Examining the social, emotional and behavioral needs of youth involved in the child welfare and juvenile justice systems.
Neely-Barnes, Susan ; Whitted, Katheryn
INTRODUCTION
In the United States, one in five youth has a mental, emotional, or
behavioral disorder and one in ten has impairment of functioning at
home, school or in the community (National Council for Community
Behavioral Healthcare, 2009). In the child welfare and juvenile justice
systems, prevalence rates of mental, emotional, and behavioral disorders
are higher with some studies indicating that rates may exceed fifty
percent (Burns, Phillips, Wagner, Barth, Kolko, Campbell, &
Yandsverk, 2004; dosReis, Zito, Safer & Soeken, 2001; Teplin, Abram,
McClelland, Dulcan, Mericle, 2002). Yet, there is still much to be
learned about the mental health needs of youth in care. The Center for
Mental Health in Schools at UCLA (2008) asserts that available
information on prevalence and incidence of mental health and treatment
services varies in both quantity and quality and there is a need for
improved surveillance of children's mental health. The current
study seeks to build upon prior work using secondary data analysis from
a non-profit agency that provides comprehensive services to youth
involved in the child welfare and juvenile justice systems. It
investigates the extent to which youth who were placed in out-of-home
care (or at risk of being placed in care) reported having problems with
peers, symptoms associated with Attention Deficit Hyperactivity Disorder
(ADHD), conduct problems and emotional problems. This study examines how
these difficulties in each problem domain vary by age group, race, and
gender.
Similarities among Youth in the Child Welfare and Juvenile Justice
Systems
Historically, the juvenile justice and child welfare systems have
been examined independently; however, in recent years attention has been
directed at the similarities among youth involved in the child welfare
and juvenile justice systems. Leone and Weinberg (2010) explain that
although youth initially come to the attention of the Department of
Children's Services for different reasons either due to abuse and
neglect or because they have committed delinquent acts, they often have
similar needs and experiences. For example, the majority of youth who
enter the child welfare system, and many of the youth who are involved
in the juvenile justice system have experienced abuse and neglect,
dysfunctional home environments, destructive and inconsistent parenting
practices, poverty, emotional and behavioral disorders, poor mental and
physical health care, poor family-school relationships, exposure to
deviant peers as well as community and societal problems that have
contributed to their entry into the child welfare and juvenile justice
systems (Derzon & Lipsey, 2000; Leone & Weinberg 2010; Wasserman
& Seracini, 2001).
A number of youth, in both the child welfare system and the
juvenile justice systems, are placed in treatment settings away from
their families. When youth are removed from their homes, they often
experience multiple losses (i.e., family, friends, school, neighborhood,
favorite possessions). Loss of the youth's primary caregiver can be
detrimental to the youth's social-emotional development and mental
health (American Academy of Pediatrics, 2000).
Youth in both systems have more mental health problems than youth
in the general population and their mental health needs often go
undetected and unaddressed (Halfon, Berkowitz, & Klee, 1992; Mears,
2001; National Justice Network, 2009). It has been estimated that
between 50% and 80% of youth involved in the child welfare system suffer
from moderate to severe mental health problems (dosReis et al., 2001;
Halfon, Mendonca, & Berkowitz, 1995; Shufelt & Cocozza, 2006).
Many of these youth involved in the juvenile justice system have one or
more mental health disorders (Shufelt & Cocozza, 2006). Shufelt and
Cocozza (2006) found that among youth in the juvenile justice system, as
many as 70% had a diagnosable mental health disorder; and, of the youth
who met the diagnosis for a mental disorder, 79% of youth met criteria
for two or more diagnoses, and over 60% of these youth were diagnosed
with three or more mental health disorders.
