Early childhood development related policy implications young children in child welfare
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Early Childhood Development & Related Policy Implications: Young Children in Child Welfare. Laurel K. Leslie, MD, MPH Institute for Clinical Research and Health Policy Studies Tufts-New England Medical Center Presentation for the 12 th National Conference on Children and the Law. Disclosures.

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

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

Laurel K. Leslie, MD, MPH

Institute for Clinical Research and Health Policy Studies

Tufts-New England Medical Center

Presentation for the 12th National Conference on Children and the Law


  • The speaker does not have any financial ties to disclose

  • These materials contain informational slides that will not be discussed during the presentation

Goal of this Presentation

  • Review what we know regarding

    • The Problem: Developmental & behavioral problems in young children in child welfare

    • Current service/treatment use

    • Information presented draws heavily on the NSCAW study (see next 5 slides)

  • Present a framework to guide development of community-based initiatives to improve outcomes

Background: National Survey of Child and Adolescent Well-being (NSCAW)

  • Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Title V, Section 429A (PL 104-193)

  • Congressional mandate to the Secretary to conduct a “national random sample study of child welfare”

  • www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw

(No prior child welfare study has ever

attempted anything remotely this ambitious)


  • Extended Research Team includes:

    • Research Triangle Institute

    • University of North Carolina

    • Caliber Associates

    • San Diego Children’s Hospital

    • CSRD, Pittsburgh Medical Center

    • Duke Medical Center

    • U.C. Berkeley

    • National Data Archive on Child Abuse and Neglect, Cornell

    • 92 Local Child Welfare Agencies

    • Children, Caregivers, and Teachers

    • Administration For Children and Families




foster care


Enter through investigation


Other gateways


No services


Ongoing services


In home




NSCAW Cohort

Data Collection Timeline

Wave 1: Baseline

Nov, 1999 – Apr, 2001

Target population: Children involved in investigations closed between October 1, 1999 and December 31, 2000

Wave 2: 12 Month Follow-up

Oct , 2000 – Apr, 2002

Wave 3: 18 Month Follow-up

Apr, 2001 – Sept, 2002

Wave 4: 36 Month Follow-up

Oct, 2002 – Apr 30, 2004

1999 ‘ 2000 ‘ ‘ ‘ ‘ 2001 ‘ ‘ ‘ ‘ 2002 ‘ ‘ ‘ ‘ 2003 ‘ ‘ ‘ ‘ 2004

Data Sources

  • Children

    • Assessments by Field Representatives

    • Interviews (children 7 and older)

  • Caregiver (parent) interviews

  • Caseworker interviews

  • Teacher questionnaires

  • Agency administrators

Defining the “Problem”

  • Young children make up a substantial proportion of children in child welfare

    • 28% of children in out-of-home care in 2002 were age 5 or younger

  • Many children experiencing abuse &/or neglect during early years of life when neurological development is most active & vulnerable

  • Some experience out-of-home placement which may positively or negatively affect a child’s neurological development

Are These Children at Risk?

  • Children with disabilities more vulnerable to maltreatment

  • Possible genetic predisposition

  • Many of these children display environmental risk factors for developmental & behavioral problems

    • Abuse/neglect/poverty/violence

    • Inadequate preventive health care so problems not prevented or identified (e.g. prenatal infections, lead exposure)

    • Parents with mental illness &/or substance abuse

    • Parenting practices (harsh, inconsistent discipline; lack of supervision; limited reinforcement of appropriate prosocial skills)

Is there a Reason to Worry? Rates

  • For young children in child welfare, high rates of problems in multiple studies

    • Developmental problems: as high as 60% compared to 4-10% in general population

    • Behavioral problems: as high as 40% compared to 3-6% in general population

NSCAW: Other Disabilities in Young Children?(Stahmer et al., 2005; percentages indicate scores < 2 SD from the mean)

Developmental/Behavioral Measures: 0-5 years

  • Developmental

    • Neurodevelopmental

      • Bayley Infant Neurodevelopmental Screener (13-24 months)

    • Cognition

      • Battelle Developmental Inventory (ages 0-4 years)

      • Kaufman Brief Intelligence Test (ages 4-5 years)

    • Speech/Language

      • Preschool Language Scale (ages 0-6 years)

  • Behavioral

    • Child Behavior Checklist (ages 18 months-5 years)

    • Social Skills Rating Scale: Prosocial Scale (ages 3-5 years)

    • Vineland Adaptive Behavior Scales (all ages)

Mental Health/Developmental Overlap in Young Children (Stahmer et al., 2005; percentages indicate scores < 2 SD from the mean)

  • Next steps

    • Define specific subgroups of need

    • Examine how need changes over time

    • Examine if service use has any impact on need

Is There a Reason to Worry? Placement Patterns

  • For children in out-of-home care,

    • Behavior problems associated with increased placement disruptions

      (James et al., 2004)

    • Developmental & behavioral problems correlated with longer lengths of stay in out-of-home care, less reunification, less adoption

    • (Horowitz et al., 1994: Landsverk et al., 1996)

Is There Reason to Worry? Outcomes

  • For older youth in child welfare, many face academic difficulties, high school drop-out rates, mental health issues, delinquency, risky behaviors

Diurnal HPA axis activity

(downregulation via chronic stress)

Note: Low daytime activity does not infer a blunted HPA stress response (see Kaufman et al., 1997)

Do foster children show atypical patterns of HPA axis activity?



