Using the CBCL to Determine the Clinical Status of...

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Children and Youth Services Review, Vol. 22, No. 1, pp. 55-73, 2ooO Copyright 0 2000 Elrvier Science Ltd Printed in the USA. All righta nserved

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Using the CBCL to Determine the Clinical Status of Children in State Custody

Craig Anne Hetlinger Celeste G. Simpkins Vanderbilt University Ten-i Combs-Orme

University of Tennessee

This manuscript reviews information on past use of the CBCL to describe the clinical status of children in state custody and the results of a recent study of a representative statewide sample. The sample included a random sample of children in state custody, including those in foster care, kinship care, group residential facilities, and state institutions. One third (34%) of the children in state custody were reported as having significant behavior problems. The narrow band scales reflecting greatest difficulties included Aggressive, Delinquent, and With- drawn behavior. The youngest teenage group was significantly more likely to have Internalizing problems in the clinical level, and those living in family homes were more likely to have scores in the non-clinical range than those in foster homes or group placements. There were no effects of gender, race, adjudication status, or length of time in custody. Implications for policy makers, caseworkers, and researchers are discussed.

Data documenting the poor clinical status or extensive mental health needs of foster children have appeared in the literature since at least 1974, when Shah categorized 308 psychiatric visits by Canadian foster children into five diagnostic groups (character disorders, learning disabilities, psychoneuroses, psy- choses, and others) and reported on the services recommended and received by these children. In the first reports in this country, Swire and Kavaler (1977) and Fanshel and Shinn (1978) both included mental health in their broader studies of the health and condition of foster children. Swire and Kavaler (1977) assessed the health problems of 668 children in foster care with eight agencies in New York City. Based on psychological testing for the school-age children and psychiatric evaluations with a selected subsample of 179 school children, they rated 35% as having moderate and another 35% as

This research was supported by grants from the National Institute for Mental Health (MH50101 and MH53623). Requests for reprints should be sent to Craig Anne Heflinger, Vanderbilt Institute for Public Policy Studies, 1207 18” Avenue South, Nashville, TN 37203, USA [c.heflingerQvanderbilt.edu].

55

56 Heflinger, Simpkins and Combs-Orme

having “marked-to-severe” psychiatric impairment. Fanshel and Shin (1978) reported on a longitudinal study of a cohort of New York foster children and noted that between one-third and one-half were “emotionally impaired” at any of the three data collection points, based on the combined judgements of psychologists, social workers, parents and teachers and a number of standardized instruments.

In the 25 years since these early reports, a number of studies have con- firmed that foster children have more mental health problems than the general population based on indications in agency records and clinical judgement and interviews (e.g., Chernoff, Combs-Orme, Risley-Curtiss & Heisler, 1994); service utilization data (e.g., Blumberg, Landsverk, Ellis-MacLeod, Ganger & Culver, 1995) and various standardized measures (e.g., Chemoff et al., 1994; Halfon, Mendonca & Berkowitz, 1995). Although these studies have demonstrated consistently the excess mental health problems among foster children, comparisons across the studies generally are difficult because of the use of different methods for measuring mental health.

Use of the Child Behavior Checklist to Document Mental Health Needs in the Foster Care Population

A number of studies have used the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1983,199l) to describe the clinical status of children in foster care. The CBCL is an empirically derived measure that is completed by the child’s parent, or by a caretaker who has had the child for 6 months or more. For children ages 4 through 18 years, a parent or primary caregiver reports on the child’s academic performance, social and peer relationships, and family relationships, and indicates how true a series of 112 problem behavior items are for the child. For children ages 2-3 years, the CBCL includes only problem behavior items. In addition to “narrow-band syndromes” such as Withdrawn Behavior, outcomes can be determined for significant problems with Internalizing Behavior (e.g., depression, anxiety), Externalizing Behavior (e.g., aggression, violence), or Total Problems.

The CBCL has major advantages as a measure of the mental health of foster children, including extensive support for its psychometric properties and national norms based on thousands of nonreferred and referred children. Standardized scores permit comparisons between gender and across age groups, although raw scores have been recommended for research because the standardized scores are truncated at the low end (Achenbach 8z Edelbrock, 1991). (This issue generally may be less critical with clinical samples, where

Clinical Status of Children in State Custody 57

fewer scores at the lower end are expected and are of less interest.) For many child welfare professionals, the functional (as opposed to diagnostic) ap- proach of the CBCL provides important and more useful information about how foster children meet their developmental tasks in the areas of behavior and social problems than do psychiatric diagnoses.