Placement Decisions and the Provision of Mental Health Services
While the mental health needs of youth in both the juvenile justice
system and the child welfare systems may be very similar, the court
system that the youth is adjudicated through often influences the type
of treatment services that the youth is provided. Placement options for
youth in state custody included foster care home, group homes,
residential treatment facilities, boot camps, psychiatric hospitals, and
detention facilities (Livsey, Sickmund, & Sladky, 2009). These
placement settings vary markedly in terms of the quality and quantity of
mental health services provided (Center for Mental Health in Schools at
UCLA, 2008).
Youth can be placed in the custody of the state for one of three
legal reasons: neglect and dependency (including abuse),
"unruly" (non-criminal) behavior, delinquency (criminal)
behavior, or mental illness (Glisson, 1996, p. 258). Glisson (1996)
explains that although, traditionally, most children who have been
abused or neglected are adjudicated through the child welfare system, in
some states, the child welfare system also assumes responsibility of the
majority of unruly cases. The majority of youth who have committed a
delinquent act are adjudicated through the juvenile justice system.
There are also a number of youth who are dually involved in both
the juvenile justice and child welfare system. There are three different
ways that youth become dually involved in both systems: 1) youth enter
the child welfare system due to abuse or neglect and then go on to
commit a delinquent act which brings them into contact with the juvenile
justice system; 2) youth initially enter the juvenile justice system
because they committed a delinquent act and the youth later discloses
abuse and neglect; or 3) the youth was adjudicated through the juvenile
justice system and upon being dismissed from state custody, the
youth's family is unable or unwilling to welcome the youth back
home upon being released from a residential treatment facility. The way
that courts handle dually involved youth varies from state to state.
When a child becomes known to multiple agencies, jurisdiction can be
assigned in a number of ways: 'concurrent,' where both
agencies retain responsibility for the youth; 'on hold,' where
the juvenile justice agency temporarily assumes responsibility for the
youth; or 'transfer,' were a child welfare case is closed when
a youth is adjudicated as delinquent (Bilchik & Nash, 2008).
Although placement processes vary, there is clear evidence that
both systems fail to address the mental health needs of the youth who
are in the state's care and custody. In fact, research suggests
that placement decisions are based on factors other than mental health
needs of youth and that placement decisions are better explained by
racial and gender biases in the system (Dembo, Turner, Borden, &
Schmeidler, 1994; Glisson, 1996). This is particularly disturbing
because research suggests that some types of out-of-home placement
facilities are not sensitive to the needs of girls or of minority
populations. In fact, there has been some research that suggests
detention and residential treatment facilities adversely impact the
mental health of girls (Hipwell & Loeber, 2006; Snyder &
Sickmund, 2006) and minority populations (Curtis, Dale, & Kendall,
1999).
While the provision of services is complex and varies widely among
states, the literature suggests that from a clinical standpoint, the
needs of youth in state custody are very similar--regardless of whether
the youth have been referred for behavioral health services through the
child welfare or the juvenile justice system (Leone & Weinberg,
2010). In an effort to better meet the mental health needs of youth in
custody, many states have restructured their service delivery system and
now have an integrated service delivery system which has been designed
to better meet the needs of youth. Models of integrated service delivery
systems provide the youth and their families with opportunities to
utilize resources from both systems and decrease duplication of services
that are costly and ineffective (Leone & Weinberg, 2010). For
example, Tennessee now requires all provider agencies to offer a
continuum of services in effort to better meet the individual mental
health needs of each youth.
The agency that supplied the data for this study serves youth who
have been referred both through the juvenile justice system and the
child welfare system and provides a continuum of services, including
residential treatment, community-based group homes, treatment foster
care, and intensive in-home services to youth with emotional and
behavioral problems. Although these initiatives have encouraged
collaboration and have brought attention to the issue, additional
research needs to be conducted in order to more fully understand the
mental health needs of youth involved in the child welfare and juvenile
justice systems.
