A National Assessment of Youth Involved with Child Welfare: Prevalence of Emotional and Behavioral

Problems, Access to Treatment, and the Role of Court Involvement

Presented by Heather D. Orton, M.S.Co-Authors: Anne M. Libby, Ph.D., Richard P. Barth,

Ph.D., William Jones, J.D., John Landsverk, Ph.D.

Background

2003 GAO report Children Placed to Obtain Mental Health Services focused on Child Welfare

U.S. General Accounting Office (2003). Children Placed to Obtain Mental Health Services . Washington, D.C.: U.S. General Accounting Office.

Studies document elevated need in foster care populations, also likely for in-home populations

Aarons, G. A., S. A. Brown, et al. (2001). "Prevalence of adolescent substance use disorders across five sectors of care." J Am Acad Child Adolesc Psychiatry 40(4): 419-426.

Halfon, N., G. Berkowitz, et al. (1992). "Mental health service utilization by children in foster care in California." Pediatrics. 89(6 Pt 2): 1238-44.

Costello, E. J., A. Angold, et al. (1996). "The Great Smokey Mountains Study of Youth: Goals, Design, and prevalence of DSM-III-R disorders." Archives of General Psychiatry 53: 1129-1136.

Systems and Services

Because Medicaid insurance obtained through CW placement, CW involvement can be service gateway

Libby, A., A. Cuellar, et al. (2002). "Substitution in a Medicaid mental health carve-out: services and costs." Journal of Health Care Finance 28(4): 11-23.

Involvement with Juvenile Justice system common; overlap with high prevalence of (untreated) mental health problems in Child Welfare

Cuellar, A., A. Libby, et al. (2001). "How capitated mental health care affects utilization by youth in the juvenile justice and child welfare systems." Mental Health Services Research 3(2): 61-72.

Cuellar, A., S. Markowitz, et al. (2004). "The relationships between mental health and substance abuse treatment and juvenile crime." Journal of Mental Health Policy and Economics 7(2): 59-68.

Study Questions

1) What is the prevalence of mental health problems among youth involved with Child Welfare?

2) To what extent are mental health problems associated with court involvement?

3) How are Medicaid insurance and court involvement associated with access to treatment services?

National Survey of Child and Adolescent Well-Being (NSCAW)

Available through the National Data Archive on Child Abuse and Neglect at Cornell University

Longitudinal study of children who were subjects of investigations of child abuse/neglect between October 1999 and December 2000 (N = 5,501)

4 waves of data: baseline, 12 months, 18 months, 36 months

Ages 0 – 14 years at baseline

NSCAW Methods

4 possible respondents: child, current caregiver, caseworker, and teacher

Complex 2-stage sample design 92 PSUs 9 strata Over-sampled: Children/families receiving services,

infants, and sexually abused children Analytic weights for sample design and non-response Estimates nationally representative of Child Welfare

population

Study Sample and Measures

Adolescents age 11 – 14 at baseline (n=1,080) Court involvement = went to court for misbehaving

(assessed by current caregiver) between baseline and Wave 3

Risky substance use = scale created using past 30 day use of all substances as reported by adolescent at baseline

CBCL assessed by caregiver at baseline Service use assessed by caseworker at Wave 2/3

Baseline Demographics

% n

Race

White 48.6 469

Black 28.1 335

Hispanic 16.3 169

Male 43.0 454

In-home 87.0 777

Medicaid 55.4 682

Age (mean, SD) 12.5 yrs (0.7 yrs)

Baseline Mental Health Problems

% n

Clinically significant CBCL (>= 64)

Internalizing 32.7 309

Externalizing 43.0 456

Total 41.4 442

Risky use of substances 27.0 268

Predicting court involvement between baseline and Wave 3

OR p-value

Externalizing CBCL 5.8 < 0.001

Internalizing CBCL 0.4 > 0.05

Total CBCL 1.6 > 0.05

Risky substance use 4.2 < 0.001

In-home 2.1 > 0.05

Abuse v. maltreatment 1.3 > 0.05

Age (years) 1.8 < 0.01

* Model also adjusted for gender and race/ethnicity (n=829)

Predicting service use among adolescents with externalizing CBCL

Mental health services

Substance use services

OR p-value OR p-value

Court involvement 3.3 < 0.05 4.0 < 0.05

Medicaid 2.9 > 0.05 1.6 > 0.05

Race/ethnicity

Black 0.3 < 0.05 2.6 > 0.05

Hispanic 0.2 < 0.05 2.3 > 0.05

Other 1.2 > 0.05 6.6 < 0.05

* Model also adjusted for gender, age, substance use, and placement (n=387)

Predicting service use among adolescents with internalizing CBCL

Mental health services

Substance use services

OR p-value OR p-value

Court involvement 5.2 < 0.05 2.2 > 0.05

Medicaid 2.5 > 0.05 1.1 > 0.05

Race/ethnicity

Black 0.1 < 0.01 0.2 > 0.05

Hispanic 0.06 < 0.001 0.9 > 0.05

Other 0.7 > 0.05 1.7 > 0.05

* Model also adjusted for gender, age, substance use, and placement (n=260)

What is the prevalence of mental health problems among youth involved with Child Welfare?

Prevalence of behavior problems was fairly high: 43% for externalizing and 33% for internalizing

Not an issue of gender – prevalence was similar among boys and girls

27% used substances in past month

To what extent are mental health problems associated with court involvement?

Externalizing problems significantly increased likelihood of court involvement; internalizing problems had no effect

Substance use increased likelihood of court involvement

Older adolescents more likely to become involved with courts

How are Medicaid insurance and court involvement associated with access to treatment services?

Medicaid did not have a significant effect on access to treatment

Court involvement increased likelihood of receiving MH and substance use services

Black and Hispanic adolescents were less likely to receive services than White adolescents

Questions?

Past month drug use at baseline

0

5

10

15

Alcohol Marijuana Sniffed glue Hard drugs

1 - 2 days3 - 11 days12+ days