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

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


stress-induced ‘blunted’patterns

0

0.2

0.4

0.6

0.8

1


00.20.4

0.60.8

1



ug/

dl

typical


ug/

dl


ug/

dl

0

0.2

0.4

0.6

0.8

1



00.20.4

0.60.8

1



ug/

dl

typical


ug/

dl


ug/

dl

0

0.2

0.4

0.6

0.8

1


00.20.4

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1



ug/

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typical


ug/

dl


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dl


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0

0.2

0.4

0.6

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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?

Documents

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