PURPOSE
This study aims to provide further information about the prevalence
of mental health problems among one of America's most vulnerable
populations, adolescents who are placed (or at-risk of being placed) in
state custody. Specifically, this study: 1) examines the prevalence of
social, emotional and behavioral problems among youth who were either
living in out-of-home placements or who were considered to be at high
risk of being placed in an out of-home placement and, 2) examines how
youths' mental health problems may differ when demographic
characteristics such as race, gender and age group comparisons are
examined. The purpose of this study is to address the following four
questions: 1) To what extent do youth living in out-of-home placements
report that they have social, emotional or behavioral problems? 2) How
do the social, emotional and behavioral problems of youth living in
out-of-home placements differ among boys and girls? 3) How do the
social, emotional and behavioral problems of youth living in out-of-home
placements differ among African Americans, Latino, and White youth? 4)
How do the social, emotional and behavioral problems of youth living in
out-of-home placements differ across developmental age groups?
METHODS AND DATA
Data Source
The majority of the youth served by this agency were referred by
the Department of Children Services (DCS), which serves children who
have been committed to DCS by the juvenile courts for delinquent
offenses and children who have been referred by the division of
protection and permanency (more commonly known as the Child Welfare
System). The agency that provided the data for this study aims to meet
the unique needs of youth who have been referred for behavioral health
services by providing a continuum of services ranging from intensive
in-home services to locked residential facilities. Participants in this
study were referred from both the juvenile justice and the child welfare
systems and consisted of youth who were living in residential treatment
facilities, group homes, foster homes or were receiving intensive
home-based services. Youth involved in home-based services were
considered to be at high-risk for becoming involved with the foster care
and juvenile justice systems; therefore, they were included in the
study.
Data were collected in 2009 from a large non-profit agency in the
Southeastern United States that serves the behavioral health needs of
youth referred by the juvenile justice and child welfare services. Data
from the provider agency's 2009 program report showed that the
population served consisted of approximately 59% male youth and 41%
female youth. Among the youth served, 42% were African American, 51%
were White, 3% were Latino (4.0% were of another race). Youth served by
the agency's programs ranged in age from birth to late adolescence.
As shown in Table 1, the sample included in this study reflects the
demographic makeup of the agency in terms of race and gender.
Procedure
This study was approved by the University of Memphis Institutional
Review Board. The reported findings were based on data from 2,575 youth
who were provided behavioral health care services at a large nonprofit
agency between 2007 and 2009. Data for this study were extracted from
the agency's electronic medical record database system. In addition
to demographic information, data from clinical assessments were stored
in the system. The Strengths and Difficulties Questionnaire was used to
screen for mental health problems and to track behavioral and emotional
difficulties overtime with planned data collection points in the future
at 6 months post admission, discharge, and 12 months post discharge.
The Strengths and Difficulties Questionnaire was administered to
caregivers of youth who were between the ages of 3 years old and 19
years old and who entered services during the 2007-2009 calendar years;
youth 11 years of age and older also completed a self-report version of
the instrument. The youth's case manager was responsible for
presenting the survey to the parent (or a caretaker of the youth) and
the youth. Whenever possible, the survey was completed by the
youth's biological parent. However, when a biological parent was
not able to or willing to complete the questionnaire, the questionnaire
was completed by the youth's foster parent or case manager.
This study was limited to analysis of questionnaires that were
completed by the youth at the time of admission into the agency between
January 5, 2007 and October 22, 2009 (n =2,600). Youth younger than 11
years of age (n = 23), youth who did not report their age (n = 2) were
omitted from the study. The resulting data set consisted of only
self-reported questionnaires, completed by youth, age 11 and older,
during the admissions process (n = 2,575). The 2,575 youth in the sample
were from 10 states: Alabama, Arkansas, Florida, Georgia, Massachusetts,
Mississippi, North Carolina, Tennessee, Texas, Virginia, and the
District of Columbia. As shown in Table 1, the sample consisted of 61.2%
male youth and 38.8% female youth. They represented a diverse racial and
ethnic mix: 38.2% African American, 58.2% White, 2.9% Latino; and 0.6%
of the respondents selected "other" (1.7% of the respondents
did not report their race). The ages of the youth at the time of
admission, who were included in this study, ranged from 11 years to 19
years of age (see Table 1).
