Addressing the Developmental Needs of Children in Child Welfare Presenters: Mimi Graham, EdD FSU C ENTER FOR P REVENTION & E ARLY I NTERVENTION P OLICY

Trajectory of Development PovertyMaltreatment Lack of Health Services Toxic Stress Nurturing Family PreK & Quality Child Care Targeted Supports Health Services Intensive Intervention Healthy At-Risk Delayed or Disordered Ready to Learn

Most Maltreated Children Have Developmental Problems 3 23 – 65% Cognitive Problems 14 – 64% Speech Delays 22 – 80% Health Problems 4 – 47% Motor Delays 10 – 61% Mental Problems

Nurturing & Responsive Relationships Intensive Intervention Targeted Social Emotional Supports High Quality Environments Nurturing & Responsive Relationships Universal Promotion Prevention Treatment 80% 15% 5% 4 Pyramid for Promoting Social Emotional Competence in Infants & Young Children The Center on the Social and Emotional Foundations for Early Learning

Enriched Environments Can Improve Development Early Head Start Accredited childcare – National Assoc. for the Education of Young Children 5 Intensive Intervention Targeted Social Emotional Supports High Quality Environments Nurturing & Responsive Relationships

Left Behind By Kindergarten: Children living in poverty average 15 IQ points below their peers. Vocabulary at Age 3 Poor children: 525 words Working class: 749 words Professional: 1,116 words By age 4, the average child in a poor family might have been exposed to 13 million fewer words than child in a working class family and 30 million fewer words than a child in a professional family. 7

Developmental screening Early Intervention Early childhood mental health consultants to childcare Specific counseling Support to siblings, biological and foster families Targeted Supports 8 Intensive Intervention Targeted Social Emotional Supports High Quality Environments Nurturing & Responsive Relationships

Opportunities for Developmental Screening for Child Welfare 1.Childcare Screening 2.CAPTA 3.Comprehensive Health Assessment 4.Comprehensive Behavioral Health Assessment

1.Developmental screening required for All children in subsidized childcare 10

Signs of Trauma in Toddlers Biting, kicking, tantrums, unprovoked aggression Lack of verbal skills to express emotions Disengagement with others Indiscriminate preferences of caregivers Skill regression Intensive Intervention Targeted Social Emotional Supports High Quality Environments Nurturing & Responsive Relationships Understand Children’s Underlying Emotional Needs in Challenging Behaviors

2. Federal Mandate for Developmental Screening of Maltreated Children CAPTA: Child Abuse Prevention & Treatment & Adoption Reform Requires states to have procedures for the referral of children under 3 involved in substantiated cases of child abuse or neglect to early intervention services 12

Few children in child welfare qualify for needed Part C intervention because of the increasingly restrictive criteria. 2 Standard Deviations below mean in 1 area or 2 areas with 1.5 Standard Deviation delays 13

NSCAW I: : 35% of children birth to 3 years need Part C early intervention services at time of contact with CWS Only 12% had an IFSP by age 3 indicating services Source: NSCAW I and II 14 A national study found that… Unmet Developmental Needs Of Children Investigated For Maltreatment

Mental Health Needs of Children Investigated for Maltreatment: NSCAW % of children birth to 2 and 32% of children 3-5 years have emotional or behavioral problems Almost 80% do not receive timely intervention/treatment or primary care services 30% of infants in care show behavioral problems at school entry Source: Casanueva, C., Smith, K., Dolan, M., & Ringeisen, H. (2011). NSCAW II Baseline Report: Maltreatment. OPRE Report # c, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

National Longitudinal Study of the Developmental Needs of Children Encountering Child Welfare with a Measured Delay – 65% of children not receiving any services – 51% of children receiving services at home – 38% of children in foster homes – 22% of children in kinship care 16 Source: Casanueva, C., Ringeisen, H., Wilson, E., Smith, K., & Dolan, M. (2011). NSCAW II Baseline Report: Child Well-Being. OPRE Report # b, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

