1. A National Assessment of Youth Involved with Child Welfare: Prevalence of Emotional and Behavioral Problems, Access to Treatment, and the Role of Court Involvement Presented by Heather D. Orton, M.S. Co-Authors: Anne M. Libby, Ph.D., Richard P. Barth, Ph.D., William Jones, J.D., John Landsverk, Ph.D.

2. Background  2003 GAO report Children Placed to Obtain Mental Health Services focused on Child Welfare U.S. General Accounting Office (2003). Children Placed to Obtain Mental Health Services. Washington, D.C.: U.S. General Accounting Office.  Studies document elevated need in foster care populations, also likely for in-home populations Aarons, G. A., S. A. Brown, et al. (2001). "Prevalence of adolescent substance use disorders across five sectors of care." J Am Acad Child Adolesc Psychiatry 40(4): 419-426. Halfon, N., G. Berkowitz, et al. (1992). "Mental health service utilization by children in foster care in California." Pediatrics. 89(6 Pt 2): 1238-44. Costello, E. J., A. Angold, et al. (1996). "The Great Smokey Mountains Study of Youth: Goals, Design, and prevalence of DSM-III-R disorders." Archives of General Psychiatry 53: 1129-1136.

3. Systems and Services  Because Medicaid insurance obtained through CW placement, CW involvement can be service gateway Libby, A., A. Cuellar, et al. (2002). "Substitution in a Medicaid mental health carve-out: services and costs." Journal of Health Care Finance 28(4): 11-23.  Involvement with Juvenile Justice system common; overlap with high prevalence of (untreated) mental health problems in Child Welfare Cuellar, A., A. Libby, et al. (2001). "How capitated mental health care affects utilization by youth in the juvenile justice and child welfare systems." Mental Health Services Research 3(2): 61-72. Cuellar, A., S. Markowitz, et al. (2004). "The relationships between mental health and substance abuse treatment and juvenile crime." Journal of Mental Health Policy and Economics 7(2): 59-68.

4. Study Questions 1)What is the prevalence of mental health problems among youth involved with Child Welfare? 2)To what extent are mental health problems associated with court involvement? 3)How are Medicaid insurance and court involvement associated with access to treatment services?

5. National Survey of Child and Adolescent Well-Being (NSCAW)  Available through the National Data Archive on Child Abuse and Neglect at Cornell University  Longitudinal study of children who were subjects of investigations of child abuse/neglect between October 1999 and December 2000 (N = 5,501)  4 waves of data: baseline, 12 months, 18 months, 36 months  Ages 0 – 14 years at baseline

6. NSCAW Methods  4 possible respondents: child, current caregiver, caseworker, and teacher  Complex 2-stage sample design 92 PSUs 9 strata Over-sampled: Children/families receiving services, infants, and sexually abused children Analytic weights for sample design and non-response Estimates nationally representative of Child Welfare population

7. Study Sample and Measures  Adolescents age 11 – 14 at baseline (n=1,080)  Court involvement = went to court for misbehaving (assessed by current caregiver) between baseline and Wave 3  Risky substance use = scale created using past 30 day use of all substances as reported by adolescent at baseline  CBCL assessed by caregiver at baseline  Service use assessed by caseworker at Wave 2/3

8. Baseline Demographics %n Race White48.6469 Black28.1335 Hispanic16.3169 Male43.0454 In-home87.0777 Medicaid55.4682 Age (mean, SD)12.5 yrs (0.7 yrs)

9. Baseline Mental Health Problems %n Clinically significant CBCL (>= 64) Internalizing32.7309 Externalizing43.0456 Total41.4442 Risky use of substances27.0268

10. Predicting court involvement between baseline and Wave 3 ORp-value Externalizing CBCL5.8< 0.001 Internalizing CBCL0.4> 0.05 Total CBCL1.6> 0.05 Risky substance use4.2< 0.001 In-home2.1> 0.05 Abuse v. maltreatment1.3> 0.05 Age (years)1.8< 0.01 * Model also adjusted for gender and race/ethnicity (n=829)

11. Predicting service use among adolescents with externalizing CBCL Mental health services Substance use services ORp-valueORp-value Court involvement3.3< 0.054.0< 0.05 Medicaid2.9> 0.051.6> 0.05 Race/ethnicity Black0.3< 0.052.6> 0.05 Hispanic0.2< 0.052.3> 0.05 Other1.2> 0.056.6< 0.05 * Model also adjusted for gender, age, substance use, and placement (n=387)

12. Predicting service use among adolescents with internalizing CBCL Mental health services Substance use services ORp-valueORp-value Court involvement5.2< 0.052.2> 0.05 Medicaid2.5> 0.051.1> 0.05 Race/ethnicity Black0.1< 0.010.2> 0.05 Hispanic0.06< 0.0010.9> 0.05 Other0.7> 0.051.7> 0.05 * Model also adjusted for gender, age, substance use, and placement (n=260)

13. What is the prevalence of mental health problems among youth involved with Child Welfare?  Prevalence of behavior problems was fairly high: 43% for externalizing and 33% for internalizing Not an issue of gender – prevalence was similar among boys and girls  27% used substances in past month

14. To what extent are mental health problems associated with court involvement?  Externalizing problems significantly increased likelihood of court involvement; internalizing problems had no effect  Substance use increased likelihood of court involvement  Older adolescents more likely to become involved with courts

15. How are Medicaid insurance and court involvement associated with access to treatment services?  Medicaid did not have a significant effect on access to treatment  Court involvement increased likelihood of receiving MH and substance use services  Black and Hispanic adolescents were less likely to receive services than White adolescents

16. Questions?

17. Past month drug use at baseline