Instrument
The Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997)
was used in this study. The SDQ is a brief behavioral screening
questionnaire for children and adolescents. The SDQ gives reliable
information about a youth's emotional health, conduct problems,
hyperactivity, peer relationship problems and prosocial behavior. The
questionnaire consists of 25 items, some positive and others negative.
The 25 items are divided among five scales of 5 items each, generalizing
scores for conduct problems, hyperactivity, emotional symptoms, peer
problems and prosocial behavior. Because the prosocial scale is not
included in the scoring algorithm for the questionnaire, analysis was
not conducted for the prosocial scale. The scale items were selected on
the basis of the diagnostic categories of the DSM-IV and ICD-10 (Mark
& Buck, 2006). The questionnaire has several forms, including: a
parent-report form, a teacher-report form and a self-report form for
youth ages 11-16. The youth self-report form was used in this study.
While the SDQ was designed and validated for youngsters (11-16 years),
it has also been used for older youths (Van Roy, Groholt, Heyerdahl,
& Clench-Aas, 2006). The present study included youth ages 11-19.
The total difficulty score is generated by summing the scores from
all of the subscales. The resultant score can range from 0-40. Scores
0-15 are considered normal, scores 16-19 are considered to be in the
borderline range and scores 20-40 are considered abnormal. The items on
the subscales are scored to generate each individual subscale score.
Subscale scores can range from 0-10. Scores above Goodman's cut
point are considered to be in the borderline or abnormal range. The cut
point score for the emotional and hyperactivity subscales is 6. Cut
points for the conduct and peer problems subscales are 4. The individual
items can be accessed at: http://www.sdqinfo.com/ScoreSheets/e2.pdf
The SDQ has been widely used in a number of countries. The SDQ is
available in 40 languages, has normative data from diverse countries
including the United States and is available free of charge from the
Internet (see http://www.sdqinfo.com). The SDQ has been used in several
national studies, including the British Child and Adolescent Mental
Health Survey (Goodman, 2001), the U.S. National Health Interview Survey
(NHIS) (Bourdon, Goodman, Rae, Simpson & Koretz, 2005), and a large
Norwegian epidemiological study (Van Roy, et al., 2006). Each of these
studies included samples of over 10,000 youth and concluded that the SDQ
was a useful and reliable assessment and screening instrument. The
psychometric properties of the SQD were also confirmed by a number of
other studies, primarily among British populations. However, studies
from a number of other countries that have examined the psychometric
properties of the SDQ include: Sweden, Finland, Bangladesh, Australia,
New Zealand and the United States. An extensive list of studies that
have examined the psychometric properties of the SDQ can be found on the
following website: http://www.sdqinfo.com/b7.html
Statistical Analysis
Data were analyzed in SPSS version 15.0. Descriptive statistics
were examined and are reported in Tables 1 and 2. To assess age groups
comparisons, the youth were divided into two groups, those under age 15
and those who were 15 years old and older. Fifteen was selected as the
cutoff, because youth between the ages of 12-14 are considered to be in
their early adolescent stage of development and those between the ages
of 15-17 are considered to be in late adolescence (Center for Disease
Control, 2005).
T-tests and ANOVAs were examined to understand the bivariate
relationships between independent variables and the SDQ subscales and
total difficulties scale. Findings of the bivariate analyses were used
to determine which variables would be tested in the multivariate
analyses.
A three-way multivariate analysis of variance (MANOVA) was used to
assess whether the level of each of the four subscale scores (emotional
symptoms, conduct problems, hyperactivity, peer problems) differed by
gender, race, or age. Interaction effects between the three factors were
also examined: 1) gender and race; 2) gender and age; and 3) race and
age. A MANOVA was determined to be the most appropriate choice for this
analysis. The MANOVA takes into account the correlations between the
dependent variables and allows for the comparison of group differences,
the focus of our research questions. A Scheffe test was used for post
hoc comparisons. Significance levels were determined to be equal to or
less than 0.05. A three-way analysis of variance (ANOVA) was used to
test whether total difficulties score on the SDQ differed by gender,
race, or age. Again, interaction effects for these three independent
variables were tested: 1) gender and race, 2) gender and age, and 3)
race and age. Three-way factorial ANOVA was chosen for this analysis
because we had a limited number of independent variables that were all
categorical.