Bruce, Fisher, Pears, & Levine (submitted)

Dozier et al. (in press)

The Good News

  • Brain is highly adaptive & malleable during these early years

  • Growing body of scientific evidence pointing to the potential for early intervention in young children

  • Intensive services with preschoolers in child welfare can normalize these cortisol patterns

  • (Fisher et al., 2006)

Programs Applicable to Young Children in Child Welfare I

  • Medical

    • Medicaid (www.cms.hhs.gov/medicaid/)

    • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program in Medicaid (www.cms.hhs.gov/medicaid/epsdt/default/asp.)

    • Title V Maternal and Child Health Services (https://.performance.hrsa.gov/mchb/)

  • Child Welfare

    • Title IV-E & Title IV-B for children & families in child welfare (http://www.acf.dhhs.gov)

Programs Applicable to Young Children in Child Welfare II

  • Social Services:

    • Title XX Social Services Block Grant (http://www.acf.hhs.gov/programs/)

  • Special Education:

    • IDEA Special Education Services (3-21 years) & Early Intervention services (0-2 years) (http:www.ed.gov)

  • State-based mental health & developmental disability programs

Child Service Use in NSCAW Sample

  • Caregiver report of service use:

    • Overall: only 22.7% of children using services

    • Primary care (p<.001)

      • 0-2 yr olds: 4.8%

      • 3-5 yr olds: 10.6%

    • Mental health (p<.001)

      • O-2 yr olds: 4.9%

      • 3-5 yr olds: 17.5%

    • Special education (p<.001)

      • 0-2 yr olds: 7.0%

      • 3-5 yr olds: 16.3%

What May be Going On? I

  • Poor identification of children with problems

    • No systematic approach

      • For children in out-of-home care, 94% of child welfare agencies screened for physical health problems, but only 47.8% screened for mental health problems, and only 57.8% screened for developmental problems (Leslie et al., 2004)

    • Accuracy of assessments

      • High use of community providers to assess needs

      • Limited use of tools; clinical judgment detects less than 1/3 of developmental problems & 50% of emotional problem

What May be Going On? II

  • Difficulty linking children to available services

    • Poor communication & different cultures/agendas between different agencies

    • Lack of a clearly identified case manager

    • Placement changes if in out-of-home care

    • Fiscal challenges faced by most public agencies

    • Child or family may not meet eligibility criteria for public program

What May be Going On? III

  • Not accessing evidence-based care

    • Most interventions that work are very intensive

    • Few studies of interventions in children in child welfare

    • Limited use of available caregivers as “therapeutic agents”, particularly foster parents

  • What should be the role of child welfare?

    • For the majority of children investigated, there is only fleeting involvement with child welfare. How much “well-being” is the responsibility of child welfare agencies when they have limited contact over time with a family?

Part II.

Finding Solutions

Models of Care I

  • Improved identification:

    • Multidisciplinary assessment centers: Philadelphia; Waterbury, CT; Syracuse, NY; Oakland, Sacramento, San Diego (http://gucchd.georgetown.edu/programs/ta_center/index.html)

    • Additional components:

      • Standardized tools, community partners, case management, trainings, MOUs for shared information/confidentiality protection

Models of Care II

  • Improved linkages between agencies

    • Health Passports

    • Placement coordinators

    • Shared information systems

    • Health units within child welfare agencies

    • Court oversight of health, development, mental health, & educational needs

Models of Care III

  • Caregivers as therapeutic agents

    • Carolyn Webster-Stratton: in-home caregivers with youth with disruptive disorders

    • Philip Fisher, Patti Chamberlin: foster caregivers with youth with developmental-behavioral problems; treatment foster care programs


  • Problems:

    • Limited “outcome” studies to show these programs link children or improve their outcomes

    • Difficult to achieve in highly urban areas or rural areas

    • Working out the details

    • Funding

Importance of Identifying Community Partners

  • Some are mandated to address these issues & may provide critical funding or staffing

  • Often need education on each other’s cultures & on the specific needs of children in child welfare

  • Public advisory boards serve to hold agencies accountable

Who are Potential Partners?

  • Medical: Medicaid, Title V, public health nursing

  • Child welfare

  • Special education & early intervention services

  • Mental health

  • Developmental disabilities

  • Community groups: CASA, others

  • Foundations, businesses, academic institutions

Importance of Defining Scope of Program

  • Which children: placement? Age? Location?

  • What types of problems?

  • Immediate or staged implementation?

  • How staffed?

  • What types of “tools” will be used

  • What are specific barriers we need to address?

Importance of Outcomes

  • To demonstrate what you do works

  • To get additional funding

  • To help other communities as they seek to find solutions

Other Sources of Information I

  • Written materials

    • Silver, J. ; Amster, B.J., Haecker, T. Young Children and Foster Care. Paul H. Brookes; 1999.

    • Shonkoff J.P. Mesiels, S.J. eds. Handbook of Early Child hood Intervention. Cambridge U. Press; 2000.

    • Shonkoff, J.P. , Phillips, D.A. From Neurons to Neighborhoods. National Academies Press. 2000

    • Leslie, L.K., Gordon, J.N., Lambros, K., Premji, K., Peoples, J., Gist, K. Addressing the developmental and mental health needs of young children in foster care. Journal of Developmental and Behavioral Pediatrics 26: 140-151, 2005.

Other Sources of Information II

  • Websites

    • CWLA (www.cwla.org)

    • ACF on NSCAW study (http://www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw/)

    • Georgetown Technical Assistance Center(http://gucchd.georgetown.edu/programs/ta_center/index.html)

    • AAP (www.aap.org)

    • AACAP (www.aacap.org)


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