Addressing the Developmental Needs of Children in Child Welfare

Presenters:Mimi Graham, EdD

FSU CENTER FOR PREVENTION & EARLY INTERVENTION POLICY

Trajectory of DevelopmentPoverty Maltreatment Lack of Health

Services Toxic Stress

Nurturing Family

PreK & Quality Child Care

Targeted Supports Health Services Intensive

Intervention

Healthy

At-Risk

Delayedor Disordered

Read

y to

Lea

rn

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Most Maltreated Children Have Developmental Problems

• 23 – 65%Cognitive Problems

• 14 – 64%Speech Delays

• 22 – 80%Health Problems

• 4 – 47%Motor Delays

• 10 – 61% Mental Problems

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Nurturing & Responsive Relationships

IntensiveInterventionTargeted

Social Emotional Supports

High Quality EnvironmentsNurturing & Responsive

Relationships

Uni

vers

al

Prom

otio

n

Prev

enti

on

Trea

tmen

t

80%

15%

5%

Pyramid for Promoting Social Emotional Competence in Infants & Young Children

The Center on the Social and Emotional Foundations for Early Learning

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Enriched Environments Can Improve Development

Early Head Start

Accredited childcare – National Assoc.for the Education of Young Children

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85

90

95

100

105

110

115

0 1 2 3 5 8 18

Age of children in years

Sta

nd

ard

ize

d T

es

t S

co

res

TreatedControl

IntensiveIntervention

Targeted Social Emotional Supports

High Quality Environments

Nurturing & Responsive Relationships

Left Behind By Kindergarten:Children living in poverty average 15 IQ points below their peers.

Vocabulary at Age 3Poor children: 525 wordsWorking class: 749 wordsProfessional: 1,116 words

By age 4, the average child in a poor family might have been exposed to 13 million fewer words than child in a working class family and

30 million fewer words than a child in a professional family. 7

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• Developmental screening

• Early Intervention

• Early childhood mental health consultants to childcare

• Specific counseling

• Support to siblings, biological and foster families

Targeted Supports

IntensiveIntervention

Targeted Social Emotional Supports

High Quality Environments

Nurturing & Responsive Relationships

Opportunities for Developmental Screening for Child Welfare

1. Childcare Screening2. CAPTA3. Comprehensive Health Assessment4. Comprehensive Behavioral Health

Assessment

1. Developmental screening required for All children in subsidized childcare

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Signs of Trauma in Toddlers

• Biting, kicking, tantrums, unprovoked aggression

• Lack of verbal skills toexpress emotions

• Disengagement with others

• Indiscriminate preferencesof caregivers

• Skill regression

IntensiveIntervention

Targeted Social Emotional Supports

High Quality Environments

Nurturing & Responsive Relationships

Understand Children’s Underlying Emotional Needs in

Challenging Behaviors

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2. Federal Mandate for Developmental Screening of Maltreated Children

CAPTA: 108-36 2003 Child Abuse Prevention & Treatment & Adoption Reform

Requires states to have procedures for the referral of children under 3 involved in substantiated cases of child abuse or neglect to early intervention services

Few children in child welfare qualify for needed Part C intervention because of the

increasingly restrictive criteria. 2 Standard Deviations below mean

in 1 area or 2 areas with 1.5 Standard Deviation delays13

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• NSCAW I: 1990-2000: 35% of children birth to 3 years need Part C early intervention services at time of contact with CWS

• Only 12% had an IFSP by age 3 indicating services

Source: NSCAW I and II

A national study found that…

Unmet Developmental Needs Of Children Investigated For Maltreatment

Mental Health Needs of Children Investigated for Maltreatment: NSCAW 1

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• 26% of children birth to 2and 32% of children 3-5 years have emotional or behavioral problems

• Almost 80% do not receive timely intervention/treatment or primary care services

• 30% of infants in care show behavioral problems at school entry

Source: Casanueva, C., Smith, K., Dolan, M., & Ringeisen, H. (2011). NSCAW II Baseline Report: Maltreatment.OPRE Report #2011-27c, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families,

U.S. Department of Health and Human Services.

National Longitudinal Studyof the Developmental Needs of

Children Encountering Child Welfare with a Measured Delay

– 65% of children not receiving any services– 51% of children receiving services at home– 38% of children in foster homes – 22% of children in kinship care

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Source: Casanueva, C., Ringeisen, H., Wilson, E., Smith, K., & Dolan, M. (2011). NSCAW II Baseline Report: Child Well-Being.OPRE Report #2011-27b, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families,

U.S. Department of Health and Human Services.

