Child maltreatment is a broad term that includes neglect, physical abuse, sexual abuse, and emotional abuse; however, the US Department of Health and Human Services reports only on neglect and physical and sexual abuse. In the US, neglect is the most common form of maltreatment (75%), followed by physical abuse (17%), sexual abuse (8.3%), psychological maltreatment (6%), and medical neglect (2.2%).1
The response to a report of alleged maltreatment is set by each state but typically includes an initial screening. When the screen is positive, Protective Services conducts an investigation to determine whether maltreatment occurred or provides an alternative response to identify the needs of the child and family.
The number of children in foster care has declined substantially over the past decade, from about 800,000 in 2005 to roughly 650,000 in 2014 (Figure).2 This trend has been true across most racial and ethnic groups; however, the rate has increased among mixed-race children (Table 1).3 Although the percentage of African American children in foster care has declined substantially, the rate is still about twice the national average. The overall duration of stay in foster care has declined during this period as well. These trends coincide with concerted efforts at the national and state level to increase family preservation services and to achieve permanency.
Mental health disorders of children in foster care
The prevalence of both medical and mental health problems among children in foster care is high. One study of children in foster care aged 2 to 14 years identified nearly 50% with clinically significant mental health problems.4 In a similar study of teenagers, 42% had at least one mental health disorder; of these, nearly one-third had 2 disorders and one-fifth had 3 disorders.5
A number of factors contribute to risk. Children in foster care are more likely to have been exposed to substances in utero, have a higher rate of family psychiatric problems, are more likely to experience substance use in parents and caregivers (2- to 3-fold higher in victimized vs non-victimized children), are less likely to have had consistent prevention and primary care services and, by definition, have experienced one or more instances of maltreatment. The presence of health and mental health challenges can also increase the risk of disrupted foster care placements and poor continuity in health and mental health care, thus compounding the loss and trauma.
CASE VIGNETTE 1
Tony, a 7-year-old boy, is placed in a short-term residential facility for assessment following failure of a foster care placement related to aggression and destructive behavior. From birth until age 6 he was in the care of his birth mother, but protective services were engaged periodically following allegations of neglect. Tony’s father briefly had custody several months before residential placement, but custody was revoked after an allegation of abuse stemming from physical discipline. Tony has been taking stimulant medication for the past 3 years.
While in the assessment facility, Tony demonstrates highly disruptive behavior, including property destruction, physical aggression, and self-injurious behavior. He also makes suicidal and homicidal threats. These behaviors become unmanageable in the residential setting, and Tony is hospitalized.
During admission, the stimulant is discontinued and an alternative stimulant and topiramate are started with Tony’s mother’s consent. On return to the assessment center, behavioral problems continue and after discussion with Tony’s father, clonidine extended- release is added. Tony’s mother objects to this recommendation but chooses not to fight it legally. Within 1 week, Tony is moved to a foster home.
Dr. Scheid is Associate Professor in the department of psychiatry at Michigan State University. She is former President and current Chair of Membership of the Michigan Psychiatric Society. She reports no conflicts of interest concerning the subject matter of this article.
1. US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2014. http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2014. Published January 25, 2016. Accessed May 12, 2016.
2. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Trends in Foster Care and Adoption: FY 2005 – FY 2014. http://www.acf.hhs.gov/sites/default/files/cb/trends_fostercare_adoption2014.pdf. Accessed May 12, 2016.
3. US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Recent Demographic Trends in Foster Care. http://www.acf.hhs.gov/programs/cb/resource/data-brief-trends-in-foster-care-1. Published September 2013. Accessed May 12, 2013.
4. Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry. 2004;43:960-970.
5. Heneghan A, Stein R, Hurlburt MS, et al. Mental health problems in teens investigated by US child welfare agencies. J Adolesc Health. 2013;5:634-640.
6. Government Accountability Office. Foster Children: HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. GAO-12-270T. http://www.gao.gov/products/GAO-12-270T. Published December 1, 2011. Accessed May 12, 2016.
7. Government Accountability Office. Foster Children: HHS Could Provide Additional Guidance to States Regarding Psychotropic Medications. GAO-14-651T. http://www.gao.gov/products/GAO-14-651T. Published May 29, 2014. Accessed May 12, 2016.
8. American Academy of Child and Adolescent Psychiatry. Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline. 2011. https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/FosterCare_BestPrinciples_FINAL.pdf. Accessed May 12, 2016.
9. American Academy of Child and Adolescent Psychiatry. Recommendations About the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems. 2015. https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/AACAP_Psychotropic_Medication_Recommendations_2015_FINAL.pdf. Accessed May 12, 2016.
10. Lee T, Fouras G, Brown R, for the AACAP Committee on Quality of Care Issues. Practice parameter for the assessment and management of youth involved with the child welfare system. J Am Acad Child Adolesc Psychiatry. 2015;54:502-517.