Developmental Status and Early Intervention Service Needs of Maltreated Children

1. Developmental Status and Early Intervention Service Needs of Maltreated Children Early Childhood Comprehensive Systems Partners Meeting The Radisson Plaza Lord Baltimore March 14, 2008 Anita A. Scarborough, University of North Carolina Richard P. Barth, University of Maryland E. Christopher Lloyd, University of Arkansas Jan Losby, ISED Solutions Tammy Mann, ZERO TO THREE This research was funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, under contract 233-03-0099 to ISED Solutions. Points of view or opinions in this presentation do not necessarily represent the official position or policies of the U.S. DHHS.

2. Organization of Presentation • Data Sources • Research Questions • Part C Eligibility • Findings • Areas for Future Research • Project Summary

3. Sources: NSCAW, NEILS, Experts, Literature Review • NSCAW • National Survey of Child and Adolescent Well-Being, the first national probability study of children and adolescents investigated by Child Welfare Services (’99 – present) • Sub-sample of 980 maltreated (substantiated/high risk) children ages birth to thirty-six months • NEILS • National Early Intervention Longitudinal Study, the first national probability study of children entering Part C Services (’97-’98-2005) • 3,338 participants, birth to thirty-one months, entering Part C • Experts • Identified for policy, service, and developmental domains related to Part C services and Child Welfare Services • Literature Review • Identified and summarized literature addressing developmental risk of children ages 0 to 3 and Early Intervention services

4. 3,338 Participants ages 0-31 months Entry to Part C in 1997-1998 20 States Follow-up every year in Part C, at age 3, & kindergarten school year 1,845 Participants ages 0–36 months 950 Substantiated or High Risk Participants 36 States Baseline was 1999-2001 Follow-up data collection 12, 18, 36 months after baseline NEILS & NSCAW Samples NEILS NSCAW • Both studies are nationally representative of their respective populations when special analytic methods are employed

5. Research Questions • What are the developmental characteristics of infants and toddlers receiving Child Welfare Services? • What do those characteristics suggest about the need for Part C early intervention services? • How might these services be best delivered to maltreated children? Goal: Facilitating CAPTA’s intent by informing the CWS and Part C communities about the developmental status of maltreated children

6. Part C Eligibility For children with disabilities birth through two years of age – 1. Developmental Delay: Criterion for delay established by individual states. 2. Conditions of Established Risk: a diagnosed physical or mental condition having a high probability of resulting in developmental delay 3. Optional category of “at-risk” of substantial delay if early intervention is not provided, based on presence of biological/medical or environmental risks. (4 states recognize environmental risk)

7. Finding #1Children birth to 36 months of age who have been maltreated are at substantial risk of experiencing developmental problems.

8. NSCAW Developmental Measures • Communication: The Pre-School Language Scales – 3rd Edition. Because of questionable reliability of scores for infants it was used for children 12 months of age and older. • Adaptive Behavior: The daily living skills portion of the Vineland Adaptive Behavior Screener was completed by the caregiver. Because of questionable reliability of scores for infants it was used for children 10 months of age and older. • Cognitive: The cognitive subscale of the Battelle Developmental Inventory. For children 4 years and older, the Kaufman Brief Intelligence Test was used.

9. *DRIGs = Delay and Risk Indicators Groups (3 mutually exclusive groups) (1) Measured Delay: • At least 1.5 SD below the mean on any measure or 1 SD below on any 2, or; • An Established Risk condition associated with delay & Part C eligible (3%) (2) High Risk: Five or more risk factors, no measured delay (3) Lower Risk: Less than five risk factors, no measured delay * DRIGs were devised and defined for this study.

10. 56% have 5 or more risk factors 82% had at least 4 risk factors Virtually all had at least 2 risk factors (99%) Maltreatment co-occurs with other problems placing children at-risk for developmental delay & later school difficulties Defining Risk

11. DRIGs Distribution at Baseline Half of all infants and toddlers had a low score on a developmental measure • Measured Delay = 49% • High Risk = 28% (5 or more risk factors) • Lower Risk = 23% (< 5 risk factors)

12. Percentage with a Measured Delay higher among cases investigated as toddlers Percentage with High Risk lower among cases investigated as toddlers Children with more risk factors are more likely substantiated at younger ages DRIGsby Age at Baseline

13. Finding #2Finding #2Compared to classification at the time of initial contact with child protective services, over time a higher proportion of children tend to be described as having fewer risks or having a low score on a developmental measure.

14. DRIGs 18 Months After Baseline • Similar distribution, however change in classification of individual children: • Measured Delay: 52% still have a Measured Delay • High Risk: 36% remain HR, with 43% now with a Measured Delay • Lower Risk: 33% remain LR, but 56% now with a Measured Delay Diagonal = Percent unchanged

15. DRIGs 36 Months After Baseline Compared To 18 Month Follow-up • 36 months after baseline only 13% High Risk; 42% Measured Delay, 45% Lower Risk • 72% LR remain the same, 22% now with a Measured Delay • Only 28% of HR classified the same, 37% now with Measured Delay Diagonal = Percent unchanged

16. Children in the Lower Risk category show more stability in classification High risk children tend not to stay there 57% remain Lower Risk Baseline 44% remain in Measured Delay Category 23% remain High Risk DRIGs 36 months After Baseline (at 3-6 years of age)

17. Cumulative Risk and Measured Delay at Baseline At baseline the relationship between risk and measured delay is clear

18. A higher proportion of Measured Delay among children receiving NO ongoing CWS Risk is distributed more evenly among placement options DRIGs and Child Welfare Placement at Baseline

19. Finding #3Few infants and toddlers with substantiated cases of maltreatment are reported to have an established risk condition (e.g., Down syndrome), as described in IDEA, that would make them eligible for Part C services.

