Early Childhood Early Childhood Development & Related Development & Related
Policy Implications: Policy Implications: Young Children in Child Young Children in Child
WelfareWelfareLaurel K. Leslie, MD, MPHLaurel K. Leslie, MD, MPH
Institute for Clinical Research and Health Policy Institute for Clinical Research and Health Policy StudiesStudies
Tufts-New England Medical CenterTufts-New England Medical Center
Presentation for the 12Presentation for the 12thth National Conference on National Conference on Children and the LawChildren and the Law
DisclosuresDisclosures
The speaker does not have any The speaker does not have any financial ties to disclosefinancial ties to disclose
These materials contain These materials contain informational slides that will not be informational slides that will not be discussed during the presentationdiscussed during the presentation
Goal of this Presentation Goal of this Presentation
Review what we know regarding Review what we know regarding – The Problem: Developmental & The Problem: Developmental &
behavioral problems in young children in behavioral problems in young children in child welfarechild welfare
– Current service/treatment useCurrent service/treatment use– Information presented draws heavily on Information presented draws heavily on
the NSCAW study (see next 5 slides)the NSCAW study (see next 5 slides) Present a framework to guide Present a framework to guide
development of community-based development of community-based initiatives to improve outcomesinitiatives to improve outcomes
Background: National Survey of Background: National Survey of Child and Adolescent Well-Child and Adolescent Well-
being (NSCAW)being (NSCAW) Personal Responsibility and Work Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, Opportunity Reconciliation Act of 1996, Title V, Section 429A (PL 104-193)Title V, Section 429A (PL 104-193)
Congressional mandate to the Secretary Congressional mandate to the Secretary to conduct a “national random sample to conduct a “national random sample study of child welfare”study of child welfare”
www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw
(No prior child welfare study has ever attempted anything remotely this ambitious)
PartnersPartners Extended Research Team Extended Research Team
includes:includes:– Research Triangle InstituteResearch Triangle Institute– University of North CarolinaUniversity of North Carolina– Caliber AssociatesCaliber Associates– San Diego Children’s HospitalSan Diego Children’s Hospital– CSRD, Pittsburgh Medical CenterCSRD, Pittsburgh Medical Center– Duke Medical CenterDuke Medical Center– U.C. BerkeleyU.C. Berkeley– National Data Archive on Child National Data Archive on Child
Abuse and Neglect, CornellAbuse and Neglect, Cornell– 92 Local Child Welfare Agencies92 Local Child Welfare Agencies – Children, Caregivers, and TeachersChildren, Caregivers, and Teachers– Administration For Children and Administration For Children and
FamiliesFamilies
NSCAW CohortNSCAW CohortTotal6,231
Enter through investigation
5,504
No services1,725
Ongoing services3,779
In home2,312
Out-of-home1467
Other gateways600
Long-term foster care
727
Data Collection TimelineData Collection TimelineTarget population: Children Target population: Children involved in investigations involved in investigations closed between October 1, 1999 closed between October 1, 1999 and December 31, 2000and December 31, 2000
Wave 1: Wave 1: BaselineBaselineNov, 1999 – Apr, 2001Nov, 1999 – Apr, 2001
Wave 2: Wave 2: 12 Month Follow-up12 Month Follow-upOct , 2000 – Apr, 2002Oct , 2000 – Apr, 2002
Wave 3: Wave 3: 18 Month Follow-up18 Month Follow-upApr, 2001 – Sept, 2002Apr, 2001 – Sept, 2002
1999 ‘ 2000 ‘ ‘ ‘ ‘ 2001 ‘ ‘ ‘ ‘ 2002 ‘ ‘ ‘ ‘ 2003 ‘ ‘ ‘ ‘ 20041999 ‘ 2000 ‘ ‘ ‘ ‘ 2001 ‘ ‘ ‘ ‘ 2002 ‘ ‘ ‘ ‘ 2003 ‘ ‘ ‘ ‘ 2004
