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Children and Youth Services Review 30 (2008) 774 – 786 www.elsevier.com/locate/childyouth

The well-being of children in foster care: Exploring physical and mental health needs
Dana J. Sullivan ⁎, Michiel A. van Zyl 1
University of Louisville, Kent School of Social Work, Louisville, KY 40292, United States Received 20 June 2007; received in revised form 22 July 2007; accepted 9 December 2007 Available online 17 December 2007

Abstract A census of children in foster care provided valuable insight into the well-being of children in one state. CHAID analysis on differences related to physical and mental health needs among various groups of children in foster care revealed a number of significant differences that are often overlooked in other types of analyses. Children's medical needs differ significantly by length of stay and emotional needs were more profound among children of certain ages. Published by Elsevier Ltd.
Keywords: Foster care; Well-being; Mental health; Physical health; CHAID

1. Introduction Historically, social workers in child welfare have focused primarily on keeping children safe from abuse and neglect, and helping them return home safely or find new adoptive homes. However, Altshuler and Gleeson (1999) described the emphasis on safety and permanency, to the exclusion of well-being, as a triangle that can only be completed when well-being becomes a focus of child welfare services. In response to this emerging professional perspective, the Adoption and Safe Families Act (ASFA) of 1997 mandated three goals for public child welfare agencies—safety, permanency, and well-being for children and families (PL 105–89). This marked the first time that well-being was made a specific goal. At the time of passage of ASFA, no consensus existed about how to measure the well-being of children, particularly the dimensions of well-being that might be affected by involvement with the child welfare system. Comparative data were not available in the literature (Poertner, McDonald, and Murray, 2000) and no national baseline existed for states to utilize in comparing the well-being of their residents with those of other states. Kentucky, along with other states, had to develop measures of well-being to gauge its progress toward meeting the federal mandate. With publication of a Final Rule in 2000, the Administration for Children and Families (ACF) outlined broad parameters within which states had to operationalize well-being. The relevant outcomes were: (a) Families have enhanced capacity to provide for their children's needs, (b) children receive appropriate services to meet their
⁎ Corresponding author. Tel.: +1 502 852 2920; fax: +1 502 852 0422. E-mail address: dana.sullivan@louisville.edu (D.J. Sullivan). 1 Tel.:+1 502 852 2430; fax:+1 502 852 0422. 0190-7409/$ - see front matter. Published by Elsevier Ltd. doi:10.1016/j.childyouth.2007.12.005

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educational needs, and (c) children receive adequate services to meet their physical and mental health needs (US DHHS, 2000b). This paper focuses on the third outcome, exploring the physical and mental health needs and the receipt of services around these needs in a population of children in foster care in one state. To address questions concerning the well-being of children in its custody, Kentucky child welfare administrators initiated the Kentucky Foster Care Census (KFCC) in July 2002. Among the census phase I goals were data collection related to five domains of well-being (physical health, mental/emotional health, physical disabilities, education, and developmental disabilities) and verification of each child's foster care placement to account for every child in custody (Huebner, Miller, Wolford, & Hommrich, 2003). This paper discusses a portion of the results of the census, focusing on exploring the prevalence of physical and emotional health problems, and assessing whether those needs were being met by the available resources and related services among children in the custody of the state child welfare agency. The Kentucky Foster Care Census adds to the knowledge base regarding the well-being of children in foster care by examining their physical and mental health needs. Kentucky was the first state to adopt a census approach to assessing well-being and these data address the ASFA outcomes by exploring the presence of physical and emotional problems and describing the provision of services in response to those needs. This approach is unique among state child welfare agencies and other states may find that it is worth replicating. 2. Literature review Children in foster care typically have more physical and mental health problems than children in the general population (Bilaver, Jaudes, Koepke, & George, 1999; Silver et al., 1999; Simms, Freundich, Battistelli, & Kaufman, 1999). They enter care with more medical, mental health, and developmental problems, and many of them do not receive adequate help for these problems while they are in the foster care system (Simms, Dubowitz, and Szilagyi, 2000). Kortenkamp and Macomber (2002) found that 27% of children in the child welfare system had behavioral and emotional problems; while 28% had problems that also included physical conditions (and learning disabilities) that impacted their ability to do activities. More than one-fourth of the subsample of children in the National Survey of Child and Adolescent Well-Being (NSCAW) who had been in foster care one year were reported by their caregivers to have a recurrent health problem (US DHHS, 2003). In a national study of foster parents, the developmental, physical and mental health needs, as well as access to care for these issues were among the major concerns identified (Pasztor, Hollinger, Inkelas, & Halfon, 2006). 2.1. Physical health and development Takayama, Wolfe, and Coulter (1998) found that 60% of the foster children in their study had some type of health problem. Younger children who had suffered neglect had higher rates of developmental delays than did other groups of children. The most common problems were illnesses of the upper respiratory system, myopia, and conditions such as tuberculosis. These are serious problems that left undetected and untreated can cause major medical problems for children, even into adulthood. Children who have been neglected and experienced changes in placements may also be at risk of suffering from more health problems than other children who have been abused (Takayama et al., 1998). In a study to test an assessment to evaluate child well-being (measured by youth self-report), Altshuler and Poertner (2003) found that youth in foster care reported higher levels of physical problems including migraine headaches and more adverse effects from injuries than the norm referenced group. In addition, they reported more occurrences of chronic medical conditions including heart disease, epilepsy, diabetes, and sickle-cell anemia. Childhood abuse also puts the victim at risk for problems into adulthood including increased physical health problems such as chronic pain syndromes (Kendall-Tackett, 2002). The use of the healthcare system and providers should be considered when examining ways to help improve the physical health of children in foster care. Friedlaender et al. (2005) identified patterns of health care use in young children that may place them at risk for maltreatment. They found that children who were victims of physical abuse and neglect changed ambulatory care providers more often than other children. Healthcare providers, including pediatricians, need to be educated about child maltreatment and the impact it has on physical health, in order to help provide more comprehensive assessments, promote more continuity of care, and to help advocate for the children in their care by being more involved in the communication of the child's care with caseworkers and even perhaps, judges and lawyers who are representing the child (Simms et al., 2000). The addition of pediatric public health nurses placed in

