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9. Service Needs and Receipt

The preceding chapters have provided broad evidence that children coming to the attention of child welfare services are, generally, substantially more likely than the general population of children to experience a social or cognitive deficit. Child welfare services are intended to be a mechanism to help address safety and permanency issues for children and, increasingly, to be a place to address issues of child well-being (Goerge, 2002). The well-being of children is a cornerstone of the federal Child and Family Services Reviews, which assess the extent to which (1) families have enhanced capacity to provide for their children’s needs, (2) children receive appropriate services to meet their educational needs, and (3) children receive adequate services to meet their physical and mental health needs (U.S. DHHS, 2002).

This chapter presents information on the need for and use of physical health, mental health, and special education services by children in the NSCAW sample. Many studies have reported on the high rates of physical, mental and developmental problems among children entering out-of-home care in CWS (Simms, Dubowitz, & Szilagyi, 2000; Simms & Halfon, 1994), but data on children receiving in-home child welfare services are limited. NSCAW allows for an examination of the needs and service use for all children involved in CWS; results take into account the background and characteristics of the children.

Because “a stable and highly skilled workforce is necessary to effectively provide child welfare services” (U.S. GAO, 2003; p. 1), this chapter also examines characteristics of child welfare workers who work with the children and families involved with the CWS. Although much more data are available about the child welfare workers who completed the surveys about the children in the study, we have focused our analyses on their demographic characteristics, backgrounds, and training. Presented here is information on the age, race/ethnicity, length of experience, and education of these important players in the delivery of child welfare services. Additional information about how agency and PSU characteristics differ and may relate to child and child welfare worker characteristics is another piece of the puzzle. The chapter concludes with a description of how agency administration and PSU urbanicity and poverty rates relate to service delivery.

9.1 Children’s Problems and Services

This chapter begins with an analysis of children’s health status and use of medical services. Whether children involved in CWS are receiving appropriate levels of medical care is an important part of assessing their overall well-being. NSCAW data do not provide any independent information on the need for health care, so in the health analyses no distinction between the need for and the receipt of services can be made. An analysis of mental health and special education services is also provided. Both of these topics are of particular interest for this population, as the background of children involved with CWS presumably contributes to their being more prone to involvement with these services as well.

9.1.1 Health

General health characteristics of children involved with CWS were obtained by report from the child’s caregiver. The vast majority of caregivers (94%) report that their children are in good, very good, or excellent health (Table 9-1). This is lower, however, than the most recently published results from the National Health Interview Survey (NHIS) (Bloom & Tonthat, 2002a), in which 98% of children aged 17 and younger are reported to have good, very good, or excellent overall health status. Comparison of these studies shows that children involved with CWS are three times more likely to be in fair or poor health than children in the general population. Among children in NHIS living below the federal poverty line, a population that may be more similar to a sample of children involved with CWS, the rate of good or higher health status is 96%. For NSCAW children, there are no significant differences in overall health status by age, gender, race/ethnicity, or setting.

Table 9-1. Health Status of Children Involved With the Child Welfare System, by Caregiver Report

