterns • For children in out-of-home care, • Behavior problems associated with increased placement disruptions (James et al., 2004) • Developmental & behavioral problems correlated with longer lengths of stay in out-of-home care, less reunification, less adoption • (Horowitz et al., 1994: Landsverk et al., 1996)

16. Is There Reason to Worry? Outcomes • For older youth in child welfare, many face academic difficulties, high school drop-out rates, mental health issues, delinquency, risky behaviors

17. Diurnal HPA axis activity (downregulation via chronic stress) Note: Low daytime activity does not infer a blunted HPA stress response (see Kaufman et al., 1997)

18. Do foster children show atypical patterns of HPA axis activity? Delaware Oregon Bruce, Fisher, Pears, & Levine (submitted) Dozier et al. (in press)

19. The Good News • Brain is highly adaptive & malleable during these early years • Growing body of scientific evidence pointing to the potential for early intervention in young children • Intensive services with preschoolers in child welfare can normalize these cortisol patterns • (Fisher et al., 2006)

20. Programs Applicable to Young Children in Child Welfare I • Medical • Medicaid (www.cms.hhs.gov/medicaid/) • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program in Medicaid (www.cms.hhs.gov/medicaid/epsdt/default/asp.) • Title V Maternal and Child Health Services (https://.performance.hrsa.gov/mchb/) • Child Welfare • Title IV-E & Title IV-B for children & families in child welfare (http://www.acf.dhhs.gov)

21. Programs Applicable to Young Children in Child Welfare II • Social Services: • Title XX Social Services Block Grant (http://www.acf.hhs.gov/programs/) • Special Education: • IDEA Special Education Services (3-21 years) & Early Intervention services (0-2 years) (http:www.ed.gov) • State-based mental health & developmental disability programs

22. Child Service Use in NSCAW Sample • Caregiver report of service use: • Overall: only 22.7% of children using services • Primary care (p<.001) • 0-2 yr olds: 4.8% • 3-5 yr olds: 10.6% • Mental health (p<.001) • O-2 yr olds: 4.9% • 3-5 yr olds: 17.5% • Special education (p<.001) • 0-2 yr olds: 7.0% • 3-5 yr olds: 16.3%

23. What May be Going On? I • Poor identification of children with problems • No systematic approach • For children in out-of-home care, 94% of child welfare agencies screened for physical health problems, but only 47.8% screened for mental health problems, and only 57.8% screened for developmental problems (Leslie et al., 2004) • Accuracy of assessments • High use of community providers to assess needs • Limited use of tools; clinical judgment detects less than 1/3 of developmental problems & 50% of emotional problem

24. What May be Going On? II • Difficulty linking children to available services • Poor communication & different cultures/agendas between different agencies • Lack of a clearly identified case manager • Placement changes if in out-of-home care • Fiscal challenges faced by most public agencies • Child or family may not meet eligibility criteria for public program

25. What May be Going On? III • Not accessing evidence-based care • Most interventions that work are very intensive • Few studies of interventions in children in child welfare • Limited use of available caregivers as “therapeutic agents”, particularly foster parents • What should be the role of child welfare? • For the majority of children investigated, there is only fleeting involvement with child welfare. How much “well-being” is the responsibility of child welfare agencies when they have limited contact over time with a family?

26. Part II. Finding Solutions

27. Models of Care I • Improved identification: • Multidisciplinary assessment centers: Philadelphia; Waterbury, CT; Syracuse, NY; Oakland, Sacramento, San Diego (http://gucchd.georgetown.edu/programs/ta_center/index.html) • Additional components: • Standardized tools, community partners, case management, trainings, MOUs for shared information/confidentiality protection

28. Models of Care II • Improved linkages between agencies • Health Passports • Placement coordinators • Shared information systems • Health units within child welfare agencies • Court oversight of health, development, mental health, & educational needs

29. Models of Care III • Caregivers as therapeutic agents • Carolyn Webster-Stratton: in-home caregivers with youth with disruptive disorders • Philip Fisher, Patti Chamberlin: foster caregivers with youth with developmental-behavioral problems; treatment foster care programs

30. Challenges • Problems: • Limited “outcome” studies to show these programs link children or improve their outcomes • Difficult to achieve in highly urban areas or rural areas • Working out the details • Funding

31. Importance of Identifying Community Partners • Some are mandated to address these issues & may provide critical funding or staffing • Often need education on each other’s cultures & on the specific needs of children in child welfare • Public advisory boards serve to hold agencies accountable

32. Who are Potential Partners? • Medical: Medicaid, Title V, public health nursing • Child welfare • Special education & early intervention services • Mental health • Developmental disabilities • Community groups: CASA, others • Foundations, businesses, academic institutions

33. Importance of Defining Scope of Program • Which children: placement? Age? Location? • What types of problems? • Immediate or staged implementation? • How staffed? • What types of “tools” will be used • What are specific barriers we need to address?

34. Importance of Outcomes • To demonstrate what you do works • To get additional funding • To help other communities as they seek to find solutions

35. Other Sources of Information I • Written materials • Silver, J. ; Amster, B.J., Haecker, T. Young Children and Foster Care. Paul H. Brookes; 1999. • Shonkoff J.P. Mesiels, S.J. eds. Handbook of Early Child hood Intervention. Cambridge U. Press; 2000. • Shonkoff, J.P. , Phillips, D.A. From Neurons to Neighborhoods. National Academies Press. 2000 • Leslie, L.K., Gordon, J.N., Lambros, K., Premji, K., Peoples, J., Gist, K. Addressing the developmental and mental health needs of young children in foster care. Journal of Developmental and Behavioral Pediatrics 26: 140-151, 2005.

36. Other Sources of Information II • Websites • CWLA (www.cwla.org) • ACF on NSCAW study (http://www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw/) • Georgetown Technical Assistance Center(http://gucchd.georgetown.edu/programs/ta_center/index.html) • AAP (www.aap.org) • AACAP (www.aacap.org)

37. Questions?