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public child welfare settings that has occurred in some areas, is important to help provide health care for children in foster care within the child welfare agency (Schneiderman, 2006). In summary, children in foster care tend to have more physical health problems than do children in the general population. Although foster children do seem to have more access to services for these problems than do other groups of children, the care may not be consistent enough and the foster parents may not have enough information about these problems to provide adequate support to or obtain adequate services for the child. Early identification of and treatment is very important, as well as the provision of preventative care. The healthcare needs of foster children should be continually monitored (Bilaver et al., 1999) in order to promote their well-being. 2.2. Mental/emotional health Children in out-of-home care often have complex mental health needs and the system is challenged to help provide or broker treatment for these children that are affected (Schneiderman, Connors, Fribourg, Gries, & Gonzales, 1998). Almost one quarter (23%) of the children in the NSCAW one year in foster care subsample had received at least one mental health service in the past year (US DHHS, 2003). Raghavan et al. (2005) found that 13.5% of the children in the child welfare system were receiving psychotropic medications, a rate that is between 2 and 3 times more often than children in the general population. Child maltreatment is a traumatic experience that can lead to emotional problems such as depression, increased aggression, lowered self-esteem, identity disturbances, feelings of guilt and shame regarding the abuse, problems with interpersonal relationships, social isolation, and increased mental illness diagnoses (such as depression, conduct disorder, or post-traumatic stress disorder) (Avery, Massat, and Lundy, 2000; Carlson, Furby, Armstrong, & Shlaes, 1997; Staudt, 2001). Repeated events of maltreatment can lead to increased behavior problems and trauma symptoms of both depression and posttraumatic stress (English et al., 2005). Stein et al. (2001) found that the majority of children in foster care have been exposed to violence and that the exposure could continue even in foster care (perhaps during visits with the biological family, in the school, or community); this experience of exposure may also result in increased distress symptoms as compared to children who have not been exposed to violence. Kendall-Tackett (2002) found that behavioral problems like engaging in harmful behaviors such as substance abuse, obesity, eating disorders, suicide, high risk sexual behavior, and smoking are more likely to found in adult survivors of childhood abuse than in adults in the general population. Leslie et al. (2000) found that visits to mental health centers by foster children were more frequent as children aged, were more frequent for males, and for those living in non-relative foster care. In addition, children scoring higher than 60 on the Child Behavior Checklist clinical scale also had more mental health visits. The NSCAW found that older children living in group care with higher CBCL scores were more likely to have received mental health services (US DHHS, 2003). Over half of the children in the NSCAW one year in foster care sample indicated a high need for mental health services, but there was also a high degree of needs that were not met (Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004). Burns et al. (2004) found that of the children (between the ages of 2 and 14 years) with completed child welfare services investigations, nearly half had emotional or behavioral problems of clinical significance. Rubin et al. (2004) found that children who had multiple placements and cycled in and out of foster care had a higher percentage of mental health services use. It is suggested that child welfare systems have processes in place to consistently link foster children that have mental health issues to services that are appropriate to meet their needs (Leslie et al., 2000). Foster parents have reported that mental health services are among those most needed by children in their care, with special education services and social services following in priority (Zima, Bussing, Yang, & Belin, 2000). Yet, they have also reported feeling left out of the process, with healthcare professionals not paying as much attention to their concerns (as compared to the biological parents and/or social workers) or providing them with enough instructions about the care of the child (Ahmann and Barton, 1999). It has also been found that children served by child welfare agencies do tend to get more medical and mental health treatment than do other children suffering from the same problems, but that are not in foster care (Bilaver et al., 1999; DosReis, Zito, Safer, & Soeken, 2001; Farmer et al., 2001). However, there is also concern that foster children may receive the wrong type of care for health problems due to medical histories that are often given to foster parents and providers in an incomplete manner (Sobel and Healy, 2001). Services may be fragmented for these children (Simms et al., 1999) and that is a cause for concern within this system of care.