RESULTS
Frequencies/cut point
Among the youth in this study, 49.4% had total difficulty scores in
the borderline or abnormal range (a score of 16 or greater) according to
Goodman's cut point. Over 75% of the youth (n = 1,977) had scores
above the cut point on at least one of the subscales indicating scores
in the borderline or abnormal range. The most frequently observed
problem domain was the conduct subscale in which over 50% of the youth
had scores equal to or greater than 4, Goodman's cut point. In
addition, over 35% of the youth reported having scores that were in the
borderline or abnormal range on the hyperactivity subscale (a score
equal to or greater than 6) and on the peer problems subscale (scores
equal to or greater than 4). Almost 25% of the youth reported symptoms
of emotional problems in the borderline or abnormal range (scores equal
to or greater than 4). Means and standard deviations for the SDQ
subscales and total scale by race, gender, and age group are reported in
Table 2.
Results of the three-way MANOVA indicated that there were
significant differences between boys and girls on the emotional subscale
with girls having higher scores than boys (F (1, 2505) = 30.29, p <
.001) (see Tables 2 & 3). Significant differences among racial
groups were found on three of the four subscales: emotional (F (2, 2505)
= 20.54, p < .001), conduct (F (2, 2505) = 5.70, p = .003) and
hyperactivity (F (2, 2505) = 42.96, p < .001). Post-hoc tests
indicated that White youth had significantly higher scores than African
American and Latino youth on the emotional and hyperactivity subscales.
White youth had significantly higher scores than African American youth
on the conduct subscale.
Significant differences among age groups were also found on three
of the four subscales: emotional (F (1, 2505) = 7.42, p = .01), conduct
(F (1, 2505) = 5.53, p = .02) and hyperactivity (F (1, 2505) = 14.12, p
< .001) with younger youth having higher scores on each subscale.
Analysis of interaction effects found two significant interaction
effects. On the emotional difficulties subscale the interaction between
gender and age was significant (F (1, 2505) = .6.20, p = .013) with
emotional scores decreasing for boys as they aged but remaining stable
for girls (see Figure 1). On the peer problems subscale, there was a
significant interaction between race and age (F (2, 2505) = 3.269, p =
.003). Scores decreased with age for White and Latino youth but
increased with age for African American youth (See Figure 2).
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
Results of the three-way ANOVA indicated that there were
significant main effects for age (F (1, 2505) = 12.44, p = 01), race (F
(2, 2505) = 26.79, p < .001) and gender (F (1, 2505) = 8.09, p = 004)
on the total difficulties score. Girls had higher scores than boys,
younger youth had higher scores than older youth, and White youth had
higher scores than Latino or African American youth. No significant
interaction effects were found on the total difficulties score.
DISCUSSION
Consistent with other research, our study found that the mental
health needs of youth involved in the child welfare and juvenile systems
were astonishingly high.
Approximately 10% of the general population of youth have scores
above the determined cutoff points (see http://www.sdqinfo.com/b4.html)
on the SDQ. The present study found that upon admission to a behavioral
health service provider agency, almost half of the youth reported a
total difficulty score that was in the borderline or abnormal range
(49.36% scored above Goodman's cut point). Over 0% of these youth
had conduct problems in the borderline or abnormal range and more than
35% had hyperactivity and peer problems subscale scores in the
borderline or abnormal range. We also found that there were significant
differences in the psychological, social and behavioral needs of
adolescents of different ages, gender and racial groups and will discuss
the implications of each of these differences.
