Transcript Foster Care Outcomes: Does Foster Care Help or Harm Children’s Emotional and Social Development? Dee Wilson Presentation to CA Medical Consultants March 17, 2008

Foster Care Outcomes:
Does Foster Care Help or Harm
Children’s Emotional and
Social Development?
Dee Wilson
Presentation to CA Medical Consultants
March 17, 2008
Many foster care placements last for brief periods
of time; median length of stay (LOS) for CPS
placements in Washington State is about 1 year.
However, approximately one quarter of children in
out-of-home care for at least 60 days in
Washington State are still in care 3 years after
their date of placement.
2
Surveys of foster children around the world almost
always elicit highly favorable views of foster care.
“We are apparently in the presence of a robust
phenomenon that does not appear to be either
sample specific or country specific.”
(Flynn, Robitaille, & Ghazal, 2006)
3
The odds of a child being reunified with
birth parents decline dramatically as
length of stay (LOS) increases.
4
Children with behavioral problems have
much lower reunification rates than
children without behavior problems.
(Landsverk, et al, 1996)
5
One-half to two-thirds of children in
out-of-home care have serious mental
health problems; only 25% of children
with MH problems receive MH
treatment.
Source: National Survey of Child and Adolescent Well-Being
6
Long LOS are associated with multiple
placements.
Almost half of children in care for 4 or
more years in Washington State have
had 5 or more placements.
7
Placement disruptions are not the same as
placement moves.
Some of the best recent research has classified
children as achieving “early stability,” “late
stability,” “variable stability,” or “unstable”
instead of counting placement events.
(Rubin, et al, 2007)
8
In one recently published Australian
study, 20% of foster youth were found
to be “homeless in care”.
Barber & Delfabbro (2006) refer to the
“truly wretched conditions under which
these foster children live.”
9
Both Rubin, et al (USA, 2007) and Barber &
Delfabbro (Australia, 2006) found that
approximately 20% of children in foster care
were “unstable” in care at 18 months to 2 years
after date of placement. Rubin, et al found that
almost one-third of children 10 and older were
still unstable in care at 18 months after original
placement date.
10
The National Survey of Child and
Adolescent Well-Being (NSCAW) has
found that “placement stability over the
first eighteen months was significantly
related to all permanency outcomes…”
(Rubin, et al, 2007)
11
In NSCAW, “regardless of a child’s
baseline risk for instability in this study,
those children who failed to achieve
placement stability were estimated to have
a 36% to 63% increased risk of behavioral
problems compared with children who
achieved any stability in foster care.”
(Rubin, et al, 2007)
12
Ryan & Testa (2005) found that male youth with 3
placements were 1.54 times more likely to be found
delinquent in the Illinois Juvenile Justice System than
male youth with 1 placement; male youth with 4
placements were 2.13 times more likely to be found
delinquent than youth with 1 placement.
The CPS substantiation history of children/youth was
also related to delinquency (the greater the number of
substantiated CPS reports the greater the odds of
delinquency). Youth placed out of the home were 1.89
times more likely to be engaged in delinquent acts than
youth remaining in the home.
13
Ryan & Testa comment that “the home environment for
children removed from parental custody is
unquestionably more deleterious compared to maltreated
children whose environment is deemed safe enough for
them to remain at home.”
However, they add, “removing children from these highrisk environments should decrease the risk of
delinquency. But our findings are that children in
placement are more likely to be delinquent.”
Ryan & Testa assert that placement instability is a major
reason why out-of-home care often fails to have a
therapeutic effect for male youth.
14
The NSCAW found that adolescent
delinquent behavior for youth in out-of-home
care was fairly stable over the first 18
months of placement.
15
Lawrance, Carlson, & Egeland (2006) compared 46 children,
0-9 at entry into care, to 46 maltreated children who remained
at home in a longitudinal study. Developmental outcomes for
these children were compared to 97 non-maltreated children.
Children who had been in foster care had more behavior
problems immediately after exit from care than maltreated
children who had not been placed out of the home.
Adolescent outcomes did not differ for the placed vs. nonplaced maltreated children. Both groups increased in
behavior problems as children became older.