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A national probability sample of US child welfare agencies, in collaboration with the National Survey of Child and Adolescent Well-Being, found that only 42.6% of the primary sampling units provided physical and mental health exams that were comprehensive in nature (Leslie et al., 2003). However, 86.4% had policies in place regarding physical health examinations and 47.8% had policies in place regarding mental health problem assessment (Leslie et al., 2003). Children in foster care tend to have more mental health and physical health needs than do children in the general population and they have many needs related to their physical and emotional well-being that should be considered by care providers, social workers, and administrators in the child welfare system. Determining the most appropriate and adequate ways for everyone involved with the child to provide early identification and treatment of problems in each of these domains, can to lead to better services, and thus better outcomes for children and families. Gaps in the literature on child well-being include the need for a more complete understanding of how the interactions of all of these variables within these domains of well-being interact to affect the outcomes of children in the child welfare system and impact the receipt of services. Studying more about the types and multiplicity of maltreatment can help to identify gaps in services that can possibly lead to better strategies regarding primary, secondary, and tertiary prevention of child abuse and neglect. 3. Well-being conceptual framework Considering both the literature and the Administration for Children and Families (ACF) Final Rule (US DHHS, 2000b) which stated what the relevant outcomes were for child and family well-being as discussed above, a conceptual framework of well-being within the ASFA requirements recognizes a three-tiered focus, including health (both physical and mental) needs, educational needs, and services to families. More specifically, the receipt of adequate or appropriate services to meet the needs is important to the well-being of the child. Families having the capacity to provide for a child's needs are also important. Fig. 1 outlines a conceptual framework of well-being, as operationalized by ASFA and measured in the CFSR process (US DHHS, 2000a), based on the well-being domains described in the Final Rule. The framework also considers effects or consequences (both short-term and long-term) if those needs are not met while children are in child welfare custody. It also highlights the consequences for the outcomes of families and children if well-being is not a priority for casework within the state child welfare agency. Child welfare policy and practice must take into account each of these domains, in order to ensure policy formulation that meets the Federal law and best practice standards. 4. Methodology This exploratory study of child well-being indicators involved the entire population of children in the state child welfare agency's foster care system in the state at a particular point in time. Before discussing specific findings, we describe the sample, the data collection protocol, and analytic methods. 4.1. Sampling On August 25, 2002, a total of 1338 foster and adoptive homes in Kentucky had at least one child living in them (Huebner et al., 2003). Nearly 3000 children living in these homes were included in the census and 131 census takers (mostly social work students from ten Kentucky universities) compiled the information (Huebner et al., 2003). All data collectors were required to attend one and a half days of training, as well as to enroll in a course during the semester at their respective universities through which they received ongoing supervision. Data collection occurred between September and January 2003. 4.2. Instrument The instrument utilized for this study, the Kentucky Foster Care Census Child Census Form, was developed specifically for this study, and included multiple questions about the demographic information of each child in foster care placement while also capturing data about each child on various domains of well-being including personal characteristics, physical health, dental care, prior placements, educational issues, visits with the biological family, and placement/visitation with siblings (Huebner et al., 2003). A separate section of the instrument was completed only by

