Developmental Status and Early Intervention Service Needs of Maltreated Children Early Childhood Comprehensive Systems Partners Meeting The Radisson Plaza.

Developmental Status and Early Intervention Service Needs of

Maltreated Children Early Childhood Comprehensive Systems Partners Meeting

The Radisson Plaza Lord Baltimore March 14, 2008

Anita A. Scarborough, University of North CarolinaRichard P. Barth, University of Maryland

E. Christopher Lloyd, University of Arkansas Jan Losby, ISED Solutions

Tammy Mann, ZERO TO THREE

This research was funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, under contract 233-03-0099 to ISED Solutions. Points of view or opinions in this presentation do not necessarily represent the official position or policies of the U.S. DHHS.

Organization of Presentation

1. Data Sources

2. Research Questions

3. Part C Eligibility

4. Findings

5. Areas for Future Research

6. Project Summary

Sources: NSCAW, NEILS, Experts, Literature Review

• NSCAW– National Survey of Child and Adolescent Well-Being, the first national

probability study of children and adolescents investigated by Child Welfare Services (’99 – present)

– Sub-sample of 980 maltreated (substantiated/high risk) children ages birth to thirty-six months

• NEILS– National Early Intervention Longitudinal Study, the first national probability

study of children entering Part C Services (’97-’98-2005)– 3,338 participants, birth to thirty-one months, entering Part C

• Experts– Identified for policy, service, and developmental domains related to Part C services and Child Welfare Services

• Literature Review– Identified and summarized literature addressing developmental risk of

children ages 0 to 3 and Early Intervention services

NEILS & NSCAW Samples

• 3,338 Participants

ages 0-31 months

• Entry to Part C in 1997-1998

• 20 States

• Follow-up every year in Part C, at age 3, & kindergarten school year

• 1,845 Participants ages 0–36 months

• 950 Substantiated or High Risk Participants

• 36 States

• Baseline was 1999-2001

• Follow-up data collection 12, 18, 36 months after baseline

NEILSNEILS NSCAWNSCAW

Both studies are nationally representative of their respective populations when special

analytic methods are employed

Research Questions

• What are the developmental characteristics of infants and toddlers receiving Child Welfare Services?

• What do those characteristics suggest about the need for Part C early intervention services?

• How might these services be best delivered to maltreated children?

Goal: Facilitating CAPTA’s intent by informing the CWS

and Part C communities about the developmental

status of maltreated children

Part C EligibilityFor children with disabilities birth through two years of age –

1. Developmental Delay: Criterion for delay established by individual

states.

2. Conditions of Established Risk: a diagnosed physical or mental

condition having a high probability of resulting in developmental

delay

3. Optional category of “at-risk” of substantial delay if early

intervention is not provided, based on presence of

biological/medical or environmental risksbiological/medical or environmental risks. (4 states recognize

environmental risk)

Finding #1

Children birth to 36 months of age who have been maltreated are at substantial risk of experiencing

developmental problems.

NSCAW Developmental MeasuresCommunication: The Pre-School Language Scales –

3rd Edition. Because of questionable reliability of scores for infants it was used for children 12 months of age and older.

Adaptive Behavior: The daily living skills portion of the Vineland Adaptive Behavior Screener was completed by the caregiver. Because of questionable reliability of scores for infants it was used for children 10 months of age and older.

Cognitive: The cognitive subscale of the Battelle Developmental Inventory. For children 4 years and older, the Kaufman Brief Intelligence Test was used.

*DRIGs = Delay and Risk Indicators Groups (3 mutually exclusive groups)

(1) Measured Delay: – At least 1.5 SD below the mean on any

measure or 1 SD below on any 2, or;– An Established Risk condition associated with

delay & Part C eligible (3%)

(2) High Risk: Five or more risk factors, no measured delay

(3) Lower Risk: Less than five risk factors, no measured delay

* DRIGs were devised and defined for this study.