20. Only 3% of young maltreated children are reported to have an Established Risk condition which would make them eligible for Part C services, compared to 38% of children entering Part C. Eligibility For Part C Services Based On Diagnosis Of An Established Risk Condition 3% of total population; N=50

21. Finding #4The proportion of children with a measured delay who have substantiated maltreatment reports does not differ markedly from children investigated for maltreatment (but not substantiated).

22. Identical percentage with a Measured Delay Higher percentage of Lower Risk cases among unsubstantiated No statistically significant differences between the groups Substantiation: A Distinction Without a Developmental Difference?

23. Finding #5Maltreated children between 24 to 36 months of age have relatively high levels of behavior problems reported by their caregivers.

24. Behavior Problems in Children 2 Years of Age and Older as Reported by CaregiversAbout 70% with a problem at baseline also had problem at 36 month follow-upSpecific interventions needed for these children and families

25. Finding #6A sizeable proportion of substantiated infants and toddlers are reported to have an Individualized Family Service Plan (IFSP), reflecting eligibility for Part C services.

26. An IFSP is a mandated component of Part C services Families participated in Part C voluntarily Proportion of children receiving Part C services, as indicated by IFSP, decreases over time IFSP by Baseline Age at Follow-Ups Part C - Individualized Family Service Plan (IFSP) Eligibility for Part C services ends at 36 months of age

27. Finding #7Families are receiving parent training and family counseling services through Child Welfare Services or by referral. It is unclear the extent to which these services provide interventions focused on enhancing child development.

28. 39% - 67% of families received parent training or family counseling in the period 18 months after investigationAs children age, fewer children get family-focused services

29. Impressions of Experts We Spoke with for this Study • CWS and Part C personnel agree that many maltreated children need Part C as well as other early intervention services • Experts believe several obstacles exist to fulfilling vision set forth in CAPTA and IDEA legislation • Policies • Service Delivery • Training & Cooperation

30. Finding #8Part C providers may not be familiar with the unique challenges associated with providing services to maltreated children and their families.

31. Impressions of Experts We Spoke with for this Study • Part C and CWS personnel often have little knowledge of each others’ areas of expertise • Differing theoretical and service orientations • Part C provider potential frustration and burnout in working with complex CWS cases • Service – Need mismatch may result in ineffectual services • CWS-involved families may be difficult to engage and/or maintain in Part C services • Hostile, overwhelmed, or chaotic families

32. Finding #9Increased training and collaboration of Child Welfare and Part C service providers may be a useful approach to facilitate CAPTA compliance and enhance developmental outcomes for children.

33. Impressions of Experts We Spoke with for This Study • Lack of centralized oversight of both systems’ accountability • CWS/Part C providers may not be aware of obligations • Part C referral may not be a priority for CWS • Development of a rapid screening tool for CWS to use prior to Part C referral to better utilize scarce resources: • For example, in rural areas Part C providers may need to travel great distances to screen a child who clearly has no developmental problems

34. Promising Options for Improving Services– Impressions of Experts We Spoke With • Cross-training workers from CWS and Part C • Developing multi-disciplinary Part C teams that include a child welfare worker • High-level oversight and facilitation of implementation of CAPTA/IDEA vision • Increase resources by leveraging other systems (e.g., Medicaid, Early Head Start) • Development of a rapid screener for use by CWS to determine need for referral

35. Areas for Future Research • Intervention. Matching levels and types of services with child and family needs • Types of families. Understanding characteristics of sub-groups of families who receive Child Welfare and Part C Services • Substantiation as a criterion for referral.Number of risk factors as an indicator of likelihood for poor developmental outcomes may be a more useful indicator of which children to refer to Part C • Engaging in intervention. Parent engagement and training approaches employed by Child Welfare Services and Part C may need considerable development

36. Future Research [continued] • Best practices on collaboration. Central to effective service delivery is the development of collaborative work models between Child Welfare and Part C • Funding models and services receipt. Services provided depend on what funding authorities support. Additional research of potential funding sources is needed • School readiness. Understanding the longer-term developmental implications of early maltreatment and early intervention on children’s development

37. Project Summary • Based on Measured Delay and/or High Risk, 79% of CWS investigated children were identified as having a measured delay or high risk status • High risk children are at higher likelihood for poor developmental outcomes, including school-age problems. • Those with a low score on a developmental measure are demonstrating an additional marker associated with academic and cognitive difficulties. • Children with more than 5 recognized risk factors are likely to persist in that category or develop measured delays.

38. Anita_Scarborough@unc.edu