Wave 4: Wave 4: 36 Month Follow-up36 Month Follow-upOct, 2002 – Apr 30, 2004Oct, 2002 – Apr 30, 2004
Data SourcesData Sources ChildrenChildren
– Assessments by Field Assessments by Field RepresentativesRepresentatives
– Interviews (children 7 and older)Interviews (children 7 and older) Caregiver (parent) interviewsCaregiver (parent) interviews Caseworker interviews Caseworker interviews Teacher questionnairesTeacher questionnaires Agency administratorsAgency administrators
Defining the “Problem”Defining the “Problem”
Young children make up a substantial Young children make up a substantial proportion of children in child welfareproportion of children in child welfare– 28% of children in out-of-home care in 2002 were 28% of children in out-of-home care in 2002 were
age 5 or youngerage 5 or younger Many children experiencing abuse &/or Many children experiencing abuse &/or
neglect during early years of life when neglect during early years of life when neurological development is most active & neurological development is most active & vulnerablevulnerable
Some experience out-of-home placement Some experience out-of-home placement which may positively or negatively affect a which may positively or negatively affect a child’s neurological developmentchild’s neurological development
Are These Children at Risk?Are These Children at Risk?
Children with disabilities more vulnerable to Children with disabilities more vulnerable to maltreatmentmaltreatment
Possible genetic predispositionPossible genetic predisposition Many of these children display environmental risk Many of these children display environmental risk
factors for developmental & behavioral problemsfactors for developmental & behavioral problems– Abuse/neglect/poverty/violenceAbuse/neglect/poverty/violence– Inadequate preventive health care so problems not Inadequate preventive health care so problems not
prevented or identified (e.g. prenatal infections, prevented or identified (e.g. prenatal infections, lead exposure)lead exposure)
– Parents with mental illness &/or substance abuseParents with mental illness &/or substance abuse– Parenting practices (harsh, inconsistent discipline; Parenting practices (harsh, inconsistent discipline;
lack of supervision; limited reinforcement of lack of supervision; limited reinforcement of appropriate prosocial skills)appropriate prosocial skills)
Is there a Reason to Worry? Is there a Reason to Worry? Rates Rates
For young children in child welfare, For young children in child welfare, high rates of problems in multiple high rates of problems in multiple studiesstudies– Developmental problems: Developmental problems: as high as as high as
60% compared to 4-10% in general 60% compared to 4-10% in general populationpopulation
– Behavioral problems: Behavioral problems: as high as 40% as high as 40% compared to 3-6% in general populationcompared to 3-6% in general population
NSCAW: Other Disabilities in NSCAW: Other Disabilities in Young Children?Young Children?
(Stahmer et al., 2005; percentages indicate scores < 2 SD from (Stahmer et al., 2005; percentages indicate scores < 2 SD from the mean)the mean)
DomainDomain Age Age (yrs)(yrs)
TotalTotal
Cognitive (BDI <4, KBIT)Cognitive (BDI <4, KBIT) 0-20-2 31%31%
3-53-5 15%15%
Adaptive (Vineland Adaptive (Vineland screener)screener)
0-20-2 6%6%
3-53-5 15%15%
Behavioral (CBCL)Behavioral (CBCL) 0-20-2 26%26%
3-53-5 32%32%
Language (PLS-3)Language (PLS-3) 0-20-2 11%11%
3-53-5 16%16%
Social Skills (SSRS)Social Skills (SSRS) 0-20-2 NANA
3-53-5 8%8%
Developmental/Behavioral Developmental/Behavioral Measures: 0-5 yearsMeasures: 0-5 years
DevelopmentalDevelopmental– NeurodevelopmentalNeurodevelopmental
Bayley Infant Neurodevelopmental Screener (13-24 Bayley Infant Neurodevelopmental Screener (13-24 months)months)