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Fig. 1. Conceptual framework for child well-being.

the foster/adoptive parent and contained questions related to the length of time since the last visit by the child welfare agency, the frequency of those visits, the foster parents' satisfaction with those visits, and their rating of the importance of the child's visits with their biological family. In addition, they rated how involved the child was with the agency staff in making decisions about their own care on a four point scale, which was 1 = rarely or never to 4 = consistently (Huebner et al., 2003). This paper focuses on the results from a series of questions pertaining to the child's needs and services provided in response to those needs. The foster parent was asked if the child had a diagnosed or identified need in a certain domain and if they were receiving adequate help for those needs. This study focused on the following questions from this series: does the child have a diagnosed medical need(s) and is the child receiving adequate help for the need; and does the child have an identified emotional need(s) and is the child receiving adequate help for the need. Each question could only be responded to with a “yes” or “no.” The instructions stated that caseworkers or foster parents could answer the question about diagnosed or identified need but that only foster parents were to answer about the adequacy of the help the child was receiving in each area. 4.2.1. Variables The analysis tested the effects of several different independent variables on the well-being outcomes of physical and mental health. These were gender, age, number of prior placements in out-of-home care, length of time spent in current out-of-home care placement, number of total months in care, type of care (foster or adoptive), geographical location of the child (urban or rural), number of months since the last physical and dental health visits to providers, number of months since the last visitation with the biological family and biological siblings, and number of months since the last visit with the child by the caseworker. Other variables included ratings of the importance of visits with the biological family and the satisfaction of the foster parents with the visits of the worker. The dependent variables were whether or not a child had a diagnosed medical or identified emotional problem and if those two types of needs were being met adequately, as rated by the foster/adoptive parents. These dependent variables were all gathered at the nominal, or categorical, level. Therefore, need and adequacy of services were operationalized as

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presence or absence, checking “yes” or “no” and did not allow for listings of specific diagnoses, co-morbidities, severity or duration of problems, or any other descriptive information. 5. Research questions The questions for this research were as follows: (1.) by exploring the well-being indicators in the census dataset, what is the well-being status of children in foster care in this state in terms of both physical and emotional health?; (2.) by exploring the well-being indicators, what differences in groups of children emerge that reflect variation in service provision for both physical and emotional health? 5.1. Data analysis Given that this research involved data from a large population (N = 2996), rather than a small sample, and since the dependent variables were measured at the nominal level, the exploratory technique CHAID (chi-square automatic interaction detection) (Kass, 1980) was used for data analysis.2 CHAID takes into account multiple independent variables and the most significant predictor to explain the dependent variable emerges, while taking into account the interaction of the variables simultaneously (Edwards, Grossi, Vito, & West, 2002). CHAID has not been used widely in the child welfare literature. It has been utilized in areas such as population census studies (Ngwane, Yadavalli, and Steffens, 2001), studies related to alleged law enforcement racial profiling in arrests (Edwards et al., 2002), marketing research (DeRada, 2005; Haughton and Oulasi, 1997; Levin and Zahavi, 2001; Sargeant and McKenzie, 1999), and political polling (Malchow, 1997). In addition, CHAID has been utilized to study patterns of gambling pathology (Welte, Barnes, Wieczorek, & Tidwell, 2004) and patterns of general practitioners' attribution of patients' emotional distress (Saltini, Mazzi, Piccolo, & Zimmerman, 2004). Tree classification techniques such as CHAID have a number of advantages over other methods when analyzing classification or regression problems. The interpretation of results summarized in a tree is simple and simplicity is useful. The segments derived by CHAID are mutually exclusive and exhaustive which means that CHAID is characterized by high transparency of the segmentation process. There is no implicit assumption that the underlying relationships between the predictor variables and the dependent variable are linear, or follow some specific non-linear link function which is the case in Generalized Linear/Non-linear Models (GLZ), often used in regression analysis. CHAID is well suited for data mining tasks, where there is little a priori knowledge nor any coherent set of theories or predictions regarding which variables are related and how. CHAID offers the opportunity to reveal simple relationships between just a few variables that could have easily gone unnoticed using other analytic techniques. Furthermore, CHAID allows for flexibility in dealing with data at different levels of measurement for dependent and predictor variables and missing values in predictor variables can be treated as a "floating category" so that partial data can be used whenever possible within the tree. CHAID also provides information for scaling variables in later analyses or future studies. CHAID is typically used to explore group differences based on categorical predictor variables, such as the wellbeing indicators obtained from the KFCC Child Census Forms database. Due to the exploratory nature of the study, many independent variables were included in the analysis to identify differences in groups of children reflecting variation in needs and service related to physical and emotional health. 6. Results The total population size for this study was 2996, all of the children in foster care at the point in time when the data were collected (Huebner et al., 2003). It is understood that cross-sectional data collection in a census has an inherent bias in that it includes a disproportionate number of children with longer lengths of stay and is not representative of all the children ever served in the foster care system. Children with shorter lengths of stays in care are under-represented, which underscores a problem common for child welfare systems tracking outcomes utilizing cross-sectional data (Usher, Gibbs, & Wildfire, 1995). Just over half of the children were female (53%, n = 1577). There was a wide range of ages among the children in the sample, with the youngest being infants less than one year old (n = 134), and the
2