		TOTAL	In-Home			Out-of-Home
			No Services	Services	Total In-Home	Foster Care	Kinship Care	Group Care	Total Out-Of-Home
		Percent/ (SE)
Overall Health (good, very good, excellent)		93.6 (0.7)	94.4 (0.9)	93.4 (0.8)	94.2 (0.7)	87.7 (2.8)	89.2 (2.9)	92.6 (3.7)	88.9 (2.3)
Chronic Health Problem		27.5 (1.4)	27.1 (1.5)	32.3 (2.3)	28.0 (1.4)	25.3 (2.3)	23.2 (4.2)	17.1 (6.5)	23.6 (2.8)
Up-to-Date Immunizations		95.8 (0.5)	95.7 (0.6)	96.5 (0.7)	95.9 (0.5)	91.6 (4.0)	95.5 (1.3)	99.6 (0.3)	94.2 (1.9)
Dentist or Dental Hygienist	Ever seen	N/A	82.2 (2.0)	76.6 (2.0)	80.7 (1.6)	N/A	N/A	N/A	N/A
	Seen since CWS investigation date	57.9 (2.3)	60.7 (3.0)	52.4 (2.4)	58.4 (2.4)	48.8 (5.3)	49.4 (6.7)	80.7 (14.1)	52.4 (3.8)
Vision Testing	Ever seen	N/A	72.9 (2.0)	72.0 (2.1)	72.7 (1.8)	N/A	N/A	N/A	N/A
	Seen since CWS investigation date	N/A	N/A	N/A	N/A	50.7 (4.2)	52.3 (5.1)	73.2 (13.2)	53.4 (3.9)
Admitted to Hospital Overnight for Illness/Injury, Since CWS Investigation		5.7 (0.7)	5.4 (0.9)	6.9 (0.9)	5.8 (0.7)	7.4 (1.3)	3.3 (0.8)	1.3 (1.0)	4.8 (0.7)
Emergency Room for Illness/injury	Last 12 months	N/A	37.4 (2.7)	35.6 (2.3)	36.9 (2.3)	N/A	N/A	N/A	N/A
	Since CWS investigation date	N/A	N/A	N/A	N/A	26.7 (3.9)	16.4 (2.3)	21.4 (11.3)	21.0 (2.2)
Serious Injury/Accident Requiring Medical Attention	Past 12 months	N/A	10.7 (1.3)	9.4 (1.4)	10.4 (1.1)	N/A	N/A	N/A	N/A
	Since CWS investigation date	6.1 (0.7)	6.8 (1.0)	5.6 (0.8)	6.5 (0.8)	4.6 (1.2)	1.8 (0.8)	4.5 (2.4)	3.2 (0.7)

Although caregivers reported good, very good, or excellent health for 94% of the children, over one-quarter (28%) reported that their child has a health problem that “lasts a long time or comes back again and again.” The most common chronic conditions are other health problems (11%), asthma (8%), and repeated ear infections (4%). Five percent of caregivers report that their child has more than one chronic health problem. There are no significant differences in report of a chronic health problem by age, gender, race/ethnicity, or setting. Comparisons of overall health status with reports of chronic health problems showed that only 17% of children identified as having a chronic health problem are described by their caregiver as being in fair or poor overall health.

With regard to immunization status, 96% of children are up to date with their scheduled immunizations according to caregiver report; children aged 0-2 years are less likely to be up to date on their immunizations than older children (p<.001). Other health indicators were assessed by caregiver report, with the time frame varying by placement setting. Caregivers of children in their home of origin were asked about lifetime or past-year history, whereas the questions for out-of-home caregivers focused on the period since the start of the CWS investigation. For children remaining at home, 81% have been to a dentist or dental hygienist at least once and 73% have had their vision tested. Children receiving in-home services are less likely to have ever visited a dentist or dental hygienist than those children not receiving services (p< .05). For children in out-of-home care, over half (52%) have visited a dentist or dental hygienist and 53% have received vision testing since the investigation date. There are no significant differences in these health status indicators by gender, race/ethnicity, or setting, although there is a trend toward children in group care reporting higher rates of dental care since the investigation date (p< .03) than children in other out-of-home settings.

Caregivers also reported on serious injuries and illnesses among children in their care. Six percent of children involved with CWS have been admitted to a hospital overnight for illness or injury since the start of the investigation; a trend is present with children in group care being less likely to have been admitted to a hospital than children in other out-of-home care settings (p<.02). Similarly, 6% of all children involved with CWS have experienced a serious injury or accident requiring a visit with a physician since the investigation date. By setting, this is reported for 7% of children remaining at home and 3% of children in out-of-home care. Finally, 21% of children in out-of-home care have visited the emergency room due to an illness or injury since the investigation date, whereas over one-third (37%) of children remaining at home have been to the emergency room in the 12 months prior to the interview. This rate is much higher than the 12-month rate reported by the 2000 NHIS for all children under 18 years of age (20%) or for children in families below the poverty line (26%) (Bloom & Thonthat, 2002).