– CognitionCognition Battelle Developmental Inventory (ages 0-4 years)Battelle Developmental Inventory (ages 0-4 years) Kaufman Brief Intelligence Test (ages 4-5 years)Kaufman Brief Intelligence Test (ages 4-5 years)
– Speech/LanguageSpeech/Language Preschool Language Scale (ages 0-6 years)Preschool Language Scale (ages 0-6 years)
BehavioralBehavioral– Child Behavior Checklist (ages 18 months-5 years)Child Behavior Checklist (ages 18 months-5 years)– Social Skills Rating Scale: Prosocial Scale (ages 3-5 years)Social Skills Rating Scale: Prosocial Scale (ages 3-5 years)– Vineland Adaptive Behavior Scales (all ages)Vineland Adaptive Behavior Scales (all ages)
Mental Health/Developmental Mental Health/Developmental Overlap in Young Children Overlap in Young Children (Stahmer (Stahmer
et al., 2005; percentages indicate scores < 2 SD from the mean)et al., 2005; percentages indicate scores < 2 SD from the mean)
0 0 AreaAreas of s of RiskRisk
1 1 Area Area of of RiskRisk
2+ 2+ Area Area of of RiskRisk
0-2 0-2 yearyearss
61%61% 29%29% 10%10%
3-5 3-5 yearyearss
49%49% 32%32% 20%20%
Next stepsNext steps– Define specific Define specific
subgroups of needsubgroups of need– Examine how need Examine how need
changes over timechanges over time– Examine if service Examine if service
use has any impact use has any impact on needon need
Is There a Reason to Worry? Is There a Reason to Worry? Placement PatternsPlacement Patterns
For children in out-of-For children in out-of-home care,home care,– Behavior problems Behavior problems
associated with increased associated with increased placement disruptionsplacement disruptions
(James et al., 2004)(James et al., 2004)
– Developmental & Developmental & behavioral problems behavioral problems correlated with longer correlated with longer lengths of stay in out-of-lengths of stay in out-of-home care, less home care, less reunification, less reunification, less adoptionadoption
– ((Horowitz et al., 1994: Landsverk et Horowitz et al., 1994: Landsverk et al., 1996) al., 1996)
Is There Reason to Worry? Is There Reason to Worry? OutcomesOutcomes
For older youth in child welfare, For older youth in child welfare, many face academic difficulties, high many face academic difficulties, high school drop-out rates, mental health school drop-out rates, mental health issues, delinquency, risky behaviorsissues, delinquency, risky behaviors
Diurnal HPA axis activity
0
0.2
0.4
0.6
0.8
1
wakeup midmorning bedtime
00.20.4
0.60.8
1
wakeup mid morning bedtime
typical daytime HPA activity
ug/
dl
typical
low daytime HPA activity
ug/
dl
chronically elevated daytime HPA activity
ug/
dl
0
0.2
0.4
0.6
0.8
1
wakeup midmorning bedtime
stress-induced ‘blunted’patterns
0
0.2
0.4
0.6
0.8
1
wakeup midmorning bedtime
00.20.4
0.60.8
1
wakeup mid morning bedtime
typical daytime HPA activity
ug/
dl
typical
low daytime HPA activity
ug/
dl
chronically elevated daytime HPA activity
ug/
dl
0
0.2
0.4
0.6
0.8
1
wakeup midmorning bedtime
stress-induced ‘blunted’patterns
00.20.4
0.60.8
1
wakeup mid morning bedtime
typical daytime HPA activity
ug/
dl
typical
low daytime HPA activity
ug/
dl
chronically elevated daytime HPA activity
ug/
dl
0
0.2
0.4
0.6
0.8
1
wakeup midmorning bedtime
00.20.4
0.60.8
1
wakeup mid morning bedtime
typical daytime HPA activity
ug/
dl
typical
low daytime HPA activity
ug/
dl
low daytime HPA activity
ug/
dl
chronically elevated daytime HPA activity
ug/
dl
chronically elevated daytime HPA activity
ug/
dl
0
0.2
0.4
0.6
0.8
1
wakeup midmorning bedtime
stress-induced ‘blunted’patterns
Note: Low daytime activity does not infer a blunted HPA stress response (see Kaufman et al., 1997)
(downregulation via chronic stress)
Do foster children show Do foster children show atypical patterns of HPA atypical patterns of HPA
axis activity?axis activity?
