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.
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.
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.
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?
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
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
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
Baseline Demographics
%
n
Race
White
48.6
469
Black
28.1
335
Hispanic
16.3
169
Male
43.0
454
In-home
87.0
777
Medicaid
55.4
682
Age (mean, SD)
12.5 yrs (0.7 yrs)
Baseline Mental Health
Problems
%
n
Internalizing
32.7
309
Externalizing
43.0
456
Total
41.4
442
27.0
268
Clinically significant CBCL (>= 64)
Risky use of substances
Predicting court involvement
between baseline and Wave 3
Externalizing CBCL
Internalizing CBCL
Total CBCL
Risky substance use
In-home
Abuse v. maltreatment
Age (years)
OR
5.8
0.4
1.6
4.2
2.1
1.3
1.8
p-value
< 0.001
> 0.05
> 0.05
< 0.001
> 0.05
> 0.05
< 0.01
* Model also adjusted for gender and race/ethnicity (n=829)
Predicting service use among
adolescents with externalizing CBCL
Mental health
services
OR
p-value
Substance use
services
OR
p-value
Court involvement
3.3
< 0.05
4.0
< 0.05
Medicaid
2.9
> 0.05
1.6
> 0.05
Race/ethnicity
Black
0.3
< 0.05
2.6
> 0.05
Hispanic
Other
0.2
1.2
< 0.05
> 0.05
2.3
6.6
> 0.05
< 0.05
* Model also adjusted for gender, age, substance use, and placement (n=387)
Predicting service use among
adolescents with internalizing CBCL
Mental health
services
OR
p-value
Substance use
services
OR
p-value
Court involvement
Medicaid
5.2
2.5
< 0.05
> 0.05
2.2
1.1
> 0.05
> 0.05
Race/ethnicity
Black
Hispanic
0.1
0.06
< 0.01
< 0.001
0.2
0.9
> 0.05
> 0.05
0.7
> 0.05
1.7
> 0.05
Other
* Model also adjusted for gender, age, substance use, and placement (n=260)
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
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
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
Questions?
Past month drug use at baseline
15
10
1 - 2 days
3 - 11 days
12+ days
5
0
Alcohol
Marijuana Sniffed glue Hard drugs