In addition to providing information on the clinical status of children in state custody, the CBCL scores can provide a more culturally sensitive de- scription of a child’s clinical status than diagnosis alone. The use of diagnosis as a single indicator of clinical status has been criticized given demonstrated bias of diagnostic applications in minority populations (Cheung & Snowden, 1990; Woodward, Dwinell, & Arons, 1992). Furthermore, measures of functioning and behavior can be useful in describing clients served, identifying target populations, and evaluating treatment effectiveness (Pokomy, 1991). They also may aid in identifying populations in need of services. Thus, the CBCL provides a method for more systematically examining clinical status.

In 1986, McIntyre and Keesler (1986) were the fmt to publish a study as- sessing the mental health of all children in foster care (n = 158,97.5% of eligible children) in a medium-sized southern city and its surrounding area. Re- porting the nine narrow-band syndromes for all eight age group and sex cate- gories, they reported 48.7% of the children to be disordered, with significantly higher frequencies than expected for 16 of the 35 Internalizing and 14 of the 26 Externalizing pattern syndromes. The relative risk for disorder among this group compared to the non-referred population norms was 8.7. These findings and others are summarized in Table 1.

Since this original use of the CBCL with foster children in 1986, others have followed, including reports on three Canadian and one Belgian sample, two each from Baltimore and California, and one each from Florida, upstate New York, and Washington State (see Table 1). In addition, Pecora provided data in 1997 on a national sample of youth in group and family care in the Casey Family Program. These studies had a variety of purposes: to describe the mental health of children in foster (HelIinckx 8z Grietens, 1994; Hulsey 8z White, 1989; Moffatt, Peddie, Stulginskas, Pless, dz Steinmetz, 1985; Pecora, 1997; Silver et al., 1992) or kinship care (Dubowitz, Zuravin, Starr, Feigel- man, & Harrington, 1993) or receiving protective services in their own homes (Trupin, Tarico, Low, Jemelka, & McClellan, 1993); to describe screening and evaluation services provided for foster children (Urquiza, Wirtz, Peter- son, & Singer, 1994); and to compare mental health among different groups of foster children (Homick, Phillips, dz Kerr, 1989; Thompson & Fuhr, 1992).

Tabl

e 1

Sum

mar

y of

FIm

Bng

s of

Stn

rBes

Usi

ng t

be C

BC

L to

Est

imat

e B

ehav

ior

Pro

blem

s fo

r C

hild

ren

in F

o&r

Car

e

Stud

y D

esig

nhm

ple

N

&R

ange

G

ende

r &

Rac

e Fi

ndin

gs

Mof

fatt

et a

l.,

31

Birt

h-18

. O

f O

fthe

35: 5

4% (

19)

4 ch

ildre

n (1

3%)

had

scor

es i

ndic

atin

g pa

thol

ogy

on

1985

(Mon

n=J)

McJ

ntyr

e &

A

ll fo

ster

chi

ldre

n in

cam

Jun

e,

Kes

sler

, 19

86

1984

. Dat

a w

ere

colle

cted

for

(K

noxv

ille)

97

.5%

of

thos

e el

igib

le

Hom

ick,

Eh

ellip

s, an

d K

err,

1989

(o

ntar

io)

Chi

ldre

n in

resi

dent

ial,

fost

er c

are,

an

d tw

o le

vels

of f

amily

sup

port

Hul

sey

&

Whi

te,

1989

(B

altim

ore)

Abu

sed

or n

egle

cted

4-8

yea

rs o

ld,

in p

rese

nt h

ome

at le

ast 3

mon

ths,

1’ ti

me-

in fo

ster

car

e (in

stitu

tions

w

ere

excl

uded

), an

d el

igib

le f

or

Med

icai

d.

Mat

ched

con

trol

grou

p.

No

info

rmat

ion

on a

ctua

l sel

ectio

n.

Mar

cus,

199

1

(Mar

ylan

d)

Syst

emat

ic s

ampl

e co

nsis

ting

ever

y 3t

i fos

ter

child

reg

iste

red

@W

OO

). C

hart

revi

ews

of 2

57 fo

ster

ch

ildre

n. E

xam

s of

a s

ub-s

ampl

e of

35

.

Chi

ldre

n w

ho h

ad li

ved

in fo

ster

ho

mes

at l

east

1 m

onth

.

the

35:

1Q;

3 3-

5; 3

1 ag

e ag

e 6-

18

158

4-18

M

ean

12.1

. SW

.1

210

12-1

6

65

4-8

Mea

n fo

ster

=

5.8

Mea

n fo

r co

ntro

ls

= 5.

5 ye

ars

52

4-13

M

ean

7.92

Y

-

mal

e; 4

6% f

emal

e.

71.5

% w

hite

28

.4%

bla

ck

For

fost

er c

are,

13

boys

(32

%)

and

28

girls

(68

%)

47.7

% m

ale;

9.2

%

whi

te,

87.7

% b

lack

, 3.

1% o

ther

44%

fem

ale.