9.1.2 Mental Health

Mental health services are examined in three categories: specialty outpatient, nonspecialty outpatient, and inpatient. To assess the use of specialty mental health services by children involved with CWS, current caregivers were asked several questions. If the child was in the home of origin, the caregiver was asked if the child had ever been to any of the following for emotional, behavioral, learning, attention, or substance abuse problems: a mental health or community health center; a therapeutic nursery (for children under age 6); day treatment (for children aged 6 and older); or a psychiatrist, psychologist, social worker, or psychiatric nurse for private professional help. The same information was obtained from the current caregiver of children in out-of-home care, although the time frame was changed to ask if the child had utilized any of these services since the date that the child welfare agency investigation began. Therefore, the permanent caregiver was asked if the child had ever received these services, whereas the out-of-home caregiver was asked if the child had received these services since the start of the investigation.

Additional questions were asked of caregivers regarding use of other, nonspecialty mental health services for emotional, behavioral, learning, attention, or substance abuse problems, including in-home counseling or in-home crisis services; visits with a family doctor or other medical doctor; visits with a school guidance counselor, school psychologist, or school social worker (for children aged 6 and older); or attendance at an outpatient drug or alcohol clinic (for children aged 10 and older). Again, caregivers of children in their homes of origin were asked if the child had ever used these services for emotional, behavioral, learning, attention, or substance abuse problems, whereas caregivers of children in out-of-home care were asked if the child had received these services since the start of the investigation.

For both specialty and nonspecialty mental health service use questions, if the caregiver indicated that a service had been used, follow-up questions examined the starting and ending dates as well as the frequency of service use. Given the difference in the reporting time frame between in-home and out-of-home caregivers, it is not possible to compare frequencies on these items directly. Instead, using information on the CWS investigation date, it was determined which children were receiving mental health services at the time of the interview. The results are presented in Table 9-2.

Overall, 11% of children involved with CWS are receiving outpatient mental health services for emotional, behavioral, learning, attention, or substance abuse problems. A total of 7% are receiving specialty mental health services, with children most often receiving private professional help from mental health clinicians (5%), followed by mental health or community health center services (2%). Use of day treatment and therapeutic nurseries are reported less frequently (0.8% and 0.3%, respectively). Nonspecialty mental health services are also being used, with 8% reportedly receiving services from a school guidance counselor, followed by in-home counseling (3%) and services from a family doctor (1%).

Table 9-2 also indicates the proportion of children currently receiving mental health services by various child and case characteristics. Not surprisingly, age appears to be a significant factor with regard to whether a child is receiving either category (specialty or nonspecialty) of mental health services, with children aged 11 years and older more likely to be receiving services than younger children (p<.001). There are no significant differences in current use of mental health services by the child’s race/ethnicity, although a trend is present by most serious abuse type: children with a most serious abuse type of “failure to provide” are less likely than those in other abuse categories to be receiving specialty outpatient mental health services (p<.04).

Use of mental health services varies greatly by setting, with children in out-of-home care being more likely to receive specialty and nonspecialty mental health services (p<. 001) than children remaining at home. Twenty-one percent of children in out-of-home care are receiving specialty mental health services, as compared with 5% of children remaining at home. A similar pattern was seen for receipt of any type of outpatient mental health service, specialty or nonspecialty (31% vs. 9% respectively). Among children in out-of-home care, there are no significant differences in use of mental health services between children in foster or kinship care, while children in group care settings are significantly more likely to use specialty or nonspecialty mental health services (63%) than children in foster (27%) or kinship (29%) care.

Table 9-2. Caregiver Report of Mental Health Outpatient Services Currently Being Received by Children Involved With the Child Welfare System