Bruce, Fisher, Pears, & Levine (submitted)
HighAverageLow
Cortisol Classification
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Perc
enta
ge o
f C
hild
ren
CC
FCGroup
HighAverageLow
Cortisol Classification
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Perc
enta
ge o
f C
hild
ren
CC
FCGroup
Percentage of comparison and foster children with typical, low, and high cortisol patterns
0
10
20
30
40
50
60
70
80
90
Typical Low High
Cortisol pattern
Perc
enta
ge o
f ch
ildre
n
Comparison
Foster
Percentage of comparison and foster children with typical, low, and high cortisol patterns
0
10
20
30
40
50
60
70
80
90
Typical Low High
Cortisol pattern
Perc
enta
ge o
f ch
ildre
n
Comparison
Foster
Oregon Delaware
Dozier et al. (in press)
The Good NewsThe Good News Brain is highly adaptive Brain is highly adaptive
& malleable during & malleable during these early yearsthese early years
Growing body of Growing body of scientific evidence scientific evidence pointing to the pointing to the potential for early potential for early intervention in young intervention in young childrenchildren
Intensive services with Intensive services with preschoolers in child preschoolers in child welfare can normalize welfare can normalize these cortisol patternsthese cortisol patterns
(Fisher et al., 2006)(Fisher et al., 2006)
Programs Applicable to Young Programs Applicable to Young Children in Child Welfare IChildren in Child Welfare I
MedicalMedical– Medicaid Medicaid (www.cms.hhs.gov/medicaid/)(www.cms.hhs.gov/medicaid/)– Early and Periodic Screening, Diagnostic, and Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) program in Medicaid Treatment (EPSDT) program in Medicaid ((www.cms.hhs.gov/medicaid/epsdt/default/aspwww.cms.hhs.gov/medicaid/epsdt/default/asp.).)
– Title V Maternal and Child Health Services Title V Maternal and Child Health Services (https://.performance.hrsa.gov/mchb/) (https://.performance.hrsa.gov/mchb/)
Child WelfareChild Welfare– Title IV-E & Title IV-B for children & families in Title IV-E & Title IV-B for children & families in
child welfare child welfare (http://www.acf.dhhs.gov)(http://www.acf.dhhs.gov)
Programs Applicable to Young Programs Applicable to Young Children in Child Welfare IIChildren in Child Welfare II
Social Services:Social Services:– Title XX Social Services Block Grant Title XX Social Services Block Grant
(http://www.acf.hhs.gov/programs/)(http://www.acf.hhs.gov/programs/) Special Education:Special Education:
– IDEA Special Education Services (3-21 IDEA Special Education Services (3-21 years) & Early Intervention services (0-2 years) & Early Intervention services (0-2 years) years) (http:www.ed.gov)(http:www.ed.gov)
State-based mental health & State-based mental health & developmental disability programsdevelopmental disability programs
Child Service Use in NSCAW Sample
Caregiver report of service use:Caregiver report of service use:– Overall: only 22.7% of children using Overall: only 22.7% of children using
servicesservices– Primary care (p<.001)Primary care (p<.001)
0-2 yr olds: 4.8%0-2 yr olds: 4.8% 3-5 yr olds: 10.6%3-5 yr olds: 10.6%
– Mental health (p<.001)Mental health (p<.001) O-2 yr olds: 4.9%O-2 yr olds: 4.9% 3-5 yr olds: 17.5%3-5 yr olds: 17.5%
– Special education (p<.001)Special education (p<.001) 0-2 yr olds: 7.0%0-2 yr olds: 7.0% 3-5 yr olds: 16.3%3-5 yr olds: 16.3%
What May be Going On? IWhat May be Going On? I Poor identification of children with problemsPoor identification of children with problems
– No systematic approachNo systematic approach For children in out-of-home care, 94% of child For children in out-of-home care, 94% of child
welfare agencies screened for physical health welfare agencies screened for physical health problems, but only 47.8% screened for mental problems, but only 47.8% screened for mental health problems, and only 57.8% screened for health problems, and only 57.8% screened for developmental problems developmental problems (Leslie et al., 2004)(Leslie et al., 2004)