Fos

ter

mot

hers

wer

e C

auca

sian

60%

. B

lack

28%

. Oth

er

12%

.

one

or m

ore

of th

e C

BC

L sc

ales

. 35

% s

uspe

cted

of

pote

ntia

l em

otio

nal

prob

lem

bas

ed o

n al

l mea

sure

s

Use

d na

rrow

ban

d sc

ales

; 77

(48.

7%)

wer

e fo

und

to b

e di

sord

ered

. R

elat

ive

risk

show

ed f

oste

r ch

ild w

as 8

.7

times

mor

e lik

ely

to m

anife

st p

sych

opat

holo

gy

than

a

hom

e-re

ared

chi

ld.

Mal

es i

n fo

ster

cam

: Mea

n To

tal B

ehav

ior

scor

e 64

(SD

7.

35).

Mea

n Jn

tem

alix

atio

n 64

(6.7

5), E

xter

naliz

atio

n 62

.6 (8

.75)

. Fem

ales

in

fost

er c

are:

Mea

n To

tal

Beh

avio

r sc

ore

68.7

(12

.0 S

D),

Inte

rnal

izat

ion

64.5

(9

.59

SD),

Exte

rnal

izat

ion

64.0

(9.2

4 SD

). M

ean

tota

l pro

blem

sco

re 6

2.4

(ran

ge 3

0-89

) fo

r fo

ster

ch

ildre

n an

d 51

.7 (r

ange

30-

88) f

or c

ontro

ls @

<.O

OO

l).

Con

trolli

ng f

or f

amily

com

posi

tion,

mat

erna

l m

arita

l st

atus

and

edu

catio

n, b

irth

orde

r, le

gal h

isto

ry,

and

mar

ital s

tabi

lity,

the

adj

uste

d di

ffer

ence

s be

twee

n th

e tw

o gr

oups

was

6.5

@ <

.06)

. Fo

ster

chi

ldre

n ar

e m

idw

ay b

etw

een

nonc

linic

al a

nd

clin

ical

for

bot

h Ex

tern

aliz

ing

and

Inte

rnal

izin

g.

Mea

n Ex

tern

aliz

atio

n 57

.0 (

13.5

SD

), Jn

tem

alix

atio

n 57

.2

(11.

6 SD

).

Stud

y D

ubow

itz e

t al

., 19

93

(Bah

imor

e)

Tmpi

n et

al.,

19

93

(Was

hing

ton

Stat

e)

Cla

rk e

t al.,

19

94

(Flo

rida)

Glis

son,

19

94

Des

ign/

sam

ple

N

Age

Ran

ge

Gen

der

& R

ace

Part

of a

larg

er s

tudy

. C

hild

ren

age

346

2-16

48

% m

ale;

90%

2-

16, i

n ki

nshi

p fo

ster

car

e at

the

Mea

n 7.

9 A

ftica

n-A

mer

ican

en

d of

Apr

il 19

89 fo

r w

hom

a

CB

CL

was

com

plet

ed b

y ca

regi

ver.

Ran

dom

ly s

elec

ted

from

cur

rent

19

1 3-

18

Gen

der

mis

sing

for

ch

ild p

rote

ctiv

e se

rvic

e ro

les.

Mea

n 9.

25;

17%

; 57%

of

the

50%

wer

e c=

re

mai

nder

wer

e fe

mal

e; 7

0% W

hite

; 8

10%

Bla

ck; 6

%

His

pani

c; 7

% N

ativ

e A

rne.

rican

; 4%

A

sian

; 4%

oth

er

39.4

% fe

mal

e,

60.6

% m

ale,

61.

4%

Whi

te,

35.6

%

Afr

ican

Am

eric

an,

3.0%

His

pani

c.

56%

mal

e

Qua

si-e

xper

imen

tal,

rand

om

109

7-15

as

sign

men

t. A

buse

d an

d ne

glec

ted

fost

er c

hild

ren

in fo

ster

hom

es o

r sh

elte

r, sc

reen

ed a

s ha

ving

men

tal

heal

th p

robl

ems.

Qua

si-e

xper

imen

tal,

pilo

t an

d 60

0 4-

18

cont

rol

coun

ties

mat

ched

on

per

Mea

n 14

.7

capi

ta in

com

e. c

usto

dy r

ates

, 90

% w

ere

popu

latio

n, a

nd p

ropo

rtion

of

the

12-1

8 po

pula

tion

unde

r 18

. C

hild

ren

ente

ring

cust

ody

who

wer

e 4

year

s ol

d or

old

er a

nd h

ad c

ompl

ete

CB

CL

& T

RP

data

wer

e el

igib

le.

86%

whi

te

Rel

ativ

e R

isk

for

beha

vior

pro

blem

s w

as 4

.9 c

ompa

red

to th

e ge

nera

l po

pula

tion.