		Specialty Mental Health					In-Home Counseling	Family Doctor	School Guidance Counselor	Alcohol & Drug Clinic	Any Out-patient Mental Health Services
		Mental Health Clinician	Community Mental Health Center	Day Treatment	Thera-peutic Nursery	Any Specialty Mental Health Out-patient Services
		Percent/ (SE)
Child Age	0-2	0.2 (0.1)	0.1 (0.03)	N/A	0.1 (0.1)	0.3 a (0.1)	0.9 (0.2)	0.3 (0.1)	N/A	N/A	1.0 c (0.2)
	3-5	1.6 (0.5)	0.4 (0.2)	N/A	0.4 (0.3)	2.3 b (0.6)	2.0 (0.8)	0.2 (0.1)	N/A	N/A	4.1 d (1.0)
	6-10	5.5 (1.2)	2.3 (0.7)	0.4 (0.2)	N/A	7.8 (1.4)	3.3 (0.9)	0.6 (0.3)	8.4 (1.6)	0.0 (0.0)	15.3 (2.3)
	11+	9.2 (1.6)	5.7 (1.3)	1.3 (0.6)	N/A	13.5 (1.9)	5.5 (1.3)	1.8 (0.7)	7.7 (1.4)	0.1 (0.1)	19.9 (2.4)
Child Race/ Ethnicity	African American	3.4 (1.1)	1.6 (0.6)	0.1 (0.1)	0.2 (0.1)	4.8 (1.4)	1.7 (0.4)	0.3 (0.2)	7.6 (1.6)	0.0 (0.0)	9.5 (1.4)
	White	5.4 (0.9)	2.9 (0.7)	1.0 (0.3)	0.1 (0.1)	7.8 (1.1)	3.9 (1.0)	1.1 (0.4)	8.4 (1.6)	0.2 (0.1)	12.8 (1.7)
	Hispanic	3.7 (1.5)	1.7 (0.9)	1.3 (1.0)	0.1 (0.04)	5.8 (1.9)	3.4 (1.5)	0.6 (0.5)	7.9 (3.4)	0.1 (0.1)	10.1 (2.7)
	Other	5.4 (2.5)	2.3 (1.3)	0.7 (0.4)	2.6 (2.4)	8.3 (3.0)	2.4 (1.1)	0.1 (0.1)	8.8 (4.3)	0.2 (0.2)	12.5 (3.6)
Child Setting/ Services	Total in-home	3.6 (0.5)	1.6 (0.4)	0.6 (0.3)	0.2 (0.2)	4.9 e (0.7)	2.5 (0.6)	0.6 (0.2)	6.5 (1.0)	0.1 (0.1)	9.1 (1.0)
	In-home, no services	3.0 (0.7)	1.3 (0.4)	0.4 (0.3)	0.2 (0.2)	4.4 (0.9)	1.3 (0.4)	0.6 (0.3)	5.5 (1.1)	0.03 (0.03)	7.3 (1.1)
	In-home, services	4.9 (1.3)	2.3 (0.6)	1.2 (0.6)	0.04 (0.03)	6.4 (1.3)	5.9 (2.0)	0.5 (0.2)	9.4 (2.0)	0.2 (0.2)	13.8 (2.2)
	Total out-of-home	13.2 (2.0)	8.4 (2.4)	2.0 (0.5)	1.2 (0.5)	21.1 (2.4)	8.2 (1.4)	2.2 (1.1)	23.0 (4.5)	0.4 (0.3)	31.2 f (3.5)
	Foster care	13.4 (2.5)	5.3 (1.8)	2.0 (1.0)	1.5 (0.9)	18.9 (2.9)	9.1 (2.2)	0.9 (0.3)	17.7 (4.5)	0.8 (0.7)	26.8 (4.1)
	Kinship foster care	8.9 (2.5)	9.0 (4.0)	1.6 (0.8)	0.6 (0.4)	18.0 (4.1)	2.8 (0.8)	1.6 (1.0)	27.9 (8.3)	0.0 (0.0)	29.1 (5.4)
	Group care	35.4 1 (12.1)	20.2 (9.9)	3.6 (1.9)	17.5 (15.7)	47.6 (11.6)	34.1 2 (10.0)	12.1 (9.8)	22.0 (7.7)	0.5 (0.5)	62.6 (11.9)
Most Serious Abuse Type	Physical abuse	5.4 (1.4)	2.6 (0.8)	1.3 (0.7)	0.1 (0.1)	8.3 (1.7)	3.3 (1.0)	0.9 (0.5)	8.2 (2.0)	0.1 (0.1)	14.3 (2.5)
	Sexual abuse	4.7 (1.5)	3.7 (1.6)	0.5 (0.3)	0	7.4 (2.0)	2.6 (1.2)	1.7 (1.1)	5.3 (1.5)	0.5 (0.4)	9.6 (2.2)
	Failure to provide	2.9 (1.0)	1.5 (0.6)	1.2 (0.8)	0.3 (0.1)	3.8 (1.1)	1.7 (0.5)	0.4 (0.1)	11.7 (3.7)	0.1 (0.1)	9.2 (1.9)
	Failure to supervise	3.6 (1.1)	1.5 (0.5)	0.3 (0.1)	0.5 (0.4)	4.9 (1.1)	3.4 (1.2)	0.1 (0.1)	8.5 (2.1)	0	10.4 (1.6)
	Other abuse	7.9 (2.3)	1.6 (1.2)	0.4 (0.2)	0.7 (0.6)	8.6 (2.4)	3.8 (1.7)	2.5 (1.5)	3.6 (1.2)	0	11.1 (2.6)
TOTAL		4.6 (0.5)	2.3 (0.4)	0.8 (0.3)	0.3 (0.1)	6.6 (0.7)	3.1 (0.6)	0.7 (0.2)	8.1 (1.1)	0.1 (0.1)	11.4 (1.1)