The program Answer Tree was the statistical software utilized for analysis (SPSS, 2001).

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oldest being 21 years old. The average age of the children in the sample was 8.3 (SD = 5.57). The median age was eight years old and the mode was two years old. 6.1. Time spent in foster care Nearly one-third of children in the sample (30.2%) had two or more prior placements in foster care (n = 811). Almost half of the children, 43.3% had no prior placements in the foster care system (n = 1162). There were also differences in the total number of months spent in care. The average total length of time in the foster care system for the children in the sample was 25.14 months (SD = 27.52). The average length of time in the current foster or adoptive home was 18.47 months (SD = 24.32). Eighty-five percent of the children were in a foster home placement, while 8% were in an adoptive placement. Seven percent of the placements were indicated as “either”, because some of the homes visited in the census were certified as both adoptive and foster homes. The placements of the children in the sample also differed by geographic location. Seventy-four percent (n = 2208) of the children in the sample were placed in a rural region of the state, while 26% (n = 788) were placed in an urban region of the state. The average length of time since the last visitation with their biological parent(s) was 3.86 months (SD = 11.75). For 49% of the children, only one month had passed since their last contact with their biological parent(s) and for 27% it had been less than one month. Eighty-one percent (n = 2380) of the children in the sample were part of a sibling group. Of those who had siblings, 55% (n = 1622) were placed with one or more of those siblings. Forty-eight percent of the children had siblings placed elsewhere. The average length of time since the last visit with a sibling(s) was 1.6 months (SD = 5.95). Slightly more than half of the children (51%) had visited with their sibling(s) within less than a month's time. 6.2. Physical and dental health The average length of time since the last physical examination was four months (SD = 3.7). The average length of time since the last dental visit was 3.62 months (SD = 3.93). 7. CHAID analysis results CHAID results are charted in an “answer tree” or a dendogram (the terms are used interchangeably in the results section), with each sub-sample being split out by predictors, which then result in the groupings of variables which more accurately portray the interactions between the independent and dependent variables than do descriptive statistics or regular chi-square analysis. Two different CHAID answer trees were estimated for both the separate domains of physical health and mental/emotional health, thus co-morbid conditions are not addressed in this study. The first tree represents the percentage of children with diagnosed or identified needs in the particular areas, with each of the independent variables that emerged as predictors of the dependent variable. The second tree in each section represents the adequacy of the resources, or how adequately the needs were being met in those areas. 7.1. Physical health 7.1.1. Diagnosed medical needs The first question asked whether or not the child had a diagnosed medical need(s). The overall rate of having a diagnosed medical need was 32% (n = 911), while 68% (n = 1901) indicated not having a diagnosed medical need. The most highly significant predictor of having a diagnosed medical need was the number of months the child had spent in foster care, x2 (2, n = 2812) = 38.13, (p b .001). The CHAID analysis identified three groups according to length of stay: children who had been in care for four months or less (20% of this sub-sample, n = 562); those who had been in care between four months and 59 months (70% of this sub-sample, n = 1965); and those who had been in care for five years or more (10% of this sub-sample, n = 285). Twenty three percent of those who had been in care for four months or less had a diagnosed medical need (n = 131), as did 33% of those who had been in care between four months and five years (n = 656), and 44% of those who had been in care for over five years (n = 124). The group that had been in care between four months and five years (quite a large span), contained the largest subsample (70%, n = 1965) and further split on the number of agency visits in the past six months, x2 (1, n = 1965) = 26.58,