Gender Differences
The findings in the present study were consistent with other
research that suggested that the mental health needs of females differ
from males (see National Justice Network, 2009). There were significant
differences among boys and girls on the total difficulties score and on
the emotional problems subscale, with girls having reported higher
scores on the total difficulties scale and on the emotional subscale;
there was not a significant difference between boys and girls scores on
the conduct, hyperactivity, or peer problems subscales. In addition,
there was an interaction effect between age and gender suggesting, that
unlike boys, the emotional difficulties of girls do not diminish as they
age.
The difference on the emotional subscale was expected since prior
research studies have found that girls tended to exhibit more
internalizing behaviors than boys (Espelage, Cauffman, Broidy,
Mazerolle, Piquero, & Steiner, 2003; Wasserman, McReynolds, Ko,
Katz, & Carpenter, 2005). In a study of 141 serious juvenile
offenders in the state of California, Espelage and colleagues (2003)
found that female offenders exhibited more acute mental health symptoms
and psychological disturbances than males. Results from the current
study indicated that girls reported internalizing behavior problems at
almost twice the rate of males. In fact, over 30% of the girls in this
study reported emotional problems in the borderline or clinical range.
While these findings are not surprising, they confirm that there are
distinct differences in how males and females respond to abuse, neglect
and trauma. These findings suggest that professionals who work with
girls who have been referred for behavioral health services need to
recognize these differences and ensure that both the internalizing and
externalizing behaviors are assessed and addressed and that these risk
factors continue as girls age.
Although the mean scores on the conduct subscale in the present
study were not statistically different among female and male youth,
these findings were disconcerting because the findings indicated that
female youth had comparable rates of conduct problems as their male
peers. While these findings were similar to other studies that suggest
the rates of externalizing problems among boys and girls are similar
(Shufelt & Cocozza, 2006; Wasserman et al., 2005), these findings
are particularly problematic since other research studies suggest that
girls who meet the criteria for conduct disorder are at greater risk for
developing severe psychopathology than boys who meet the criteria for
conduct disorder (see Veysey, 2003). Furthermore, Veysey emphasizes that
the long-term prognosis for girls with antisocial behavior who do not
receive treatment is bleak (2003). In an extensive review of the
literature Pajer (1998) found that the outcomes for girls with either
conduct disorder or delinquency had increased rates of criminality,
psychiatric morbidity, dysfunctional and violent relationships and
service utilization. Clearly, this findings warrant additional attention
in the research literature.
Although the mean scores on the ADHD subscale in the present study
were not statistically different among female and male youth, this
finding is interesting because it suggests that female youth in this
study report similar rates of ADHD symptoms as their male peers. This
finding was unexpected, first because in the general population, boys
are twice as likely to be diagnosed with ADHD compared to girls (Center
for Disease Control and Prevention, 2007). Secondly, the findings from
our study were exceptionally high when compared to findings from the
NHIS. The NHIS study used SDQ to assess ADHD symptoms among 10,367
children ages 4 to 17 and found the prevalence of clinically significant
SDQ ADHD symptoms was 4.19% among male youth and 1.77% among female
youth (Cuffe, Moore, & McKeown, 2005). While a number of these
studies suggest that boys are far more likely to be diagnosed as having
ADHD than girls, other research has pointed to the increasing rates of
ADHD diagnosis among girls (Robinson, Skaer, Sclar and Galin, 2002).
These authors attributed the increase in the diagnosis of ADHD among
girls to greater physician and public awareness of this condition. The
high prevalence of ADHD symptoms among girls in this study is important
because the research literature suggest that girls with ADHD are at
higher risk for a number of life long pathological problems including
antisocial, addictive, mood, anxiety, and eating disorders (Biederman,
Petty, Monuteaux, Fried, Byrne, Mirto, Spencer, Wilens, & Faraone,
2010; Hinshaw, Owens, Sami, & Fargeon, 2006). These findings point
to the need to better understand why the prevalence of ADHD symptoms is
so high among female youth who are involved in the child welfare and
juvenile justice systems and to implement intervention efforts
specifically designed for girls.