Children placed in kin foster homes had less internalizing
problems at exit from care than children placed in non-kin
homes.
16
Rubin, et al’s (2007) analysis of the National Survey of
Child and Adolescent Well-Being (NSCAW) found that
the strongest predictor of a child’s behavioral
adjustment 18 months after entering care was the
child’s level of behavioral problems at entry into care.
Younger, healthier children with few behavior problems
at entry into care had the best behavioral outcomes.
Most children with poor CBCL scores at baseline had
abnormal scores 18 months later, even when these
children had stable placements.
17
The NSCAW indicates that in the aggregate
foster care does not markedly improve or
harm children’s functioning for most
behaviorally troubled children.
18
However, aggregate trends for children in care mask
considerable variability in children’s developmental
outcomes. Three factors which mediate these
differences are:
 Children’s behavior problems at entry into care,
 Children’s placement histories, and
 The quality of children’s relationship with substitute
caregivers which are, in turn, affected by caregiver
characteristics such as emotional warmth, acceptance,
skills in managing children’s behavior, and commitment to
the child.
(Rubin et al, 2007; Shlonsky & Berrick, 2001)
19
The evidence continues to mount that exposure to chronic
maltreatment has devastating effects on children’s
development.
In his recently published (2008) study of 347 foster children
4-9 years of age in New South Wales, Australia, TarrenSweeney found that length of exposure to chronic
maltreatment prior to entry into care was the major factor
influencing children’s mental health status.
Tarren-Sweeney asserts that “longer time in care was
protective” (of children’s development), even though almost
20% of the foster children had been abused or neglected in
care.
20
Caregiver Report of Severe Violence
 Conflict Tactics Scale Parent to Child version
 Severe violence sub-scale
hit child with fist or kicked him or her
grabbed child around neck and choked him or her
beat child up
burned or scalded child
hit child with a hard object on some other part of the
body besides bottom
threw or knocked child down
 Limited to children who remained in home
following the investigation for maltreatment
(Barth, 2005)
21
Caregiver Report of Severe Violence
Infants/Toddlers (0-2)
5 1
6
88%
None
Worsened
Preschoolers (3-5)
4
7 3
86%
None
Worsened
Improved
Continued
Improved
Continued
(Barth, 2005)
22
Caregiver Report of Severe Violence (2)
Middle Childhood (6-10)
10
Adolescents (11+)
42
6 5
12
85%
None
Worsened
77%
Improved
Continued
None
Worsened
Improved
Continued
Among children older than 6, a significantly higher proportion had a
decreased incidence of severe violence at 18 month than an increased
incidence (6-10, p < .01; 11+, p < .05)
(Barth, 2005)
23
Probability of Experiencing Severe Violence
0.12
0.1
Baseline
18 months
0.08
.12
.09
.08
.08
0.06
.07
.06
0.04
0.02
0
3
6
Violence
increases in
the lives of
the youngest
children,
then begins
to decrease
in middle
childhood
10
Age in years*
(Barth, 2005)
24
Caregiver Report of Severe Violence and Official
Re-report of Maltreatment for In-home Children
Proportion of all caregivers
reporting severe violence at
18 months
% (SE)
Proportion of caregivers
reporting severe violence
with an official re-report by
18 months % (SE)
0-2 (n=1006)
4.9 (1.3)
8.7 (7.6)
3-5 (n=497)
10.5 (2.9)
25.4 (11.4)
6-10 (n=790)
5.6 (1.1)
39.4 (9.6)
11+ (n=601)
10.2 (2.4)
31.1 (10.6)
Total (n=935)
7.6 (1.1)
28.9 (5.0)
All analyses are on weighted data, Ns are unweighted.
• Among caregivers of infants and toddlers who reported using severe violence at 18
months, less than 9% had an official re-report of child maltreatment.
• Overall, of those children with caregiver reported severe violence, 29% had an
official re-report.