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Fig. 2. Diagnosed medical needs CHAID tree.

p b .001. However, only two groups emerged as significantly different, those that had less than seven visits in which 31% of them had a diagnosed medical need (n = 553), and those that had more than seven visits, in which 49% of them had a diagnosed medical need (n = 103). The risk estimate is a measure of a tree's predictive accuracy (SPSS, 2001). For this dendogram, the risk estimate was .32 (SE = .009), indicative of a moderate risk of misclassification in this tree analysis. Fig. 2 shows the progression of the CHAID analysis for this variable. Subsequent results will be shown by table only.3 Other variables that were included in the model but that did not emerge as significant predictors of having a diagnosed medical need were gender, region, the number of prior foster care placements, length of time since the last physical, and length of time spent in the current placement. 7.2. Mental/emotional health 7.2.1. Identified emotional needs In the emotional needs domain, 44% of the children in the sample were indicated to have an identified emotional need (n = 1231), while 56% of the sample were identified as not having an identified emotional need (n = 1566). The most significant predictor of identified emotional need was age of the child, x2 (6, n = 2797) = 419.91, p b .001. Age was split into seven groups: less than one year old (12% of this sub-sample, n = 339); ages one through two (8% of this sub-sample, n = 212); ages two through three (7% of this sub-sample, n = 198); ages three through five (13% of this sub-sample, n = 354); ages five through 12 (33% of this sub-sample, n = 920); ages 12 through 16 (19% of this subsample, n = 527), and over age 16 (9% of this sub-sample, n = 247). The three older groups had a higher percentage of identified emotional need(s) than did the younger groups, all of which exceeded the baseline of 44%. The group with the highest percentage of identified emotional needs was the five to 12 year-olds, of which 62% had an identified emotional need (n = 574). The next highest was the 12–16 year-old group, of which 56% had an identified emotional need (n = 294). The oldest group, those over age 16, had a slightly lower rate of need, which was 46% (n = 114). The five to 12 year-old group further split by number of months in care, x2 (2, n = 920) = 27.25, p b .001. Three groups split
Fig. 2 is presented in order to visually display the results of the CHAID analysis to give the reader a representation of the graphing of the succession of the significance of the variables.
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Table 1 Diagnosed emotional needs CHAID analysis Variable splits Age of child: x (6, n = 2797) = 419.91, p b .001 Less than 1 Age 1–2 Age 2.1–3 Age 3.1–5 Age 12.1–16 Older than 16 Age 5.1–12 And number of months in care: x 2 (2, n = 920) = 27.25, p b .001 Less than 7 months 7–40 months More than 40 months
2

Percentage with a diagnosed emotional need n = 1231, 44.01% n = 28, 8.3% n = 39, 18.4% n = 54, 27.3% n = 128, 36.2% n = 294, 56% n = 114, 46% n = 574, 62.4% n = 121, 51% n = 296, 63% n = 157, 75%

out, and as time in care increased, so did the percentage with an identified emotional need. Those children who had been in care for less than seven months had a 51% rate of identified emotional needs (n = 121), while those who had been in care between seven and 40 months (3 years and four months) had a 63% rate of identified emotional needs (n = 296), and finally 75% of those in care for more than 40 months had an identified emotional need (n = 157). The risk estimate for this tree was .31 (SE = .008). This is approximately the same level as the medical-need tree and is indicative of a moderate risk of misclassification. Table 1 shows the progression of the CHAID analysis for this variable. Other independent variables in the model that did not emerge as significant predictors of identified emotional need were region, time in current placement, length of time since last visit with the worker, and foster/adoptive parent satisfaction with visits by the caseworker. 7.2.2. Adequacy of medical and emotional health resources After asking if the child had a need in a certain area, the respondent was asked if the child was receiving adequate resources in the area. With regard to both medical and emotional needs, region of commitment was the most significant predictor of receiving adequate resources. Seventy-eight percent of children were indicated to be receiving adequate medical resources (n = 2178), while 22% were not (n = 615). Geographic region emerged as the most significant predictor of the adequacy of medical resources, x2 (5, n = 2793) = 186.76, p b .001. Six different groups of regions emerged and they were a mixture of rural and urban regions, meaning that the regions clustered and varied on the percentage of adequacy of resources provided. The mixture of both urban and rural regions indicated that there were both rural and urban regions with a high percentage of adequate medical resources and with a low percentage of adequate medical resources (the range was 59.1% to 97.45%). This range indicates regional differences and suggests that even in some regions where there may not be as many resources, the majority of the children in foster care seem to be getting access to needed services for their diagnosed medical needs, while those in some urban areas are not receiving enough services in this area. More than three-fourths of respondents (78%) indicated that the emotional health resources the children were receiving were adequate (n = 2315), while 22% said that they were not adequate (n = 644) and region again emerged as the most significant predictor, x2 (5, n = 2959) = 134.85, p b .001. Six different groups formed, again a mixture of urban and rural regions, indicating a variance in the adequacy of the mental health resources by region. The range of