Ove

rall,

35%

abn

orm

al;

18%

ab

norm

al o

n in

tern

aliz

atio

n, 2

4% a

bnor

mal

on

exte

rnal

izat

ion.

C

asew

orke

rs f

illed

out

the

CB

CL.

52

% w

ere

MSW

or

MA

, 47%

BA

. Th

ey h

ad k

now

n th

e ch

ildre

n an

av

erag

e of

14

mon

ths.

Mea

n to

tal p

robl

em s

core

was

54.

0 (S

.E.M

. 1.

2).

Mea

n In

tern

aliz

atio

n 53

.4 (S

.E.M

. 1.

0); E

xter

naliz

atio

n 54

.2

(S.E

.M.

1.2)

.

At t

ime

1, M

ean

Exte

rnal

izin

g sc

ores

69.

3 an

d 67

.9 fo

r tw

o gr

oups

. M

ean

Inte

rnal

izin

g sc

ores

65.

02 a

nd

60.7

9, T

ime

4: th

e m

eans

sco

res

wer

e 64

.57

and

66.5

8 fo

r Ex

tern

aliz

ing,

and

59.

64 a

nd 5

9.76

.

Bas

elin

e Pi

lot

scor

es:

Tota

l Pro

blem

Beh

avio

r m

ean

= 68

.2 (s

d 12

.17)

. Int

erna

lizin

g rn

eana

3.76

(s

d 9.

88)

Exte

rnal

izin

g m

ean=

6699

(s

d 11

.27)

. B

asel

ine

Con

trol

scor

es:

Tota

l Pro

blem

Beh

avio

r m

ean

= 68

.01

(sd

12.6

1). I

nter

naliz

ing

mea

n =

62.9

9 (s

d 11

.48)

. Ex

tern

aliz

ing

mea

n =

67.1

2 (s

d 11

.45)

.

(Tab

le c

onti

nued

on

next

pag

e)

Stud

y

Hel

linck

x an

d G

riete

ns,

1994

(B

elgi

um)

smith

, 19

94

Urq

uixa

et

al.,

1994

(S

acra

men

to)

smith

, 19

95

(New

Yor

k)

Arm

sden

, Pe

cora

, and

Pa

yne,

199

6 (S

eattl

e)

Des

ign/

sam

ple

Chi

ldre

n fr

om s

elec

ted

fost

er c

are

agen

cies

; Su

rvey

s w

ere

mai

led

to

638

fost

er p

aren

ts.

273

(43%

) co

mpl

eted

and

retu

rned

the

qu

estio

nnai

res.

sam

e as

sm

ith,

1995

.

Stra

tifie

d sa

mpl

e of

abu

sed

and/

or

167

43%

1-3

, ne

glec

ted,

1- 1

1 ye

ars

old,

no

29%

3-5

, and

pr

evio

usly

ide

ntifi

ed p

robl

em.

28%

6-1

1

A c

onve

nien

ce s

ampl

e fr

om t

he

Dep

artm

ent o

f So

cial

Ser

vice

s ro

les.

Fost

er C

hild

ren

with

an

olde

r si

bs i

n th

e sa

me

fost

er h

ome

for

1 m

onth

or m

ore

in n

on-r

elat

ive

care

. A

dmis

sion

s to

the

Cas

ey F

amily

Pr

ogra

m f

or w

hom

bot

h C

BC

L an

d TR

F in

take

sco

res

wer

e ob

tain

ed.

75%

of

the

tota

l int

ake

met

this

cr

iteria

.

N A

ge R

ange

273

4-12

; 33

%

age

4-6;

35%

ag

e 7-

9; 3

2%

; age

10-

12

38

3-6;

Mea

n 53

.3 m

onth

s

25

Mea

n ag

e of

Fo

ster

chi

ld

52.2

mon

ths,

sib

84.4

m

onth

s 36

2 4-

18

Mea

n 10

.5

Y-

Gen

der

& R

ace

.49%

fem

ale

47%

fem

ale,

47%

C

auca

sian

, 37

%

Afr

ican

Am

eric

an

52%

mal

e, 4

1%

blac

k, 3

5% w

hite

, 23

% la

tino,

1%

A

sian

48

% C

auca

sian

, 36

% A

fric

an

Am

eric

an,

56%

Fem

ale,

47%

C

auca

sian

, 25

%

Afr

ican

Am

eric

an,

12%

His

pani

c, 1

0%

Nat

ive

Am

eric

an,

5% P

acifi

c Is

land

er,

and

1% A

sian

.

Find

ings

Mea

n (r

aw)

Exte

rnal

izin

g sc

ore=

20.7

(SD

15.

4).

Inte

mal

izin

g=7.

6 (S

D 5

.8).