Racial/Ethnic Differences
The differences between racial groups on the total difficulty scale
and three of the four subscale scores was also an interesting finding.
In the present study, Whites had higher mean scores than African
American youth on the total difficulties scale and on three of the
subscales (with the exception of the peer problems subscale, which was
not statistically significant). These finding differed from data from
the 2001-2003 NHIS which found no difference in parent reports of severe
difficulties between Non-Hispanic black children and non-Hispanic white
children (Pastor, Reuben, & Falkenstem, 2006). Furthermore, a number
of studies have suggested that African American youth are more likely to
be removed from their home than White youth who exhibit similar behavior
problems (Poe-Yamagata & Jones, 2000; Pope, Lovell, & Hsia,
2002; Whaley, 1998). These findings suggest that White youth must
exhibit more severe behavioral problems before they are placed in
out-of-home care. It is also important to note that these differences
were reported during the admission process. This is significant because
a previous study has suggested that the mental health outcomes of
African American youth worsen as a result of being in foster care
(Curtis et al., 1999). Curtis et al., (1999) found that African American
youth have fewer mental health problems when they enter foster care than
when they leave foster care. Furthermore, Glisson (1996) found that
White youth are more likely to receive mental health services than
African American youth and factors associated with the referral were not
related to the severity of mental health needs, but to a lack of
services and resources.
White youth had higher scores than Latino youth on the emotional
and hyperactivity subscales as well as on the total difficulty score.
These findings were consistent findings from 2001 -2003 NHIS data which
found that the parents of Hispanic youth reported that their child had
less difficulties overall (i.e., conduct problems, emotional problems,
ADHD symptoms, peer problems) than non-Hispanic white or non-Hispanic
black children (Pastor et al., 2006; Simpson, Bloom, Cohen, &
Blumberg, 2005). In regard to ADHD symptoms, NHIS data indicated among
youth in the general population, 7.4% of White youth were reported by
their parents to have ADHD symptoms while only 5.1% of Hispanic or
Latino parents reported that their children had symptoms of ADHD (Bloom
& Cohen, 2007).
There was a significant interaction effect between race and age for
peer problems. Peer problems improved for White and Latino youth as they
aged but worsened for African American youth. The finding suggests that
African American youth involved in the child welfare system may be
especially at-risk for developing more chronic and severe social,
emotional and behavioral difficulties that interfere with their ability
to relate to others. Clearly, African American youth need to be
evaluated and receive services for the social, emotional and behavioral
difficulties early on, before their difficulties worsen. Together, these
research findings point to the need for additional research that would
help us to better understand how the assessment, intervention and
treatment needs may differ among youth of different racial and ethnic
backgrounds.
Age Group Differences
The present study indicated that the behavioral, social and
emotional needs of youth during their early adolescence were
particularly high. The younger youth in this study had more difficulty
in all of the problem domains (conduct, emotional difficulties,
hyperactivity), with the exception of peer problems, in which the
differences were not statistically significant. Among youth under age
15, slightly more than half of the youth in this study had a difficulty
score above Goodman's cut point. These findings suggest further
research is needed to explore why these differences exist and whether
prevention efforts can be utilized to target youth in their
pre-adolescent and early adolescent development. These findings were
contrary to NHIS data from 2001-2003 which found that youth between the
ages of 11-14 years were less likely to experience difficulties in
emotions, concentration, behavior, or being able to get along with
others problems than youth between the ages of 15-17 years (4.9% vs.
6.1% respectively) (Simpson et al., 2005). There is a substantial body
of research that suggests the youth's mental health difficulties
are most amenable to change if they are addressed early on. These
findings suggest that among youth in custody, many youth have social,
emotional and behavioral problems that need to be assessed and addressed
early on, before behaviors become entrenched and more severe.