– Accuracy of assessmentsAccuracy of assessments High use of community providers to assess High use of community providers to assess
needsneeds Limited use of tools; clinical judgment detects Limited use of tools; clinical judgment detects
less than 1/3 of developmental problems & less than 1/3 of developmental problems & 50% of emotional problem50% of emotional problem
What May be Going On? IIWhat May be Going On? II
Difficulty linking children to available Difficulty linking children to available servicesservices– Poor communication & different Poor communication & different
cultures/agendas between different cultures/agendas between different agenciesagencies
– Lack of a clearly identified case managerLack of a clearly identified case manager– Placement changes if in out-of-home carePlacement changes if in out-of-home care– Fiscal challenges faced by most public Fiscal challenges faced by most public
agenciesagencies– Child or family may not meet eligibility Child or family may not meet eligibility
criteria for public programcriteria for public program
What May be Going On? IIIWhat May be Going On? III Not accessing evidence-based careNot accessing evidence-based care
– Most interventions that work are very intensiveMost interventions that work are very intensive– Few studies of interventions in children in child Few studies of interventions in children in child
welfarewelfare– Limited use of available caregivers as Limited use of available caregivers as
“therapeutic agents”, particularly foster “therapeutic agents”, particularly foster parentsparents
What should be the role of child welfare?What should be the role of child welfare?– For the majority of children investigated, there For the majority of children investigated, there
is only fleeting involvement with child welfare. is only fleeting involvement with child welfare. How much “well-being” is the responsibility of How much “well-being” is the responsibility of child welfare agencies when they have limited child welfare agencies when they have limited contact over time with a family?contact over time with a family?
Part II.Part II.
Finding SolutionsFinding Solutions
Models of Care IModels of Care I
Improved identification:Improved identification:– Multidisciplinary assessment centers: Multidisciplinary assessment centers:
Philadelphia; Waterbury, CT; Syracuse, Philadelphia; Waterbury, CT; Syracuse, NY; Oakland, Sacramento, San Diego NY; Oakland, Sacramento, San Diego (http://gucchd.georgetown.edu/program(http://gucchd.georgetown.edu/programs/ta_center/index.html)s/ta_center/index.html)
– Additional components: Additional components: Standardized tools, community Standardized tools, community
partners, case management, partners, case management, trainings, MOUs for shared trainings, MOUs for shared information/confidentiality protectioninformation/confidentiality protection
Models of Care IIModels of Care II
Improved linkages between agenciesImproved linkages between agencies– Health PassportsHealth Passports– Placement coordinatorsPlacement coordinators– Shared information systemsShared information systems– Health units within child welfare Health units within child welfare
agenciesagencies– Court oversight of health, development, Court oversight of health, development,
mental health, & educational needsmental health, & educational needs
Models of Care IIIModels of Care III
Caregivers as therapeutic agentsCaregivers as therapeutic agents– Carolyn Webster-Stratton: in-home Carolyn Webster-Stratton: in-home
caregivers with youth with disruptive caregivers with youth with disruptive disordersdisorders
– Philip Fisher, Patti Chamberlin: foster Philip Fisher, Patti Chamberlin: foster caregivers with youth with caregivers with youth with developmental-behavioral problems; developmental-behavioral problems; treatment foster care programstreatment foster care programs
ChallengesChallenges