On

Tota

l Pro

blem

sco

re

5 1.

6% w

ere

norm

al,

41.4

% c

linic

al;

Exte

rnal

izat

ion

55%

nor

mal

, 36

.6%

clin

ical

; In

tern

aliz

atio

n 20

.9%

cl

inic

al.

Rat

es f

or S

yndr

omes

are

pre

sent

ed.

Ave

rage

Ext

erna

lizin

g (r

aw)

scor

e w

as 2

0.7

(SD

15.

4)

and

for

Inte

rnal

izin

g 7.

6 (S

D 5

.8).

Old

er k

ids

had

low

er p

robl

em s

core

s. C

urre

nt c

ageg

iver

com

plet

ed t

he C

BC

L. T

otal

sco

re

31%

(n=

41 o

f 15

2 C

BC

Ls)

in c

linic

al r

ange

; 39

% o

f F

thos

e c4

int

erna

lizin

g.

B .

Mea

n (r

aw)

Exte

mal

izai

ng 2

1 (b

orde

rline

), ra

nge

2-63

; ?$

In

tern

aliz

ing

7.2,

ran

ge O

-20.

,’ F

Mea

n To

tal

Prob

lem

sco

re. 5

5.9

at in

take

. Tho

se

acce

pted

int

o th

e C

asey

pro

ject

had

low

er s

core

s at

t

inta

ke t

han

thos

e no

t ac

cept

ed.

The

inta

ke p

roce

ss o

f C

asey

may

scr

een

out t

he m

ore

serio

us d

iffic

ultie

s. B

a h

Stud

y

Gar

land

et

al, 1

996

(San

Die

go)

Bic

kman

, et

al.,

1997

(O

hio)

Deb

t&am

ple

Chi

ldre

n, a

ge 2

-17,

who

ent

ered

fo

ster

cam

dur

ing

a de

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Other studies have been concerned primarily with predicting service utilization (Garland, Landsverk, Hough, & Ellis-MacLeod, 1996) or the outcomes of interventions with foster children (Clark et al., 1994). Marcus (1991) described foster children’s mental health and their attachments to birth and foster parents.

Published Studies Are Not Easily Comparable

As Table 1 shows, the CBCL has the distinct advantage of permitting comparisons across studies; however, researchers do not always present their findings in a format that facilitates such comparisons. Although McIntyre and Keesler (1986) presented extensive data obtained from the CBCL, they did not indicate what proportion of foster children scored in the clinical range for the Internalizing and Externalizing subscales, which combine the narrow-band syndromes. Since this study, the Internalizing and Externalizing subscales have become perhaps the most frequently reported measures. Some studies presented proportions disordered without mean scores for individual subscales (Dubowitz et al., 1993; Garland et al., 1996; Marcus, 1991; Thompson 8z Fuhr, 1992; Urquiza et al., 1994). Some of these studies discussed proportions disordered on the behavior problems subscales (Dubowitz et al., 1993; Mar- cus, 199 1; Thompson & Fuhr, 1992), while others provided proportions only for those with clinical-level scores for the Total Problem Score (Urquiza et al., 1994). Garland et al. (1996) used a dichotomous variable indicating a Total Problem score above the clinical cut-point as a predictor of service use and provided a figure showing the distribution of that variable among foster children who had suffered different types of maltreatment.

Several reports provided only mean scores on the Total or on the Exter- nalizing, and Internalizing Problems Scales without data about the proportions disordered on these scales. Because standardized scores have truncated scores at the lower end, standardized mean scores, having excluded the lower scores, are artificially inflated. Hulsey and White’s (1989) comparison of foster children and public health clinic children matched on sociodemographic variables; Trupin et al’s (1993) report on foster children in Washington State; and Clark et al’s (1994) report on abused and neglected Florida foster children all present such distorted means. Pecora (1997) presented both percentages disordered and means, using standardized scores, on the Casey Family Program youth. Only Smith (1994,1995), on the other hand, presented the more accu- rate mean raw scores in her study of a sample of 38 preschoolers in foster care.

clinical status of Children in state custody 63

An additional issue is the variability of the samples. The samples ranged from n=25 in a study of children placed in foster care with siblings (Smith, 1995) to n=362 in an evaluation of a specific residential program (Armsden & Pecora, 1996). One study (Clark et al., 1994) selected children already be- lieved to have mental health problems, while three others (Bickman, Summer- felt, Firth, & Douglas, 1997; Thompson & Fuhr, 1992; Urquiza et al., 1994) selected only children without previously identified problems. Marcus (1991) and Garland et al. (1996) excluded children who had been in their placements for under one and five months, respectively, perhaps under-representing children who stay in care for only a short time.