N/A = Not Applicable (Caregivers of children in this age group were not asked regarding use of this service). a Children aged 0-2 are less likely than children aged 11 and older to be currently receiving specialty outpatient mental health services, by caregiver report (X2 = 33.4, p<.001). (back) b Children aged 3-5 are less likely than children aged 11 and older to be currently receiving specialty outpatient mental health services, by caregiver report (X2 = 28.3, p< .001). (back) c Children aged 0-2 are less likely than children aged 11 and older to be currently receiving outpatient mental health services, by caregiver report (X2 = 47.3, p<.001). (back) d Children aged 3-5 are less likely than children aged 11 and older to be currently receiving outpatient mental health services, by caregiver report (X2 = 45.7, p<.001). (back) e Children remaining at home are less likely than children in out-of-home care to be currently receiving specialty outpatient mental health services, by caregiver report (X2 = 27.8, p<.001). (back) f Children remaining at home are less likely than children in out-of-home care to be currently receiving outpatient mental health services, by caregiver report (X2 = 25.5, p<.001). (back) 1 Caregivers were asked if child had received “private professional help from a psychiatrist, psychologist, social worker, or psychiatric nurse.” It is not possible to determine if these services were provided in the community or in the group care setting. (back) 2 Caregiver was asked whether child had received “any in-home counseling or in-home crises services.” The caregiver may be interpreting services received in the group care setting as in-home services. (back)

9.1.3 Specialty Outpatient Mental Health Services for Children

To further examine the relationship between various child and case characteristics and the receipt of outpatient specialty mental health services by children involved with CWS, a logistic regression was performed that modeled current receipt of any of the four specialty mental health services as reported by caregivers, controlling for race/ethnicity, age, gender, service setting, and most serious abuse type. 32 The results are summarized in Table 9-3. Younger children (aged 5 years and under) continue to be less likely to receive specialty mental health services than older children (p<.001), whereas those in out-of-home settings are more likely than those remaining at home and not receiving services to be receiving specialty mental health services (p<.001 for both foster and kinship foster care settings).

Table 9-3. Logistic Regression Modeling Current Receipt of Any Specialty Mental Health Outpatient Service by Children Involved with the Child Welfare System

		Any Specialty	Mental Health Service
		OR	95% CI
Age (continuous)		1.20**_i	1.14, 1.27
Gender	Male	0.89	0.43, 1.83
	Female	(reference group)
Race/Ethnicity	White	(reference group)
	African American	0.52	0.22, 1.22
	Hispanic	1.01	0.41, 2.45
	Other	1.32	0.58, 3.01
Child Setting/ Services	In home, no services	(reference group)
	In home, services	1.93	0.97, 3.84
	Foster care	8.89**_ii	4.72, 16.75
	Kinship foster care	5.90**_iii	3.27, 10.62
	Group care	#_i	#_ii
Most Serious Abuse Type	Physical abuse	(reference group)
	Sexual abuse	0.66	0.33, 1.33
	Failure to provide	0.50	0.21, 1.16
	Failure to supervise	0.52	0.25, 1.10
	Other	0.93	0.40, 2.18

Cox and Snell pseudo-R2 is NA ** p<.001 (back: **_i, **_ii, **_iii) # Due to small cell size, the odds ratio for Group care could not be calculated. (back: #_i, #_ii)