Problems: Problems: – Limited “outcome” studies to show Limited “outcome” studies to show
these programs link children or improve these programs link children or improve their outcomestheir outcomes
– Difficult to achieve in highly urban areas Difficult to achieve in highly urban areas or rural areasor rural areas
– Working out the detailsWorking out the details– FundingFunding
Importance of Identifying Importance of Identifying Community PartnersCommunity Partners
Some are mandated to address these Some are mandated to address these issues & may provide critical funding issues & may provide critical funding or staffingor staffing
Often need education on each Often need education on each other’s cultures & on the specific other’s cultures & on the specific needs of children in child welfareneeds of children in child welfare
Public advisory boards serve to hold Public advisory boards serve to hold agencies accountableagencies accountable
Who are Potential Partners?Who are Potential Partners? Medical: Medicaid, Title Medical: Medicaid, Title
V, public health nursingV, public health nursing Child welfareChild welfare Special education & Special education &
early intervention early intervention servicesservices
Mental healthMental health Developmental Developmental
disabilitiesdisabilities Community groups: Community groups:
CASA, othersCASA, others Foundations, businesses, Foundations, businesses,
academic institutionsacademic institutions
Importance of Defining Importance of Defining Scope of ProgramScope of Program
Which children: placement? Age? Which children: placement? Age? Location?Location?
What types of problems?What types of problems? Immediate or staged implementation?Immediate or staged implementation? How staffed?How staffed? What types of “tools” will be usedWhat types of “tools” will be used What are specific barriers we need to What are specific barriers we need to
address?address?
Importance of OutcomesImportance of Outcomes
To demonstrate what you do worksTo demonstrate what you do works To get additional fundingTo get additional funding To help other communities as they To help other communities as they
seek to find solutionsseek to find solutions
Other Sources of Other Sources of Information IInformation I
Written materialsWritten materials– Silver, J. ; Amster, B.J., Haecker, T. Young Children Silver, J. ; Amster, B.J., Haecker, T. Young Children
and Foster Care. Paul H. Brookes; 1999.and Foster Care. Paul H. Brookes; 1999.– Shonkoff J.P. Mesiels, S.J. eds. Handbook of Early Shonkoff J.P. Mesiels, S.J. eds. Handbook of Early
Child hood Intervention. Cambridge U. Press; Child hood Intervention. Cambridge U. Press; 2000.2000.
– Shonkoff, J.P. , Phillips, D.A. From Neurons to Shonkoff, J.P. , Phillips, D.A. From Neurons to Neighborhoods. National Academies Press. 2000Neighborhoods. National Academies Press. 2000
– Leslie, L.K., Gordon, J.N., Lambros, K., Premji, K., Leslie, L.K., Gordon, J.N., Lambros, K., Premji, K., Peoples, J., Gist, K. Addressing the developmental Peoples, J., Gist, K. Addressing the developmental and mental health needs of young children in and mental health needs of young children in foster care. Journal of Developmental and foster care. Journal of Developmental and Behavioral Pediatrics 26: 140-151, 2005.Behavioral Pediatrics 26: 140-151, 2005.
Other Sources of Other Sources of Information IIInformation II
WebsitesWebsites– CWLA CWLA (www.cwla.org)(www.cwla.org)– ACF on NSCAW study ACF on NSCAW study
(http://www.acf.hhs.gov/programs/opre/ab(http://www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw/)use_neglect/nscaw/)
– Georgetown Technical Assistance CenterGeorgetown Technical Assistance Center((http://gucchd.georgetown.edu/programs/thttp://gucchd.georgetown.edu/programs/ta_center/index.htmla_center/index.html))
– AAPAAP ( (www.aap.orgwww.aap.org))– AACAP AACAP (www.aacap.org)(www.aacap.org)
Questions?Questions?
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