Estimated Children Encountering Florida Child Welfare System With Delay(s) & Not Receiving Part C Services Type of Child Welfare Involvement Children 0-3 in Florida Child Welfare, SFY National Study Percentages of Children with Measured Delays Estimated No. of Florida Children in Child Welfare with Delay Investigations with “No Findings” 19,24765%12,511 Children Not Served or Referred to Prevention Programs* 8,47665% 5,509 Children Served at Home 9,01551%4,598 Children Served Out of Home 14,68038%5,578 Total # Children in all Situations 51,418 28,196 Total Estimated # Child Welfare Children Served by Part C** 2,652 Estimated # of children with delays not getting Part C 25,544 Source: Radigan, Hogan & Graham, (2011). Helping the Child Welfare Population in Early Intervention: Implications for Practice. Available at 17

3. American Academy of Pediatrics Recommendations for Health Care of Young Children in Foster Care Initial health screening (within 72 hours) Comprehensive health assessment (within 30 days of removal) and must address the physical, behavioral, dental and developmental Well Child Check-ups completed with EPSDT periodicity schedule. (1, 2, 4, 6, 9, 12, 15, 18 months; then annually from age 2) American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care. (2002). Health care of young children in foster care. Pediatrics, 109(3),

DCF/CBC Requirements Initial Health Screening (within 72 hours) Comprehensive Health Assessment (within 30 days of removal) and must address the physical, behavioral, dental and developmental Comprehensive Health Plan 19

4. Comprehensive Behavioral Health Assessment 0-5 Medicaid Handbook, (page 2-2-6) The assessment must include, at a minimum, the following information related to the child and the child’s family: Reason for referral; Personal and family history; Placement history, including adjustment to a new care giver and home; Sources of information (i.e., counselor, hospital, law enforcement); Interviews and interventions; Cognitive functioning. Screening for emotional-social development, problem solving, communication, response of the child and family to the assessment and ability to collaborate with the assessor; Previous and current medications including psychotropics; Last physical examination, and any known medical problems including pre-natal, pregnancy and delivery history which may affect the child’s mental health status, such as prenatal exposure, accidents, injuries, etc.; History of mental health treatment of parents and child’s siblings. The mother’s history, including a depression screen; History of current or past alcohol or chemical dependency of parents and child; Legal involvement and status of child and family; Resources including income, entitlements, health care benefits, subsidized housing, social services, etc.; Emotional status – hands on interactive assessment of the infant regarding sensory and regulatory functioning, attention, engagement, constitutional characteristics, and organization and integration of behavior; Educational analysis – daycare issues concerning behavioral and developmental concerns; Functional analysis – presenting strengths and problems of both child and family;

Unhealed Trauma 21 National Survey for Child and Adolescent Well-Being II (NSCAW) White, Havalchak, Jackson, O’Brien & Pecora, % of Foster Children Have Mental Health Problems At least one diagnosis in lifetime

Observations Need for trauma based mental health interventions. 15 month old KH was drug exposed during pregnancy. No recommendations in CBHA to address development nor future assessments. 3.5 year old DL. Foster parent has concerns re: his nightmares/ does not sleep at childcare/no assessment 2.5 year old EJ. Described in chart as “very hyper” 4 year-old has behavioral problems in childcare---bites and kicks, defecates in his pants 2 year old CH “cries a lot”. 5.5 year old CP. Foster parent reports that behavior is “problematic- doesn’t listen, doesn’t want to be told what to do.”

Untreated Adverse Early Childhood Events Only Exacerbate Over Time Childhood Developmental Delays Expulsion Adolescence Delinquency Mental Health Sexual Activity Drugs & Alcohol Violence Adulthood Psychiatric Problems Drug Abuse Alcohol Crime 23 Source: Adverse Childhood Experiences (ACE) Study. Available at

Nurturing responsive emotionally available caregiver Enriched environment with early childhood mental health consultation to address his trauma & needs Medical evaluation to address failure to thrive, nutrition, physical issues. Developmental assessment with appropriate early intervention services Frequent contact with mom IMH evaluation of parent/child relationship and dyadic therapy to improve repair and enhance 24 What Does Children Like Billy Need to Thrive?

Florida Association for Infant Mental Health 12th Annual Conference June 12, 2013 Tampa FL Infusing Infant Mental Health into Early Childhood Systems: How to Screen, How to Intervene & How to Fund IMH Services Early Steps Child Welfare & Baby Courts Home Visiting Childcare