A similar logistic regression, adding the child’s CBCL score as a potential predictor variable, was run for children aged 2 and older (CBCL scores were not obtained on children under 2). Increasing age (p<.001) and out-of-home placement continued to be significantly related to increased likelihood of mental health service use (p<.001) for each of the three out-of-home placement settings), whereas children with CBCL scores above the borderline/clinical cut-point of 60 are almost four times more likely to be receiving mental health services than those below the cut-point (p<.001) (Table 9-4). Children receiving in-home CWS services were no more likely to also be receiving outpatient mental health services than those children in their home of origin who were not receiving CWS services. The involvement of child welfare services does not, at least in the short term, appear to increase access to children’s mental health services, unless the children are in out-of-home care. It should be noted, however, that system policies and procedures may impact who receives services. For instance, a policy may dictate that children placed in out of home care routinely receive a mental health assessment.

Table 9-4. Logistic Regression Modeling Current Receipt of Any Specialty Mental Health Outpatient Service by Children Involved with the Child Welfare System, Aged 2 Years and Older

		Any Specialty	Mental Health Service
		OR	95% CI
Age (continuous)		1.15**_i	1.08, 1.22
Gender	Male	0.80	0.39, 1.65
	Female	(reference group)
Race/ Ethnicity	White	(reference group)
	African American	0.54	0.23, 1.25
	Hispanic	1.11	0.44, 2.80
	Other	1.26	0.52, 3.04
Child Setting/ Services	In home, no services	(reference group)
	In home, services	1.76	0.86, 3.58
	Foster care	8.26**_ii	4.27, 15.97
	Kinship foster care	6.62**_iii	3.52, 12.46
	Group care	10.84**_iv	3.63, 32.34
CBCL Scores	Nonclinical score	(reference group)
	Borderline or clinical score	3.34**_v	2.02, 5.53
Most Serious Abuse Type	Physical abuse	(reference group)
	Sexual abuse	0.66	0.33, 1.34
	Failure to provide	0.54	0.25, 1.18
	Failure to supervise	0.57	0.28, 1.18
	Other	0.94	0.41, 2.13

Cox and Snell pseudo-R2 is .08 ** p<.001 (back: **_i, **_ii, **_iii, **_iv, **_v)

9.1.4 Inpatient Mental Health Services for Children

Use of inpatient services was examined through caregiver report. Lifetime use was reported for children remaining at home, whereas use since the CWS investigation date was reported for children in out-of-home care. Approximately 7% of children remaining at home had a lifetime history of inpatient service use (Table 9-5). There is no significant difference in inpatient mental health service use between children remaining at home who are receiving services and those who are not receiving services.

Table 9-5. Caregiver Report of Lifetime Receipt of Inpatient Mental Health Services for Children Living in Their Home of Origin

		In-Home
		No Services	Services	TOTAL In-Home
		Percent / (SE)
Institutional/ Inpatient	Psychiatric hospital	4.7 (0.9)	5.2 (0.8)	4.8 (0.7)
	Medical hospital, psychiatric unit	1.9 (0.6)	3.2 (0.7)	2.3 (0.5)
	Residential treatment center or group home	1.9 (0.6)	2.1 (0.6)	1.9 (0.5)
	Emergency shelter	1.6 (0.6)	1.4 (0.5)	1.5 (0.5)
	Hospital emergency room	2.2 (0.7)	3.3 (0.8)	2.5 (0.6)
	Detox or inpatient drug or alcohol services	0.2 (0.2)	1.2 (0.7)	0.5 (0.2)
Any Inpatient Services		7.1 (1.0)	7.6 (0.9)	7.2 (0.8)

Among children in out-of-home care, 13% have used inpatient mental health services since the investigation date (Table 9-6). There are significant differences in inpatient mental health service use among children in the three out-of-home placement settings, with those in group care being more likely than those in either foster care or kinship foster care to have used any inpatient services, as well as residential treatment center or group home services, since the CWS investigation date. It is important to note, however, that in the analyses examining inpatient services for children in out-of-home care, group care is considered both a placement setting and a mental health treatment, leading to higher overall rates of inpatient mental health service use by children in group care settings.