Table 2 Dependent variables by independent variable predictors Dependent variable Diagnosed medical need Adequacy of medical resources Identified emotional need Adequacy of emotional resources First level predictor (independent variable) Number of months in care x 2 (2, n = 2812) = 38.13, p b .001 Region x 2 (5, n = 2793) = 186.76, p b .001 Age x 2 (6, n = 2797) = 419.91, p b .001 Region x 2 (5, n = 2959) = 134.85, p b .001

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respondents indicating the mental health resources were adequate was from 64.75% to 97.32%. Table 2 summarizes each dependent variable by the first-level independent variable. 8. Discussion 8.1. Physical/medical needs About one-third of the children in this sample were indicated to have a diagnosed medical need. The rate of identified medical needs was a little lower for this sample than some of the child welfare literature suggests, which has been as high as 60% (Takayama et al., 1998), but is very close to some studies citing 27–28% of the children in foster care having medical problems (Kortenkamp and Macomber, 2002). The group of children in care the longest also had the highest percentage of “yes” responses to the question of having a diagnosed medical need. As time in care increases, so should workers' vigilance of screening for medical needs. It seems that these medical needs go unmet while in foster care, and that they accumulate. Number of months in care and number of visits by agency workers in the past six months were also predictors of having a diagnosed medical need. Children with at least monthly visits had a higher percentage of needs. Younger children had more medical needs. This may indicate that younger children who have been maltreated are not getting the medical care they need before entering care. Overall, most of the children in the sample (78%) were judged to be receiving adequate resources for their diagnosed medical need. Geographical region of commitment was the strongest predictor and it is interesting to note that the groups that emerged combined both urban and rural regions, so it cannot be said that the urban regions had more adequate medical resources than did the rural regions. However, it could be that even though there are resources in the urban areas, the children in foster care may not have access to them. Leslie et al. (2003) identified this as a problem across the country in child welfare. A current strategy to meet the physical health needs of children in foster care is to hire nurses that will work on teams alongside social workers to promote safety and promote better coordination of treatment for medical issues (Schneiderman, 2006). It is a positive finding that most of the children are getting adequate help for their medical needs. Bilaver et al. (1999) found that children served by child welfare agencies tend to get more physical health treatment than do children in the general population; though Leslie et al. (2003) found that comprehensive physical and mental health exams were still not being conducted for every child entering foster care. 8.2. Emotional needs Age was the most significant predictor in this domain. The group with the highest percentage of identified emotional need was children ages 5–12. Those in this age range who had been in care the longest had the highest rate of diagnosed emotional need. As a trend, as the number of months in care and the number of prior placements increased, so did the presence of a diagnosed or identified emotional need for the children in those groups. In addition to age, number of months in care also makes a difference. Data from the 2001–2003 child sample of the National Health Interview Survey (NHIS), which is based on a nationally representative sample, indicated that about 5% of children ages 4–17 were reported by their parents to have severe emotional or behavioral problem and that 17% reported having minor difficulties in this area (SAMHSA, 2004). These percentages are lower than this study of children in foster care. However, the overall fairly high percentage of emotional need fits with existing literature regarding the mental health of children in foster care (DosReis et al., 2001; Farmer et al., 2001; Leslie et al., 2000; US DHHS, 2003), which says that foster children are likely to have diagnosed mental health problems. However, some studies have estimated a higher percentage of need, at 80% (Zima et al., 2000). The age group with the highest need (5–12) also coincided with the study by Burns et al. (2004), who found that children in foster care ages 2–14 had a higher likelihood of having mental health problems; and DosReis et al. (2001) who found that children in foster care ages 6–14 had higher rates of mental health services utilization. Overall, most of the children were judged to be receiving adequate resources for identified emotional problems (78%). Other studies have also found a high rate of usage of mental health services by children in foster care (DosReis et al., 2001; Farmer et al., 2001). Just as the adequacy of the medical resources was affected most by region, so was the adequacy of the emotional resources. Again, these represent a mixture of urban and rural regions, indicating that even in some regions where there may not be as many resources, the children in foster care seem to be getting access to

