A Preliminary Analysis of the Receipt of Mental Health Services Consistent With National Standards Among Children in the Child Welfare System

摘要

Objectives. We sought to examine the extent to which children in the child welfare system receive mental health care consistent with national standards. Methods. We used data from 4 waves (3 years of follow-up) of the National Survey of Child and Adolescent Well-Being, the nation's first longitudinal study of children in the child welfare system, and the Area Resource File to examine rates of screening, assessment, and referral to mental health services among 3802 youths presenting to child welfare agencies. Weighted population-averaged logistic regression models were used to identify variables associated with standards-consistent care. Results. Only half of all children in the sample received care consistent with any 1 national standard, and less than one tenth received care consistent with all of them. Older children, those exhibiting externalizing behaviors, and those placed in foster care had, on average, higher odds of receiving care consistent with national standards. Conclusions. Adverse consequences of childhood disadvantage cannot be reduced unless greater collaboration occurs between child welfare and mental health agencies. Current changes to Medicaid regulations that weaken entitlements to screening and assessment may also worsen mental health disparities among these vulnerable children. Ensuring that children in the child welfare system receive high-quality mental health services has been a policy priority for the past 2 decades, and professional organizations have proposed standards of care specifically tailored for this population. However, there is no information on the extent to which children in the child welfare system actually receive care that is consistent with these national standards. Attention to standards-consistent mental health care is important because children in the child welfare system have very high needs for mental health services. Nearly half of all children coming into contact with child welfare agencies nationally have clinically significant emotional or behavioral problems, 1 and 40% to 60% of children in the child welfare system may have a psychiatric diagnosis. 2 Local and regional studies have also documented high rates of problems across several domains among these children. 3 – 5 Children in foster care have between 10 and 20 times the rate of utilization of mental health services when compared with children maintained within their homes, 6 – 8 and national estimates suggest that the point prevalence of psychotropic medication use is 13.5% 9 —far above the 4% seen among privately insured children 10 and the 5% to 6% seen among Medicaid-enrolled children. 11 , 12 Given this magnitude of service use and the unique vulnerabilities of children in child welfare, the Child Welfare League of America proposed standards for the provision of health and mental health services for children in foster care in 1988. 13 The American Academy of Pediatrics proposed similar standards in 1994 and in 2002, 14 , 15 as did the American Academy of Child and Adolescent Psychiatry in 2001. 16 , 17 These recommendations are highly convergent with regard to mental health care and suggest that all children should receive a mental health screening when placed into foster care, a subsequent comprehensive mental health assessment by a mental health professional within a month of being placed into foster care, and a systematic, coordinated approach to the delivery of services to meet children's ongoing mental health needs. These standards since have been operationalized for use by child welfare agencies and extended to children who are not placed in foster care. For example, the Council on Accreditation, presumably informed by the literature documenting significant mental health needs among non–foster-care child welfare populations, 1 evaluates child protective services agencies on their case-management abilities, including needs assessment and the provision of counseling and intensive mental health services. 18 These standards govern processes of care—not quality of clinical care—and are primarily designed to assist child welfare agencies in implementing organizational structures and processes that can improve child well-being. Passage of the 1997 Adoption and Safe Families Act 19–21 provided additional federal impetus to standards development, and states are currently evaluated on the extent to which children “receive adequate services to meet their … mental health needs.” 22 Despite professional consensus and federal legislation and regulation, there is little information on whether children in the child welfare system actually receive care that is consistent with these standards. In 2002, Halfon et al. reported on the overall inadequacy of services available to children in foster care 23 ; a key informant survey of st

机译：目标。我们试图研究儿童福利系统中的儿童在多大程度上获得符合国家标准的精神卫生保健。方法。我们使用了全国儿童和青少年福祉调查的4次波（为期3年的跟踪研究），全国首次在儿童福利系统中对儿童进行的纵向研究以及区域资源档案中的数据来检查筛查率，评估并转介给儿童福利机构的3802名青年中的心理健康服务。加权人口平均逻辑回归模型用于确定与标准一致护理有关的变量。结果。样本中所有儿童中只有一半接受了符合任何一项国家标准的照料，只有不到十分之一的儿童接受了符合所有标准的照料。平均而言，年龄较大的孩子，表现出外在行为的孩子和被寄养的孩子接受国家照料的机会更高。结论。除非儿童福利和精神卫生机构之间开展更大的合作，否则不能减少不利于儿童的不利后果。当前对医疗补助条例的更改削弱了筛查和评估的权利，也可能使这些弱势儿童的心理健康差异更加恶化。在过去的20年中，确保儿童福利系统中的儿童获得高质量的精神卫生服务一直是政策优先事项，专业组织已经提出了专门针对该人群的护理标准。但是，没有任何信息说明儿童福利系统中的儿童实际获得的照顾与这些国家标准相符的程度。重视符合标准的精神保健非常重要，因为儿童福利系统中的儿童对精神保健服务的需求非常高。在全国范围内，与儿童福利机构接触的所有儿童中，几乎有一半具有临床上显着的情绪或行为问题， 1 ，儿童福利系统中40％至60％的儿童可能有精神病诊断。 > 2 地方和区域研究也证明这些儿童在多个领域的问题发生率很高。 3 – 5 寄养儿童的心理利用率是儿童的10到20倍。卫生服务与在家中待养的儿童相比， 6 – 8 和国家估计表明，精神药物的使用率是13.5％ 9 ，远高于4％在接受私人保险的儿童中， 10 和在参加医疗补助的儿童中所占的百分比为5％至6％。 11，12 儿童福利方面，美国儿童福利联盟提出了针对儿童福利的标准1988年为寄养儿童提供健康和心理健康服务的愿景。 13 美国儿科学会在1994年和2002年提出了类似的标准， 14，15 2001年，美国儿童和青少年精神病学研究院。 16，17 这些建议在精神卫生保健方面高度趋同，建议所有儿童在接受寄养时均应接受精神卫生筛查，其后由精神保健专业人员在寄养服务后的一个月内进行全面的精神保健评估，并采取系统，协调的方式来提供服务以满足儿童持续的精神保健需求。自那时以来，这些标准已经投入使用，供儿童福利机构使用，并扩展到了没有被寄养的儿童。例如，认证委员会大概以记录了非寄养儿童福利人群中重要的精神健康需求的文献为依据， 1 评估了儿童保护服务机构的案件管理能力，包括需求 18 这些标准规范护理过程，而不是临床护理质量，其主要目的是协助儿童福利机构实施能够改善孩子的健康。 1997年《领养和安全家庭法》 19-21 的通过，为标准制定提供了额外的联邦动力，目前，各州正在对儿童“获得足够的服务来满足……心理健康需求”的程度进行评估。 ” 22 尽管有专业共识和联邦法律法规，但关于儿童福利系统中的儿童是否实际获得符合这些标准的照料的信息很少。在2002年，Halfon等人。报告了在寄养中为儿童提供的服务总体不足 23 ; st的关键信息提供者调查

A Preliminary Analysis of the Receipt of Mental Health Services Consistent With National Standards Among Children in the Child Welfare System

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