Furthermore, the foster care population is a limited sample of the children for whom the state is responsible. Children who have been placed in state custody or under state supervision are also placed in family homes (their homes of origin, relatives or other kinship care), sometimes with a formal foster care designation if in kinship care but often not. Children and youth in state custody also are placed in group homes, mental hospitals, and juvenile correctional facilities. By focusing only on children in foster care, a limited and perhaps skewed view is developed. In the state where the current study took place, almost two-thirds (64%) lived in these other residential arrange- ments. To date, no comprehensive examination of all of these children has been published.

The present study, based on a representative random sample of children in state care (ages 2 to 18 years) in Tennessee addressed both of these con- cerns. First, the full range of data obtained from the CBCL is presented. In addition, the sample includes children in the full range of residential ar- rangements possible in state custody instead of focusing solely on foster care.

Sample Methods

This study was a secondary analysis of data collected on children and youth in state custody through the Children’s Program Outcome Review Team (C-PORT). The C-PORT process was initiated in 1994 by the Tennes- see Commission on Children and Youth (TCCY, 1997) as an independent evaluation of the service system for children in custody of the State of Ten- nessee. Charged as an advocacy agency for policies and services to promote and protect the health, well-being, and development of all children and youth in Tennessee, the TCCY has responsibility for monitoring and evaluation of

64 Heflinger, Simpkins and Combs-Onne

the Children’s Program. The C-PORT evaluation conducts intensive case reviews on a random and representative sample of children and youth in state custody guided by a structured interview protocol that yields Child/Family and Service System variables. The CBCL was added to the data collection process in 1995. This manuscript presents the findings of the 1996 data collection effort.

The sample of children selected for C-PORT was randomly drawn from an enumeration of children in custody of the state of Tennessee during Janu- ary 1996. Stratified samples were drawn from each of the state’s 12 regions, with over sampling in some areas to allow for comparisons by region. For the current analyses, the over-sampled cases were eliminated to create a sample that is representative of children in state custody on the day of enumeration.

Table 2 CORS, C-PORT, and CBCL Samples

Total Age

CORS 1996 C-WRT 1996 Eligible for CBCL 1996 Com- custody State Sample 1996: Caretaker had plete

Ages 2-18 Ages 2- 18 known => 2 months CBCL

10378 330 311 254

2-5 6-12 13-15 16-18

Gender Male Female

Race Black White Other

Residence Family Foster

Group Adjudication

Dependent Unruly Delinquent

12% 20% 17% 21% 26% 23% 24% 25% 26% 19% 20% 20% 36% 38% 39% 35%

59% 55% 55% 55% 41% 45% 45% 45%

38% 35% 34% 33% 61% 61% 62% 63% 1% 4% 4% 4%

28% 29% 28% 39% 41% 41% 34% 30% 30%

67% 70% 70% 13% 12% 12% 21% 19% 18%


From the total 330 children and youth in the 1996 C-PORT sample who were in the eligible age range (2- 18 years old) to have one of the CBCL ver- sions completed, several had caretakers who had known the youth less than 2 months or who overtly declined to respond, reducing the total number eligible (to 3 11). Of this number, 82% (n=254) actually completed the CBCL (see Table 2). There was little variation in participation rates over age, gender or racial groups or for children with different adjudication classifications or residential placements (see Table 3).

Table 3 CBCL Sample

Number eligible %* completed CBCLs

Total Eligible* 311 Age Group

Birth - 5 years 65 80% 6-12 years 75 84% 13-15 59 86% 16-18 112 79%

Gender Female 169 83% Male 142 80%

Race African-American 106 78% White 191 84% Other 14 71%

Residence Family Home 91 79% Foster Home 126 83% Group Residence 94 82%

Adjudication Dependent/Neglected 216 82% Unruly 36 86% Delinquent 59 78%

Total Eligible & Completed 311 82% *Proportion of the eligible children in the C-PORT sample for whom CBCLs were completed.

66 Hefinger, Simpkins and Combs-Orme

Scores on a measure of psychosocial functioning were also available to examine potential bias in the CBCL sample (see Heflinger & Simpkins, 1997). When comparing children in the total C-PORT sample with or without a completed CBCL, there were no significant differences in the total functioning score. However, those with a CBCL were rated as significantly less impaired on two of the sub-scales of that measure, indicating that the CBCL scores for this sample may under-represent the level of mental health difficulties in the custody population.

The success of the C-PORT random selection process can also be examined through the similarity in characteristics between the entire 1996 custody population and the drawn C-PORT sample (see Table 2). The only noticeable difference is in age group, where the C-PORT sample selected a higher proportion of children aged 5 years or younger, thus also decreasing the relative proportion of children in the older age groups.