(Barth, 2005)
25
Conclusions: Re-Report
 Although the majority of re-reports are not
substantiated, about one in five children has
at least one re-report over the 18 months
 Children in out-of-home care still have some risk of
recurrent maltreatment
Possible explanations for maltreatment include:
occurred prior to child entering foster care
occurred during visit with biological family
child on child maltreatment in foster or group home
(Barth, 2005)
26
Conclusions: Re-Report
 Receipt of parenting services associated with
increased likelihood or re-report
Possible explanations include:
Families with greater needs selected into services
Agency surveillance
Services do not adequately family needs
(Barth, 2005)
27
Caregiver Report of Violent Parenting
Tactics
 Many caregivers (8%) report using severe
violence toward their child following child
welfare involvement
 A large proportion of severe violence
remains unreported. This is especially true
for infants and toddlers.
 Violence between intimate partners often
leads to an increase in the amount of
severe violence children experience
(Barth, 2005)
28
In addition, there are some studies which
indicate that foster children make better
progress on standard developmental
measures than reunified children.
29
(Bellamy, 2008)
30
Bellamy’s analysis (2008) of NSCAW data
for 604 children in foster care for longer
than 8 months found a small overall
decline in CBCL scores while reunified
children had a fourfold increase in
internalizing behavior problems at 18
month follow-up.
31
Bellamy found that reunification outcomes for
children were mediated by caregivers’ mental
health and overall family stress, rather than by
reunification per se.
Bellamy also found that “continued long-term
foster care does not inherently worsen this
high-risk group’s behavioral health over time."
32
Taussig, Clyman, & Landsverk’s (2001) study of
149 ethnically diverse children 7-12 years of age in
foster care for at least 5 months in San Diego
found that “youth who reunify with their biological
families after placement in foster care have more
behavioral and emotional health problems than
youth who do not reunify.”
“These findings were consistent across the range
of outcomes examined: Engagement in risk
behaviors, life course outcomes, and current
emotional and behavioral symptomatology.”
33
The non-reunified youth in Taussig, et al’s
study had experienced an average of 8
placements after 6 years in care.
These researchers could locate only 62% of
reunified youth for the follow-up interview.
34
20-30% of children reunified with birth parents
re-enter out-of-home care within 3-5 years.
For many foster children, placement instability
does not stop with return to birth parents.
35
One possible interpretation of NSCAW findings
regarding out-of-home care is that foster care for
behaviorally-troubled children is neither especially
therapeutic nor harmful, unless children have highly
unstable placement histories.
However, the single most distressing NSCAW
findings regarding out-of-home care concern infants
and toddlers.
36
National Survey of Child
and Adolescent Well-Being (NSCAW)
Infants did worse on developmental measures
after 18 months in care.
 Bayley Infant Neurodevelopmental Screener (BINS)
 Vineland Adaptive Behavior Scales (VABS)
 Battelle Developmental Inventory (BDI)
 Preschool Language Scale (PLS-3)
37
Developmental Measures in NSCAW
Bayley Infant Neurodevelopmental
Screener (BINS)
Vineland Adaptive Behavior Scales
(VABS)
Battelle Developmental Inventory (BDI)
Preschool Language Scale (PLS-3)
38
Infants (0-3):
Overall Change Over 18 Months
Average Score
at 18-Months:
Measure
BINS
6.1
0.5
VABS
89.6
-9
BDI
-2.26
PLS-3
42.2
-5.73
-10
-8
-6
88.1
-4
-2
0
2
Change in points
(Barth, 2005)
39
Infants (0-3):
Age as a Significant Predictor
Measure
BINS
Younger
infants are
much more
likely to
show
greater
deterioration
2.25
-0.08
-1.66
VABS
0.87
-7.61
-15.58
1.48
BDI
-1.99
-5.42
PLS-3
0.51
-4.69
-9.78
-20
-15
-10
-5
0
5
Change in points
Youngest
50th percentile
Oldest
(Barth, 2005)
40
Summary: Age 0-2
 No significant measured improvements in
development for infants
 In general, infants < 2 years decline in all
measures, those 25-35 months improve
 Children with lower HOME-SF scores see greater
declines in three of the four measures
 Children in nonurban PSUs see higher risk for
developmental delay and neurological
impairment and worsening language skills
 Males decline in cognitive development and
social skills
(Barth, 2005)
41
Summary: Age 3-5
 Slight decline in social skills; improvement in
language skills; stable level of problem
behavior
 Age in months is a significant predictor of
change, but not in a consistent direction
 Prior CWS history is a predictor of change for
both social and language skills
 Could be that they receive greater level of intervention,
this time
 Could be that prior involvement already raised the level
of their care or treatment
(Barth, 2005)
42
Summary: Age 6-10
 Only age group that showed
improvements, although slight, in all
developmental measures examined
 Only age group where age is not a
significant predictor of rate of change for
any domain
 Maltreatment type is the only significant
predictor across more than one domain,
yet with varied results
(Barth, 2005)
43
National Survey of Child
and Adolescent Well-Being (NSCAW)
• Adolescents deteriorated while in foster care
on standard measures of well being.
