Anne-Marie Conn

Identification of social‐emotional problems among young children in foster care

BACKGROUND Little is known about how best to implement behavioral screening recommendations in practice, especially for children in foster care, who are at risk for having social-emotional problems. Two validated screening tools are recommended for use with young children: the Ages and Stages Questionnaire: Social Emotional (ASQ-SE) identifies emotional problems, and the Ages and Stages Questionnaire (ASQ) identifies general developmental delays in five domains, including personal-social problems. The current study examined: (1) whether systematic use of a social-emotional screening tool improves the detection rate of social-emotional problems, compared to reliance on clinical judgment; (2) the relative effectiveness of two validated instruments to screen for social-emotional problems; and (3) the patterns of social-emotional problems among children in foster care. METHODS We used retrospective chart review of children in foster care ages 6 months to 5.5 years: 192 children before and 159 after screening implementation, to measure detection rates for social-emotional problems among children. The ASQ-SE and the ASQ were used in multivariable logistic regression analyses to examine associations between children with social-emotional problems. RESULTS Use of the screening tool identified 24% of the children as having a social-emotional problem, while provider surveillance detected 4%. We identified significantly more children with social-emotional problems using the ASQ-SE than using the ASQ, and agreement between the instruments ranged from 56% to 75%, when data were stratified by age group. Multivariable modeling showed that preschool children were more likely to have a social-emotional problem than toddlers and infants (aOR = 3.4, 95% CI = 1.1-10.8). CONCLUSIONS Systematic screening using the ASQ-SE increased the detection rate for social-emotional problems among young children in foster care, compared to provider surveillance and the ASQ. A specific social-emotional screening tool appears to detect children with psychosocial concerns who would not be detected with a broader developmental screening tool.

Improved Detection of Developmental Delays Among Young Children in Foster Care

OBJECTIVE: Our goal was to determine if systematic use of a validated developmental screening instrument is feasible and improves the detection of developmental delay (DD) in a pediatric medical home for children in foster care. DESIGN AND METHODS: This study had a pre-post study design, following a practice intervention to screen all children in foster care for DD by using the Ages and Stages Questionnaire (ASQ). The baseline detection rate was determined by medical chart review for all children aged 4 to 61 months who were new to foster care (NFC) during a 2-year period. After implementation of systematic screening, caregivers of young children who were NFC or already in foster care (IFC) completed the ASQ at preventive health care visits. We assessed the feasibility of systematic screening (the percentage of ASQs completed among the NFC and IFC groups). We compared the detection of DD among the baseline NFC group and the screening-NFC group by using bivariate and multivariable logistic regression. RESULTS: Of 261 visits that occurred after initiation of screening, 251 (96%) visits had a completed ASQ form in the medical chart, demonstrating high feasibility. Among children who were NFC, the detection of DD was higher in the screening than baseline period for the entire population (58% vs 29%; P < .001), for each age group (infants: 37% vs 14%; toddlers: 89% vs 42%; preschool: 82% vs 44%; all P ≤ .01), and for all developmental domains. On adjusted analyses, the detection of potential DD in toddler and preschool children was higher among the NFC screening group than the NFC baseline group. CONCLUSION: Systematic screening for DD using the ASQ was feasible and seemed to double the detection of DDs.

Validating office-based screening for psychosocial strengths and difficulties among youths in foster care.

OBJECTIVES: To assess the effectiveness of social-emotional screening in the primary care setting for youths in foster care. METHODS: The setting was a primary care practice for all youth in home-based foster care in 1 county. Subjects were youths, aged 11 to 17 years, and their foster parents; both completed a Strengths and Difficulties Questionnaire at well-child visits. The Strengths and Difficulties Questionnaire is a previously validated 25-item tool that has 5 domains: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems; and prosocial behaviors and an overall total difficulties score. We first compared youth versus parent Strengths and Difficulties Questionnaire scores and then assessed the accuracy of these Strengths and Difficulties Questionnaire scores by comparing them in a subsample of youths (n = 50) with results of home-based structured clinical interviews using the Childrens Interview for Psychiatric Syndromes. RESULTS: Of 138 subjects with both youth and parent reports, 78% had prosocial behaviors (strengths), and 70% had 1 or more social-emotional problems. Parents reported significantly more conduct problems (38% vs 16%; P < .0001) and total difficulties (30% vs 16%; P = .002) than did youth. The Strengths and Difficulties Questionnaire had better agreement with the Childrens Interview for Psychiatric Syndromes (n = 50) for any Strengths and Difficulties Questionnaire–identified problem for combined youth and foster-parent reports (93%), compared with youth report alone (54%) or parent report alone (71%). CONCLUSIONS: Although most youths in foster care have social-emotional problems, most have strengths as well. Youth and foster-parent perspectives on these problems differ. Systematic social-emotional screening in primary care that includes both youth and parent reports can identify youths who may benefit from services.