Measures

The clinical status of children and youth was examined through a caregiver-completed behavioral checklist. The Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1991), described above, relies upon parent/caregiver report of the child behavior and has been norm referenced for large populations (Zima, Wells, & Freeman, 1994). The CBCL provides a total score indicative of clinical status as well as two broad-band scores (externalizing, internalizing) and sub-scale scores. The cutting points for borderline and clinical designation are based on t-scores formed on a clinical population (Achenbach & Edelbrock, 1991; McConaughy & Achenbach, 1988). Current caregivers who had been responsible for the child for at least two months were asked to complete the 112 behavioral items. Caregivers who completed the CBCL included biological and’adoptive parents, foster parents, and group care workers of children in residential treatment facilities.

CIinical Status of Children in State Custody 67

Findings

As discussed above, the CBCL provides information about problems at the global level (Total Problem score), within two broad bands called Inter- nalizing and Externalizing behavior, and within ten sub-scales describing specific behavior syndromes. At the global level, one third (34%) of the children in custody (see Table 4) were reported as having significant behavior problems. Approximately one-fourth (23%) exhibited problems to such a great extent that they were considered to be in the clinical range, or similar to children already receiving treatment in clinical settings.

Table 4 Frequencies, Means and Standard Deviations for the CBCL

Applic- Mean Mean able Total CBCL Raw CBCL t-

Ages Percent of Children by Num- Subscale scores (Years) Category’ ber Scores (SD) (SD)

Non- Border Clinic- Clinical line al

Total Problem Score 2-18 67% 11% 23% 254 32.4 (27.7) 53.0 (13.6) Internalization Scale 2-18 Externalization Scale 2-18 Withdrawn 2-18 Somatic complaints 2-18 Anxiety/depression 2-18 Social problems 4-18 Thought problems 4-18 Attention problems 4-18 Delinquent behavior 4-18 Aggressive behavior 2-18 Sleep Disorders 2-3 Destructive 2-3

73% 67% 76% 76% 76% 82% 82% 85% 80% 74%

8% 10% 15% 15% 17% 10% 9% 8% 12% 15% 85% 74%

19% 254 23% 254 9% 254 8% 254 8% 254 8% 227 9% 227 8% 227 9% 227 11% 254 15% 27 26% 27

8.1 (7.8) 12.8 (11.6) 3.1 (3.2) 1.2 (2.0) 4.4 (4.6) 2.6 (2.8) 1.3 (2.1) 4.8 (4.3) 3.5 (4.0) 9.1 (8.4)

51.74 54.52

52.6 (11.9) 53.6 (13.4)

42.5 (10.0) 45.2 (7.0) 41.0 (9.1) 41.8 (9.0) 45.3 (9.2)

39.5 (10. 6). 43.8 (9.5)

41.7 (10.9) 2.85 6.50

‘CBCL Scores are T Scores based on raw scores that ranged from 0 to 236. These T scores range from 23 to 100. For theTotal Problem, Internalization, and Externalization Scales, scores of less than 60 are considered non-clinical, 60-63 are borderline, and 64 or more are considered clinical. For all syndrome scales, scores of 65 or less are considered non-clinical, 66 through 70 are considered borderline, and 71 or greater are considered clinical (Achenbach & Edelbrock, 1991).


When the behavior problems are summed to form the Internalizing, Ex- ternalizing and Total problems scores, however, the extent of the problems for a large number of these children becomes more apparent. Nineteen percent (19%) of the children had scores in the clinical range for internalizing behaviors, and 23% scored in the clinical range for externalizing behaviors.

At the sub-scale level, from 8 to 11% of children generally received scores in the clinical range in each subscale. This increases to 18-26% when the borderline range of scores is included. However, the two narrow band scales for 2-3 year olds show that all the children in that age range fell in the borderline or clinical areas. With the exception of those two scales, the narrow band scale areas reflecting greatest difficulty in this population were Ag- gressive, Delinquent, Withdrawn, Somatic Complaints, and Anxiety/ depression.

Among the variables shown in Table 5, only age group and place of residence were associated with clinical status on the Behavior Problem Scales. The young teenage group (13-15 years) was significantly more likely (p c .05) than the other age groups to demonstrate Internalizing problems at the clinical levels (37%); Externalizing and Total Problems were not significant, although the comparison was borderline significant @ c .06) for Extemaliz- ing problems. The curious findings with 2-3 year olds on the last two narrow band scales were not reflected in these results and will need further examination. Children living in their own family homes (though in State custody) were more likely @ c .05) to be in the non-clinical range on the Internalizing scales (80%) than were children living in foster (77%) or group homes (61%). There were no effects for race, gender, or length of time in custody.

Summary and Conclusions

Information from a standardized behavioral checklist provided a wealth of information about the clinical status of children in state custody. This study provides one of very few representative samples of this population and provides needed descriptive information for evaluating and planning for mental health needs.