Estimated Children Encountering Florida Child Welfare System With Delay(s)

& Not Receiving Part C ServicesType of Child Welfare

InvolvementChildren 0-3 in

Florida Child Welfare,SFY 2009-2010

National Study Percentages of Children with Measured Delays

Estimated No. of Florida Children in Child Welfare

with Delay

Investigations with “No Findings” 19,247 65% 12,511

Children Not Served or Referred to Prevention Programs* 8,476 65% 5,509

Children Served at Home 9,015 51% 4,598

Children Served Out of Home 14,680 38% 5,578

Total # Children in all Situations 51,418 28,196

Total Estimated # Child Welfare Children Served by Part C** 2,652

Estimated # of children with delays not getting Part C 25,544Source: Radigan, Hogan & Graham, (2011). Helping the Child Welfare Population in Early Intervention:

Implications for Practice. Available at www.cpeip.fsu.edu. 17

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3. American Academy of PediatricsRecommendations for Health Care of Young

Children in Foster Care• Initial health screening

(within 72 hours)

• Comprehensive healthassessment (within 30 days of removal) and must address the physical, behavioral, dental and developmental

• Well Child Check-ups completed with EPSDT periodicity schedule.(1, 2, 4, 6, 9, 12, 15, 18 months; then annually from age 2)American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care. (2002). Health care of young children in foster care. Pediatrics, 109(3), 536-541

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DCF/CBC Requirements

• Initial Health Screening

(within 72 hours)

• Comprehensive Health Assessment (within 30 days of removal) and must address the physical, behavioral, dental and developmental

• Comprehensive Health Plan

4. Comprehensive Behavioral Health Assessment 0-5

Medicaid Handbook, (page 2-2-6) The assessment must include, at a minimum, the following information related to the child and the child’s family:• Reason for referral;• Personal and family history;• Placement history, including adjustment to a new care giver and home;• Sources of information (i.e., counselor, hospital, law enforcement);• Interviews and interventions;• Cognitive functioning. Screening for emotional-social development, problem solving, communication, response of the child and family to the assessment and ability to collaborate with the assessor;• Previous and current medications including psychotropics;• Last physical examination, and any known medical problems including pre-natal, pregnancy and delivery history which may affect the child’s mental health status, such as prenatal exposure, accidents, injuries, etc.;• History of mental health treatment of parents and child’s siblings. The mother’s history, including a depression screen;• History of current or past alcohol or chemical dependency of parents and child;• Legal involvement and status of child and family;• Resources including income, entitlements, health care benefits, subsidized housing, social services, etc.;• Emotional status – hands on interactive assessment of the infant regardingsensory and regulatory functioning, attention, engagement, constitutionalcharacteristics, and organization and integration of behavior;• Educational analysis – daycare issues concerning behavioral and developmental concerns;• Functional analysis – presenting strengths and problems of both child and family;

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Unhealed Trauma

National Survey for Child and Adolescent Well-Being II (NSCAW)White, Havalchak, Jackson, O’Brien & Pecora, 2007.

63% of Foster Children Have Mental Health ProblemsAt least one diagnosis in lifetime

Observations

Need for trauma based mental health interventions.• 15 month old KH was drug exposed during pregnancy. No

recommendations in CBHA to address development nor future assessments.

• 3.5 year old DL. Foster parent has concerns re: his nightmares/ does not sleep at childcare/no assessment

• 2.5 year old EJ. Described in chart as “very hyper”

• 4 year-old has behavioral problems in childcare---bites and kicks, defecates in his pants

• 2 year old CH “cries a lot”.

• 5.5 year old CP. Foster parent reports that behavior is “problematic- doesn’t listen, doesn’t want to be told what to do.”

Untreated Adverse Early Childhood Events Only Exacerbate Over Time

Childhood• Developmental

Delays• Expulsion

Adolescence• Delinquency• Mental Health• Sexual Activity• Drugs & Alcohol• Violence

Adulthood• Psychiatric Problems• Drug Abuse• Alcohol• Crime

23Source: Adverse Childhood Experiences (ACE) Study. Available at www.cdc.gov/ace/index.htm

• Nurturing responsive emotionally available caregiver

• Enriched environment with early childhood mental health consultation to address his trauma & needs

• Medical evaluation to address failure to thrive, nutrition, physical issues.

• Developmental assessment with appropriate early intervention services

• Frequent contact with mom• IMH evaluation of parent/child

relationship and dyadic therapy to improve repair and enhance

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What Does Children Like Billy Need to Thrive?

Florida Association for Infant Mental Health12th Annual Conference

June 12, 2013 Tampa FL

Infusing Infant Mental Health into Early Childhood Systems: • How to Screen, • How to Intervene & • How to Fund IMH Services

Early Steps Child Welfare & Baby Courts Home Visiting Childcare