44
Implications
 Children who became involved with child welfare
services do not show marked gains in
development during the first 18-months
The youngest children show declines on
developmental measures
 Out-of-home care does not appear to offer
protection leading to improvement in
developmental status over 18 months as might
be expected
Yet, among the older children, those with prior
CWS involvement did better
(Barth, 2005)
45
Implications
 CWS may be focusing on the more explicit goals
of safety and permanency than on well-being,
which appears to be beyond its current scope
Revisions to CAPTA that require referrals of
substantiated infant cases to early intervention
seem very timely and need rapid implementation
Specialized infant units may also be valuable
Reductions in infant placements my help
(Barth, 2005)
46
The growth in kinship care has been described
by one scholar as the most significant change in
foster care services over the past two decades.
In Washington State, the kinship care rate has
increased from around 26% to 40% of children in
out-of-home care.
47
Kinship care is more stable than
foster care.
48
However, an analysis of NSCAW data (n=567)
by Barth, Guo, Green, and McCrae (2007)
found that children in non-kin foster care were
more behaviorally troubled at baseline than
children placed with relatives. These authors
state that “differences between children in
kinship and non-kinship care… may simply
reflect these pre-existing differences…”
49
In this same NSCAW analysis, children in
kinship care improved more on the CBCL after
18 months in care than children in non-kin care;
but on other developmental measures (e.g.,
Vineland, Social Skills Rating System), there
were no significant differences in improvement /
lack of improvement at 18 months after entry
into care.
50
One of the most concerning findings in this study is
that “about one-fifth of the children were rated as
experiencing both low responsiveness and high
punitiveness at both baseline an at 18 months,” a
statistic that did not differ for kin and non-kin
caregivers.
“Low responsiveness” and “high punitiveness” is
another way of describing harsh emotionally
unresponsive parenting.
51
This study also found that one-fifth of foster
parents (kin and non-kin) were poor, and that
only 42% of non-kin foster parents had more
than a high school degree.
“Any general notion that foster parents are
predominantly middle-class is untrue,” these
authors state.
52
Acute and chronic placement shortages are
having a large negative effect on the quality of
foster care in Washington State and nationally.
53
Foster care systems experiencing acute and
chronic shortages of homes cannot:
 Match children’s needs to foster family strengths
and capacities
 Keep siblings together, especially sibling groups of
larger than 2 children
 Place children in their own neighborhoods /
communities
 Maintain high standards of care
54
Foster home recruitment initiatives over the
past 10 years have not been effective
despite a large investment of resources;
and, as a result, the Children’s
Administration has placed an increased
emphasis on kinship care.
55
New strategies must be found to recruit and
retain foster homes, or the number of
children entering out-of-home care must be
greatly reduced.
56
Possible strategies:



Neighborhood- / community-based recruitment
campaigns
Professional foster care
Better support / a larger percentage of the foster
care system run by private agencies
57
It is also useful to have some humility about our
collective understanding of the needs of children.
What do these items have in common?










Indenture
Almshouses
Orphanages
Orphan Trains / Foster care
Mother’s Pensions
Therapeutic Foster Care
Kinship Care / Family Group Conferencing
Juvenile Institutions
Residential Care
Wrap Around / Community Placement
All of the items on this list were child welfare reforms at
one point.