Defining Risk

Risk Factor %

Maltreatment 100

Poor Parenting Skills 61

Minority Race/Ethnicity 58

Single Caregiver 48

Poverty 46

Domestic Violence 40

Substance Abuse 39

Caregiver MH Problems 30

Low Caregiver Education 29

Biological/Medical Risk 22

Four or More Children 14

Teenaged Caregiver 19

• 56% have 5 or more risk factors

• 82% had at least 4 risk factors

• Virtually all had at least 2 risk factors (99%)

• Maltreatment co-occurs with other problems placing children at-risk for developmental delay & later school difficulties

DRIGs Distribution at Baseline

Half of all infants and toddlers had a low score on a developmental measure

• Measured Delay = 49%

• High Risk = 28% (5 or more risk factors)

• Lower Risk = 23% (< 5 risk factors)

DRIGs by Age at Baseline

0

10

20

30

40

50

60

70

80

0 - 3 Months 4 - 6 Months 7 - 9 Months 10 - 12Months

13 - 24Months

25 - 36Months

Wei

ghed

Per

cent

Measured Delay High Risk Lower Risk

• Percentage with a Measured Delay higher among cases investigated as toddlers

• Percentage with High Risk lower among cases investigated as toddlers

• Children with more risk factors are more likely substantiated at younger ages

Finding #2

Finding #2

Compared to classification at the time of initial contact with child protective services, over time a

higher proportion of children tend to be described as having

fewer risks or having a low score on a developmental measure.

Baseline (0-36 months in age)

Approximately 18 months after Baseline

(18-54 months in age)

Measured Delay(50%)

High Risk

(29%)

Lower Risk (21%)

Measured Delay (49%)

52 31 18

High Risk (28%)

4343 36 22

Lower Risk (23%)

5656 11 33Diagonal = Percent unchanged

DRIGs 18 Months After Baseline• Similar distribution,

however change in classification of individual children:

• Measured Delay: 52% still have a Measured Delay

• High Risk: 36% remain HR, with 43% now with a Measured Delay

• Lower Risk: 33% remain LR, but 56% now with a Measured Delay

Approximately 36 months after Baseline

(3-6 years of age)

18 months after Baseline(18-54 months in age)

Measured Delay(42%)

High Risk

(13%)

Lower Risk

(45%)

Measured Delay (50%)

57 10 33

High Risk (29%)

3737 28 35

Lower Risk (29%)

2222 6 72 Diagonal = Percent unchanged

DRIGs 36 Months After Baseline Compared To 18 Month Follow-up

• 36 months after baseline only 13% High Risk; 42% Measured Delay, 45% Lower Risk

• 72% LR remain the same, 22% now with a Measured Delay

• Only 28% of HR classified the same, 37% now with Measured Delay

DRIGs 36 months After Baseline (at 3-6 years of age)

49

28

23Measured Delay

High Risk

Lower Risk

44% remain in Measured Delay Category

57% remain Lower Risk

23% remain High Risk

Baseline

• Children in the Lower Risk category show more stability in classification

• High risk children tend not to stay there

Cumulative Risk and Measured Delay at Baseline

5

18

44

76

9299

0

10

20

30

40

50

60

70

80

90

100

Up to 2 3 4 5 6 7

Number of risks

Per

cen

tag

e w

ith

mea

sure

d d

elay

At baseline the relationship between risk and measured delay is clear

DRIGs and Child Welfare Placement at Baseline

65

15

21

51

29

20

38

25

37

22

58

20

0

10

20

30

40

50

60

70

Measured Delay High Risk Lower Risk

Perc

ent

In Home no CWS (30%)

In Home CWS (40%)

Foster Care (18%)

Kinship (9%)

• A higher proportion of Measured Delay among children receiving NO ongoing CWS

• Risk is distributed more evenly among placement options

Finding #3

Few infants and toddlers with substantiated cases of

maltreatment are reported to have an established risk

condition (e.g., Down syndrome), as described in IDEA, that would

make them eligible for Part C services.

Eligibility For Part C Services Based On Diagnosis Of An Established Risk Condition

3% of total population; N=50

Birth Defect26%

Epilepsy6%

Cerebral Palsy5%

Spina Bifida5%

Fetal Alcohol Syndrome

23%

Blood Disorder5%

Traumatic Brain Injury18%

Sickle Cell Anemia

12%

Only 3% of young maltreated children are reported to have an Established Risk condition which would make them eligible for Part C services, compared to 38% of children entering Part C.

Finding #4

The proportion of children with a measured delay who have

substantiated maltreatment reports does not differ markedly

from children investigated for maltreatment (but not

substantiated).

Substantiation: A Distinction Without a Developmental Difference?

49

2328

49

34

18

0

10

20

30

40

50

60

Measured Delay High Risk Lower Risk

Perce

nt

Unsubstantiated Substantiated

Identical percentage with a Measured Delay

Higher percentage of Lower Risk cases among unsubstantiated

No statistically significant differences between the groups

Finding #5

Maltreated children between 24 to 36 months of age have relatively high levels of behavior problems

reported by their caregivers.

