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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

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
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
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
nscaw cohort




foster care


Enter through investigation


Other gateways


No services


Ongoing services


In home




NSCAW Cohort

data collection timeline
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
Data Sources
  • Children
    • Assessments by Field Representatives
    • Interviews (children 7 and older)
  • Caregiver (parent) interviews
  • Caseworker interviews
  • Teacher questionnaires
  • Agency administrators
defining the problem
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
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
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/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
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
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
Do foster children show atypical patterns of HPA axis activity?



Bruce, Fisher, Pears, & Levine (submitted)

Dozier et al. (in press)

the good news
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
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
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
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
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
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
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

Part II.

Finding Solutions

models of care i
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
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
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
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
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
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
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
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
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)