Early Childhood Development

1
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

2
Disclosures

• The speaker does not have any financial ties to
  disclose
• These materials contain informational slides that
  will not be discussed during the presentation

3
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

4
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)
5
Partners

• Extended Research Team includes
• Research Triangle Institute
• University of North Carolina
• Caliber Associates
• San Diego Childrens 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

6
NSCAW Cohort
7
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
8
Data Sources

• Children
• Assessments by Field Representatives
• Interviews (children 7 and older)
• Caregiver (parent) interviews
• Caseworker interviews
• Teacher questionnaires
• Agency administrators

9
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 childs
  neurological development

10
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)

11
NSCAW Study Different Risks by Child Setting
Percent Yes
12
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

13
NSCAW Other Disabilities in Young
Children?(Stahmer et al., 2005 percentages
indicate scores 14
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)

15
Mental Health/Developmental Overlap in Young
Children (Stahmer et al., 2005 percentages
indicate scores

Next steps

Define specific subgroups of need

Examine how need changes over time

Examine if service use has any impact on need

16
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)

17
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

18
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)
19
Do foster children show atypical patterns of HPA
axis activity?
Delaware
Oregon
Bruce, Fisher, Pears, Levine (submitted)
Dozier et al. (in press)
20
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)

21
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)

22
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)
  (httpwww.ed.gov)
• State-based mental health developmental
  disability programs

23
Child Service Use in NSCAW Sample

• Caregiver report of service use
• Overall only 22.7 of children using services
• Primary care (p
• 0-2 yr olds 4.8
• 3-5 yr olds 10.6
• Mental health (p
• O-2 yr olds 4.9
• 3-5 yr olds 17.5
• Special education (p
• 0-2 yr olds 7.0
• 3-5 yr olds 16.3

24
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

25
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

26
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?

27
Part II.

• Finding Solutions

28
Models of Care I

• Improved identification
• Multidisciplinary assessment centers
  Philadelphia Waterbury, CT Syracuse, NY
  Oakland, Sacramento, San Diego (http//gucchd.geor
  getown.edu/programs/ta_center/index.html)
• Additional components
• Standardized tools, community partners, case
  management, trainings, MOUs for shared
  information/confidentiality protection

29
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

30
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-behaviora
  l problems treatment foster care programs

31
Challenges

• 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

32
Importance of Identifying Community Partners

• Some are mandated to address these issues may
  provide critical funding or staffing
• Often need education on each others cultures
  on the specific needs of children in child
  welfare
• Public advisory boards serve to hold agencies
  accountable

33
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

34
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?

35
Importance of Outcomes

• To demonstrate what you do works
• To get additional funding
• To help other communities as they seek to find
  solutions

36
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.

37
Other Sources of Information II

• Websites
• CWLA (www.cwla.org)
• ACF on NSCAW study (http//www.acf.hhs.gov/program
  s/opre/abuse_neglect/nscaw/)
• Georgetown Technical Assistance
  Center(http//gucchd.georgetown.edu/programs/ta_ce
  nter/index.html)
• AAP (www.aap.org)
• AACAP (www.aacap.org)

38
Questions?