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needed services for emotional needs, while those in some urban areas are not receiving enough mental health services. This seems unusual, given that urban areas tend to have more providers of needed services for children. It seems that some children's needs are being overlooked. Perhaps more coordination between the worker and foster parent needs to occur, in order to ensure that needed services are provided. Transportation to needed services may be a barrier. Helping foster parents navigate the systems of care needed for children in foster care is very important to help prevent unmet needs. Larger caseloads in urban areas may be a barrier to workers being able to assess children and refer to needed services in a timely manner. 9. Limitations One of the limitations of the study involves instrumentation, specifically inter-rater reliability inherent in the fact that 131 census takers collected data, and they varied in their level of education (both graduate and undergraduate students participated). In addition, questions about diagnosed medical needs and identified emotional needs were asked only as “yes” or “no” questions and no follow-up questions were used to gather further information. It also was not feasible to assess the adequacy of resources received because no information was obtained about treatment modality, duration, or outcomes. This limits the type of analysis that could be conducted and the generalizabilty of the study. The survey did not seek information about the type of maltreatment or its severity. Future studies should focus on types of maltreatment, severity, chronicity, and comorbidity, to better understand how these differences impact the physical and mental health of foster children. Also, lacking information about the child's racial identity, it was not possible to assess potential disparities in wellbeing across racial groups. 10. Conclusions To promote the well-being of children, it is vitally important for state child welfare agencies to know the scope of the medical and emotional needs of the children in their care, as well as to know if they are receiving resources appropriate to their needs. This study adds to the literature on the physical and mental health of children in foster care by presenting results from a state census on the needs of the children in their foster care system. This state's approach can serve as an example to other states of the need to more fully explore the needs of the children in their care and to identify patterns and gaps in services in order to better meet their needs. These data have the potential to add to the child well-being knowledge base by providing a descriptive picture of the foster children in Kentucky and exploring relationships between indicators of well-being. These data support the child well-being conceptual framework by demonstrating that a study guided by the ASFA/CFSR outcome framework yielded a picture of the well-being of children in care as related to their physical and mental health. This study focused on a cross-sectional sample and points to the potential impact on short-term consequences specific to mental and physical health. Studies showing longer-term pictures of well-being are needed, across more domains. Results from this study indicate that children who are older and have been in care longer tend to have more physical and mental health needs. Child welfare workers and foster parents should be aware that the 5–12 age group is most likely to have an identified emotional need and to work with mental health professionals for an accurate assessment to determine what services are needed. This study also indicates a need to focus more on resource-poor communities and look at strategies to eliminate regional disparities. Both urban and rural areas of the state had areas where the resources were not adequate. Although the urban regions tend to have more services and resources, these data indicated that the children in foster care do not always have access to resources they need. More research is needed in this area, including needs assessments, to help identify the resources that are missing and the barriers to accessing the existing resources. Collaboration, including case consultation, with providers of physical and mental health services is also essential to meet the needs of this population. The knowledge gained from this study about the well-being of the children in care shows the benefit of focusing on well-being in practice and policy, as well as safety and permanency (Altshuler and Gleeson, 1999). Policy and practice must align in order for children in care to receive the resources they need. Ongoing study of child well-being should be incorporated into agency policy. The census approach described here, combined with databases developed from State Automated Child Welfare Information Systems (SACWIS), could yield valuable information for policymakers and child welfare administrators, and lead to a better understanding of the needs of children in foster care.

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Acknowledgments The authors wish to thank Dr. Viola Miller whose vision made the Kentucky Foster Care Census possible, as well as Dr. Ruth Huebner, Bruce Wolford, and Bonnie Hommrich whose leadership and dedication saw the census through to completion. In addition, we thank Dr. Lynn Usher for reviewing earlier drafts. References
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