58
Nevertheless, the need for non-kin foster care
is not likely to greatly diminish without dramatic
reductions in the child poverty rate and/or major
improvements in child welfare in-home services
for parents with co-occurring substance abuse
and mental health disorders.
59
Barth and his colleagues have written that “a
vision for excellence in foster care is needed.”
These experts recommend increasing financial
support for foster parents, “linking every foster
parent to a resource center” or resource
person, and providing “consistent, powerful,
supportive in-home training.”
60
It is difficult to understand how foster care can
become a therapeutic system for behaviorallytroubled children without developing a cadre of
professional foster parents and implementing
evidence-based practice models.
61
Bibliography
Barber, J. G., & Delfabbro, P. H. (2006). Psychosocial well-being and
placement stability in foster care: Implications for policy and practice. In R.
F. Flynn, P. M. Dudding, & J. G. Barber (Eds.), Promoting resilience in child
welfare (pp. 157-172). Ottawa: University of Ottawa Press.
Barth, R. P. (2005, May 19). National Survey of Child and Adolescent WellBeing (NSCAW): How Are the Children Faring and Did Mental Health
Services Help? Presented at the University of Washington School of Social
Work.
Barth, R. P., Guo, S., Green, R. L., & McCrae, J.S. (2007). Kinship care and
nonkinship foster care: Informing the new debate. In R. Haskins, Wulczyn,
F., & Webb, M. B. (Eds.), Child protection: Using research to improve
policy and practice (pp. 187-206). Washington, D.C.: Brookings Institution
Press.
62
Bibliography
Bellamy, J. L. (2008). Behavioral problems following reunification of children in
long-term foster care. Children and Youth Services Review, 30, 216-228.
Doyle, J. J. (2007). Child protection and child outcomes: Measuring the effects
of foster care. The American Economic Review, 97, 1583-1610.
Flynn, R. J., Robitaille, A., & Ghazal, H. (2006). Placement satisfaction of
young people living in foster or group homes. In R. F. Flynn, P. M. Dudding,
& J. G. Barber (Eds.), Promoting resilience in child welfare (pp. 191-205).
Ottawa: University of Ottawa Press.
Landsverk, J., Davis, I., Ganger, W., Newton, R., & Johnson, I. (1996). Impact
of child psychosocial functioning on reunification from out-of-home
placement. Children and Youth Services Review, 18, 447-462.
63
Bibliography
Lawrence, C. R., Carlson, E. A., & Egeland, B. (2006). The impact of foster
care on development. Development and Psychopathology, 18, 57-76.
Rubin, D. M., O’Reilly, A. L. R., Haffner, L., Luan, X., & Localio, A. R. (2007).
Placement stability and early behavioral outcomes among children in outof-home care. In R. Haskins, Wulczyn, F., & Webb, M. B. (Eds.), Child
protection: Using research to improve policy and practice (pp. 171-186).
Washington, D.C.: Brookings Institution Press.
Rubin, D. M., O’Reilly, A. L. R., Luan, X., & Localio, A. R. (2007). The impact of
placement stability on behavioral well-being for children in foster care.
Pediatrics, 119, 336-344.
Ryan, J. P., & Testa, M. F. (2005). Child maltreatment and juvenile delinquency:
Investigating the role of placement and placement instability. Children and
Youth Services Review, 27, 227-249.
64
Bibliography
Shlonsky, A. R. & Berrick, J. D. (2001). Assessing and promoting quality in kin
and nonkin foster care. Social Service Review, 75, 60-83.
Taussig, H. N., Clyman, R. B., & Lansverk, J. (2001). Children who return home
from foster care: A 6-year prospective study of behavioral health outcomes
in adolescence. Pediatrics, 108: e10. Retrieved March 10, 2008, from
http://pediatrics.aappublications.org/cgi/reprint/108/1/e10
Tarren-Sweeney, M. (2008). Retrospective and concurrent predictors of the
mental health of children in care. Children and Youth Services Review, 30,
1-25.
Wilson, L., & Conroy, J. (1999). Satisfaction of children in out-of-home care.
Child Welfare, 78, 53-69.
65