Logistic regressions, including the child’s CBCL score as a potential predictor variable, were run for two categories of inpatient service use: (1) receipt of any inpatient mental health services (Table 9-7) and (2) receipt of psychiatric hospital services (a psychiatric hospital or a psychiatric unit of medical hospital) (Table 9-8). For children remaining at home, increasing age and borderline or clinical CBCL score predicts lifetime use of inpatient services for both categories (p<.001); male children are also more likely than female children to report psychiatric hospitalization during their lifetime (p<.01).

The results of the logistic regression varied for children in out-of-home care by the type of inpatient service examined. When “any use of inpatient mental health service since CWS investigation date” was modeled, several variables were significant (out-of-home caregivers were asked only about services since the investigation date because they would have limited knowledge of the child’s lifetime history). Increasing age and borderline or clinical CBCL scores continued to be associated with use of inpatient services since the investigation date (p<.001 for each) (Table 9-9). In addition, African American children in out-of-home care are more likely than White children in out-of-home care to have utilized inpatient mental health services since the start of the investigation. Type of out-of home-placement is also a factor, with children in kinship care less likely (p<.05) and children in group homes (p<.01) more likely than children in foster care to have accessed inpatient mental health services. This may be somewhat misleading, however, as a group home may be both a placement setting and an inpatient mental health service, as noted earlier.

Table 9-6. Caregiver Report of Receipt of Inpatient Mental Health Services Since the CWS Investigation Date by Children in Out-of-Home Care

		Out-of-Home
		Foster Care	Kinship Foster Care	Group Care	TOTAL Out-of-Home
		Percent /(SE)
Institutional/ Inpatient	Psychiatric hospital	5.2 (2.2)	2.0 (0.8)	25.2 (10.6)	5.9 (1.6)
	Medical hospital, psychiatric unit	1.9 (1.2)	0.2 (0.2)	1.9 (1.2)	1.1 (0.5)
	Residential treatmentcenter or group home	3.9 a (1.6)	1.9 b (1.3)	54.8 (12.8)	8.9 (1.8)
	Emergency shelter	2.4 (0.9)	1.1 (0.6)	27.4 (10.7)	5.5 (1.8)
	Hospital emergency room	2.3 (1.3)	0.2 (0.1)	1.4 (1.0)	1.2 (0.5)
	Detox or inpatient drug or alcohol services	0.0 (0.0)	0.0 (0.0)	1.4 (1.1)	0.3 (0.2)
Any Inpatient Services		10.6 c (2.7)	4.1 d (1.4)	59.5 (13.1)	13.1 (2.0)

a Children in foster care are less likely than children in group care to have received residential treatment center or group home care since the CWS investigation date, by caregiver report (X2 = 13.9, p<.001). (back) b Children in kinship foster care are less likely than children in group care to have received residential treatment center or group home care since the CWS investigation date, by caregiver report (X2 = 14.6, p<.001). (back) c Children in foster care are less likely than children in group care to have received any inpatient mental health service since the CWS investigation date, by caregiver report (X2 = 13.1, p<.001). (back) d Children in kinship foster care are less likely than children in group care to have received any inpatient mental health service since the CWS investigation date, by caregiver report (X2 = 15.9, p<.001). (back)

When the regression model is run to examine use of inpatient psychiatric hospital services (both psychiatric hospital and psychiatric unit of medical hospital), the impact of race/ethnicity and placement setting are not evident. However, the associations of increasing age and borderline or clinical CBCL score (p<.001) with service use continue to be present (Table 9-10).

9.1.5 Special Education

Caregiver report of need for and use of special education services was also obtained for children involved with CWS. Over one-quarter of the caregivers report that they have ever been told by an education or health professional that their child had learning problems, special needs, or developmental disabilities. Caregivers also report that 17% of the children have been tested for learning problems since the start of the CWS investigation (the mean period from investigation start to interview date was 7.1 months) (Table 9-11). Almost one in five (19%) children is classified as needing special education services, defined as having the caregiver report that the child has been given an individualized education program (IEP) or individualized family service plan (IFSP). Fifteen percent are currently receiving special education services, as compared with 11% of children nationwide (U.S. Department of Education, 2001).