On the CBCL, 34% of the children were rated as having significant behavior problems. The greatest numbers of children were rated in the clinical range for the Aggressive, Delinquent, and Withdrawn behavior sub-scales. It should be noted that, based on sample analysis described above, these CBCL results


likely under-represent the amount of mental health difficulties in this population.

Table 5 Proportion of Children br CBnieal, Borderline, and Non-eBnical Ranges

Total Problem Score Intemalixing Externalizing

Age Non- Clinical

Non- Total Bor- der- line 6% 14% 14% 9%

Non- Clinical Clinical

15% 81% 22% 81% 33% 57% 22% 73%

Bor- der- Clinical line 8% 11% 10% 9% 6% 31% 9% 18%

Clini Cd

Bor- der- line 6% 10% 16% 9%

Clinical her

19% 64% 53% 69%

81% 68% 49% 69%

14% 52 22% 63 35% 51 22% 88

66% 9% 25% 13% 6% 21% 61% 8% 25% 161 68% 14% 18% 14% 13% 13% 11% 12% 11% 83 10% 0% 30% 10% 10% 20% 50% 20% 30% 10

66% 11% 23% 12% 9% 19% 66% 9% 25% 61% 10% 23% 15% 8% 11% 68% 11% 20%

74% 8% 18% 80% 3% 17% 74% 1% 19%

67% 11% 22% 71% 10% 13% 69% 11% 20% 60% 12% 28% 61% 12% 21% 60% 10% 30%

68% 11% 21% 15% 9% 16% 10% 9% 21% 61% 10% 29% 68% 6% 26% 58% 10% 32% 65% 11% 24% 69% 9% 22% 63% 13% 24%

66% 11% 11% 14% 9% 11% 65% 11% 24% 12% 6% 23% 73% 5% 23% 12% 1% 21%

140 114

12

105 II

111 31 46

46 88

Birth - 5 yrs 6-12 years 13 -15 years 16-18 years

Race white AfliCdAlll

Other Gender

Male Female

Residence Family

home Foster home Group home

Adjudication Dependent Unruly Delinquent

Length of custody

O-5 months 6- 11 months 18 + months 64% 12% 24% 13% 11% 16% 65% 12% 23% 115

These findings provide a representative picture of the range of children in state custody. Direct comparisons to the findings listed above in Table 1 are difficult given the variety of different samples and methods for reporting results, however, these findings do not contradict those above. Similar to Garland et al. (1996). Marcus (1991), and Trupin et al. (1993). standardized Total, In- ternalizing and Externalizing scores were in the low 50s. In general, studies


that reported higher scores or greater percent in the clinical range had samples already selected for mental health problems.

These findings indicate relatively high levels of mental health problems and subsequent treatment needs for the general population of children in state custody. Not only was problem behavior documented for the groups that have come into custody specifically for mental health needs or delinquent or crimi- nal behavior, it was also documented for the dependent/neglected population served by the primary child welfare agency. Since the dependent/neglected population makes up 80% of the children in custody, these percentiles translate into large numbers of children. In Tennessee, the total custody population in 1996 was approximately 10,000 children and youth. A minimum 32% rate of significant mental health problems for the dependent/neglected population translates into at least 2560 children in need of mental health intervention across the state.

At both the state and national levels, these figures reinforce the need for increased resources for assessment and treatment. The decreased financial assistance for families under the Temporary Assistance for Needy Families (TANF) program is a cautionary note in this regard, as it is possible that additional stress associated with extreme financial need may bring more children with greater problems into State custody.

These findings also have implications for training custodial case workers. Clearly, this level of mental health needs is not necessarily documented or identified by those adults charged with oversight of these children. Training case workers to recognize potential areas of difficulty and to seek needed assessment, support, and treatment is critical. In addition, continuity of case workers would help sustain the identification of intervention with needs in this population.

It is obvious from the above findings that the inclusion of the CBCL provides much needed information about the clinical status and behavior of the children and youth in state custody. This checklist provided relatively cost- effective mechanisms for allowing in-depth descriptions of the needs of children in state care in the domains of their daily functioning. The results “make sense.” and correspond to other evidence from family members and caseworkers who have described the problems and needs of these children, so the validity of the instruments in this setting is also supported.

A final word to researchers and evaluators would include the suggestion to make study findings more usable and generalizable by adopting several strategies. First, documenting findings by presenting the standardized and raw

CIinicaI Status of Children In State Custody 71

scores in addition to the proportions in the clinical and borderline ranges would make results clearer. Second, including findings on the behavior problems scales (Total problems, Internalizing and Externalizing Behavior) as well as the narrow band scores would provide a more comprehensive picture. Finally, being descriptive about the sampling methods and the representative- ness of the resulting sample would allow more direct comparison. While these suggestions appear elementary, they have not been universally followed in studies published to date.

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