25

1412

24

11

19

31

18

24

0

10

20

30

40

Baseline 18 Months 36 Months

Perc

ent

Internal (I)External (E)

Any (I or E)

Behavior Problems in Children 2 Years of Age and Older as

Reported by Caregivers

About 70% with a problem at baseline also had problem at 36 month follow-up

Specific interventions needed for these

children and families

Finding #6

A sizeable proportion of substantiated infants and toddlers are

reported to have an Individualized Family Service Plan (IFSP), reflecting

eligibility for Part C services.

Part C - Individualized Family Service Plan (IFSP)

Eligibility for Part C services ends at 36 months of age

28

20

13

29

22

13

20 19

27

0

5

10

15

20

25

30

35

12 months 18 months 36 months

Perc

ent

All ages0-12 mos13-24 mos25-36 mos

• An IFSP is a mandated component of Part C services

• Families participated in Part C voluntarily

• Proportion of children receiving Part C services, as indicated by IFSP, decreases over time

IFSP by Baseline Age at Follow-Ups

Finding #7

Families are receiving parent training and family counseling services through Child Welfare

Services or by referral. It is unclear the extent to which these

services provide interventions focused on enhancing child

development.

Services Received Between Baseline and 18 Months

Parent Training

Family Counseling

Vision Hearing Therapeutic Nursery

Head Start

Age at baseline

% % % % % %

0-12 64 39 18 14 <1 34

13-24 66 51 16 8 <1 50

25-36 67 54 10 6 <1 45

Services Received Between 18 and 36 Months

0-12 14 16 9 15 <1 39

13-24 30 31 13 11 3 56

25-36 9 20 6 6 0 36 

39% - 67% of families

received parent training or family

counseling in the period 18 months after investigation

As children age, fewer children

get family-focused services

Impressions of Experts We Spoke with for this Study

• CWS and Part C personnel agree that many maltreated children need Part C as well as other early intervention services

• Experts believe several obstacles exist to fulfilling vision set forth in CAPTA and IDEA legislation– Policies– Service Delivery– Training & Cooperation

Finding #8

Part C providers may not be familiar with the unique

challenges associated with providing services to maltreated

children and their families.

Impressions of Experts We Spoke with for this Study

• Part C and CWS personnel often have little knowledge of each others’ areas of expertise

• Differing theoretical and service orientations

• Part C provider potential frustration and burnout in working with complex CWS cases

• Service – Need mismatch may result in ineffectual services

• CWS-involved families may be difficult to engage and/or maintain in Part C services– Hostile, overwhelmed, or chaotic families

Finding #9

Increased training and collaboration of Child Welfare

and Part C service providers may be a useful approach to facilitate CAPTA compliance and enhance

developmental outcomes for children.

Impressions of Experts We Spoke with for This Study

• Lack of centralized oversight of both systems’ accountability

• CWS/Part C providers may not be aware of obligations

• Part C referral may not be a priority for CWS• Development of a rapid screening tool for

CWS to use prior to Part C referral to better utilize scarce resources: – For example, in rural areas Part C providers

may need to travel great distances to screen a child who clearly has no developmental problems

Promising Options for Improving Services– Impressions of Experts We Spoke With

• Cross-training workers from CWS and Part C

• Developing multi-disciplinary Part C teams that include a

child welfare worker

• High-level oversight and facilitation of implementation of

CAPTA/IDEA vision

• Increase resources by leveraging other systems (e.g.,

Medicaid, Early Head Start)

• Development of a rapid screener for use by CWS to

determine need for referral

Areas for Future Research

• Intervention. Matching levels and types of services with child and family needs

• Types of families. Understanding characteristics of sub-groups of families who receive Child Welfare and Part C Services

• Substantiation as a criterion for referral. Number of risk factors as an indicator of likelihood for poor developmental outcomes may be a more useful indicator of which children to refer to Part C

• Engaging in intervention. Parent engagement and training approaches employed by Child Welfare Services and Part C may need considerable development

Future Research [continued]

• Best practices on collaboration. Central to effective service delivery is the development of collaborative work models between Child Welfare and Part C

• Funding models and services receipt. Services provided depend on what funding authorities support. Additional research of potential funding sources is needed

• School readiness. Understanding the longer-term developmental implications of early maltreatment and early intervention on children’s development

Project Summary• Based on Measured Delay and/or High Risk, 79% of

CWS investigated children were identified as having a measured delay or high risk status

• High risk children are at higher likelihood for poor developmental outcomes, including school-age problems.

• Those with a low score on a developmental measure are demonstrating an additional marker associated with academic and cognitive difficulties.

• Children with more than 5 recognized risk factors are likely to persist in that category or develop measured delays.

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