Use of a Brief Standardized Screening Instrument in a Primary Care Setting to Enhance Detection of Social-Emotional Problems Among Youth in Foster Care

OBJECTIVE To determine whether systematic use of a validated social-emotional screening instrument in a primary care setting is feasible and improves detection of social-emotional problems among youth in foster care. METHODS Before-and-after study design, following a practice intervention to screen all youth in foster care for psychosocial problems using the Strengths and Difficulties Questionnaire (SDQ), a validated instrument with 5 subdomains. After implementation of systematic screening, youth aged 11 to 17 years and their foster parents completed the SDQ at routine health maintenance visits. We assessed feasibility of screening by measuring the completion rates of SDQ by youth and foster parents. We compared the detection of psychosocial problems during a 2-year period before systematic screening to the detection after implementation of systematic screening with the SDQ. We used chart reviews to assess detection at baseline and after implementing systematic screening. RESULTS Altogether, 92% of 212 youth with routine visits that occurred after initiation of screening had a completed SDQ in the medical record, demonstrating high feasibility of systematic screening. Detection of a potential mental health problem was higher in the screening period than baseline period for the entire population (54% vs 27%, P < .001). More than one-fourth of youth had 2 or more significant social-emotional problem domains on the SDQ. CONCLUSIONS Systematic screening for potential social-emotional problems among youth in foster care was feasible within a primary care setting and doubled the detection rate of potential psychosocial problems.

Trends in Child Protection and Out-of-Home Care

BACKGROUND: Over the past decades, increased knowledge about childhood abuse and trauma have prompted changes in child welfare policy, and practice that may have affected the out-of-home (OOH) care population. However, little is known about recent national trends in child maltreatment, OOH placement, or characteristics of children in OOH care. The objective of this study was to examine trends in child maltreatment and characteristics of children in OOH care. METHODS: We analyzed 2 federal administrative databases to identify and characterize US children who were maltreated (National Child Abuse and Neglect Data System) or in OOH care (Adoption and Foster Care Analysis and Reporting System). We assessed trends between 2000 and 2010. RESULTS: The number of suspected maltreatment cases increased 17% from 2000 to 2010, yet the number of substantiated cases decreased 7% and the number of children in OOH care decreased 25%. Despite the decrease in OOH placements, we found a 19% increase in the number of children who entered OOH care because of maltreatment (vs other causes), a 36% increase in the number of children with multiple (vs single) types of maltreatment, and a 60% increase in the number of children in OOH care identified as emotionally disturbed. CONCLUSIONS: From 2000 to 2010, fewer suspected cases of maltreatment were substantiated, despite increased investigations, and fewer maltreated children were placed in OOH care. These changes may have led to a smaller but more complex OOH care population with substantial previous trauma and emotional problems.

Mental Health Treatment Experiences and Expectations in Foster Care: A Qualitative Investigation

This study explores perspectives on mental health treatment experiences and expectations for youth in foster care and their foster parents. In-depth interviews were conducted and identified for major themes: (1) the dual stigma of foster care and mental health care; (2) the lack of engagement in mental health therapy; (3) trust issues with the therapist and other individuals; and (4) the desire to integrate mental health services with primary care services. These results have implications for mental health service delivery and suggest opportunities to improve mental health treatment through an integrated care approach.

Childhood Trauma Management in Primary Care

Heather Forkey, MD, Anne-Marie Conn, PhD, MEd* Foster Children Evaluation Services (FaCES), UMASS Memorial Children’s Medical Center, University of Massachusetts Medical School, 55 Lake Avenue, Worcester, MA 01655, USA; Division of General Pediatrics, Department of Pediatrics, Strong Children’s Research Center, School of Medicine and Dentistry, University of Rochester, University of Rochester Medical Center, 601 Elmwood Avenue, Box 777, Rochester, NY 14642, USA

Parental perspectives of screening for adverse childhood experiences in pediatric primary care

Introduction: Pediatricians recognize a need to mitigate the negative impact that adverse childhood experiences (ACEs) can have on health and development. However, ACEs screening and interventions in primary care pediatrics may be inhibited by concerns about parental perceptions. We assessed parent perspectives of screening for ACEs in the pediatric primary care setting, to understand their views on the potential impact of their ACEs on their parenting and to identify opportunities for pediatric anticipatory guidance. Method: We used purposive sampling to recruit parents of children <6 years receiving care at an urban, pediatric clinic. Semistructured questions guided 1:1 interviews that were later coded by multiple researchers to verify reliability. A thematic framework approach guided analysis and identified main themes and subthemes. Results: We reached thematic saturation after 15 parent interviews, which consistently revealed 3 interrelated themes. First, parents strongly supported ACEs screening as a bridge to needed services, and they recommended using a trauma-sensitive, person-centered approach in pediatric practices. Second, parents understood the intergenerational impact of ACEs and expressed a desire to break the cycle of adversity. Finally, parents saw their child’s pediatrician as a potential change-agent who could provide support to meet their parenting goals. Discussion: Parents want to discuss their ACEs and receive help and guidance from pediatricians. Furthermore, they perceive their child’s pediatrician as having an important role to play in meeting their parenting goals. It is important to ensure that pediatricians have the training, skills and familiarity with available resources to meet parental expectations.