Table 9-7. Logistic Regression Modeling Lifetime Receipt of Any Inpatient Mental Health Services by Children in their Home of Origin, Aged 2 Years and Older

		Any Inpatient Mental Health Service Use
		OR	95% CI
Age (continuous)		1.29**_i	1.20, 1.39
Gender	Male	1.89	1.07, 3.34
	Female	(reference group)
Race/Ethnicity	White	(reference group)
	African American	0.73	.36, 1.48
	Hispanic	1.11	.51, 2.42
	Other	0.65	.26, 1.62
Child Setting/ Services	In home, no services	(reference group)
	In home, services	0.98	.61, 1.59
CBCL Scores	Non-clinical score	(reference group)
	Borderline or clinical score	3.34**_ii	1.82, 6.16

Cox and Snell pseudo-R2 is .08 n=2874 ** p<.001 (back: **_i, **_ii)

Table 9-8. Logistic Regression Modeling Lifetime Receipt of Psychiatric Hospital Services by Children in their Home of Origin, Aged 2 Years and Older

		Psychiatric Hospital Service Use
		OR	95% CI
Age (continuous)		1.28**	1.18, 1.38
Gender	Male	2.33*_i	1.25, 4.35
	Female	(reference group)
Race/Ethnicity	White	(reference group)
	African American	0.62	.27, 1.42
	Hispanic	1.06	.44, 2.54
	Other	0.70	.25, 1.96
Child Setting/ Services	In home, no CWS	(reference group)
	In home, CWS	0.98	0.56, 1.69
CBCL Scores	Nonclinical score	(reference group)
	Borderline or clinical score	2.88**_ii	1.41, 5.89

Cox and Snell pseudo-R2 is .06 n=2873 * p<.01 (back: *_i, **_ii) ** p<.001 (back)

Table 9-9. Logistic Regression Modeling Any Inpatient Mental Health Services Since the CWS Investigation Date by Children Living in Out-of-Home Care, Aged 2 Years and Older

		Any Inpatient Mental	Health Service Use
		OR	95% CI
Age (continuous)		1.39**_i	1.23, 1.56
Gender	Male	1.16	.46, 2.96
	Female	(reference group)
Race/ Ethnicity	White	(reference group)
	African American	4.83**_ii	2.11, 11.08
	Hispanic	1.43	.39, 5.27
	Other	1.10	.32, 3.82
Child Setting/ Services	Foster care	(reference group)
	Kinship foster care	0.30	.11, .82
	Group care	7.35*	2.25, 24.00
CBCL Scores	Nonclinical score	(reference group)
	Borderline or clinical score	8.25**_iii	3.58, 19.00

Cox and Snell pseudo-R2 is .27 * p<.01; (back) ** p<.001 (back: **_i, **_ii, **_iii)

Younger children (aged 0-2 and 3-5 years) are less likely than older children (aged 6-10 and 11 years and older) to have been identified by an education or health professional of having learning problems, special needs, or developmental disabilities (p<.001). Female children and African American or Hispanic children are also less likely than male children (p<.001) and White or “other” racial/ethnic category children (p<.01), respectively, to have a professional report a special education need. In addition, younger children (aged 0-2 and 3-5 years) are also less likely than children aged 11 years and older to have been tested for special education needs, to have an IEP/IFSP (p<.001 for both), or to be receiving special education services (p<.001 for both). Finally, children in their homes of origin are significantly less likely than those in out-of-home care to have been assessed for special education needs since the start of the CWS investigation (p<.001).

For those children who have not been tested for or classified as needing special education services, 24% of caregivers report that the child needs testing (Table 9-12). A majority of caregivers reporting an unmet need (62%) indicate that the testing has not been received for other reasons.

Table 9-10. Logistic Regression Modeling Any Psychiatric Hospital Services Since CWS Investigation Date by Children Living in Out-of-Home Care (Aged 2+)

		Psychiatric	Hospital Service Use
		OR	95% CI
Age (continuous)		1.26**_i	1.11, 1.44
Gender	Male	1.15	.36, 3.66
	Female	(reference group)
Race/ Ethnicity	White	(reference group)
	African American	1.94	.60, 6.34
	Hispanic	0.73	.15, 3.55
	Other	0.44	.10, 1.94
Child Setting/ Services	Foster care	(reference group)
	Kinship foster care	0.28	.08, 1.05
	Group care	2.06	.67, 6.34
CBCL Scores	Nonclinical score	(reference group)