LIMITATIONS
Although this study included a large sample of youth from several
states, several limitations should be noted. First, the behavioral
difficulties were self reported by the youth and no independent
assessment was provided. Therefore, it is possible that youth
over-reported or underreported their social, emotional, or behavioral
difficulties. However, previous research using the SDQ has indicated
relatively good reliability and validity of the self-report version of
this instrument (Goodman, 2001).
Second, the participants in this study consisted of youth who were
referred for behavioral health services and consisted of youth who were
referred through both the child welfare and the juvenile justice
systems. Because many of the children who were referred by DCS are
involved in both the juvenile justice and the child welfare systems and
many youth transition between these two systems, the agency was not able
to provide data that would allow for the analysis of these two groups
independently. Therefore, it was not possible to separate these two
groups and analyze the data based on the specific service delivery
system. However, since many of the youth involved in this study
transition between the juvenile justice and the child welfare system and
the characteristics and the needs of these children are similar, this
type of analysis was not deemed imperative to the purpose of this study.
It is important to note that nationally, it is common for state child
welfare and juvenile justice agencies to refer children and youth to
private agencies for care, protection, behavioral health treatment, and
rehabilitation services. In fact, nationally, nearly one-third of
juvenile offenders are held in privately operated facilities (Snyder
& Sickmund, 2006).
Third, this study consisted of youth who were receiving services in
treatment foster care homes, residential treatment facilities, group
homes and in-home services. There was no attempt to examine the
behavioral or social emotional differences that likely existed among
youth who received services from different types of treatment programs
(i.e., foster care, group home, residential, home-based services). The
findings in this study are not reflective of the general population and
efforts to make generalizations to youth receiving services through
other provider agencies should be carefully considered.
Finally, this study did not investigate the historical data of the
youth or important demographic information about the youth's family
of origin (marital status of the biological parents, socioeconomic
status of the biological parents, whether the youth's biological
parents had legal custody of their child) nor was the youth's
service history examined. For example, the number of times the youth had
previously been in foster care, whether the youth had received mental
health services in the past and the reason for the referral to the
provider agency was not included in the statistical analysis. Since a
substantial body of research demonstrated that cumulative risk factors
were correlated with social, emotional and behavioral functioning, it is
likely that youth who have a history that includes a number of risk
factors would likely have resulted in these youth having higher scores
on the SDQ. However, no statistical analysis was employed to test these
assumptions.
CONCLUSION
The results of the present study point to the high prevalence of
social, emotional and behavioral problems among youth who have come to
the attention of the child welfare and the juvenile justice systems.
This study suggests that significant differences exist among the
youths' demographic variables and social, emotional and behavioral
problems. Clinicians and other service providers need to be aware of how
the mental health needs of youth may present differently among males and
females, among different racial and ethnic groups and among youth in
different developmental age groups. While a number of limitations exist
in the present study, new information was generated regarding the
relationship between demographics and mental health service needs.
Actively pursuing needed services for youth involved in the child
welfare and juvenile justice systems may prevent future costs associated
with juvenile and criminal activity, mental illness, substance abuse and
domestic violence. Future research needs to be initiated to examine
factors that contribute best to favorable treatment outcomes and to
address whether the youth's behaviors are negatively or positively
impacted by the services they receive while in residential and treatment
foster care placements. With better information, both juvenile justice
and child welfare agencies can better assess and design interventions
that will more effectively meet the needs of youth who are in the care
and custody of the state. Future research is also needed in order to
better understand how emotional difficulties, conduct, peer problems,
and hyperactivity change over time spent in the service system and
whether these patterns of change differ by race/ethnicity, age, or
gender.
The use of assessment tools, such as the SDQ, can help to identify
the mental health needs of youth and reduce biases in the treatment of
mental health needs and to ensure that the unique needs of each child
are identified and interventions are developmentally and, culturally
appropriate. Additional research studies need to be initiated in order
to improve our understanding of how the symptoms of social, emotional
and behavioral problems differ among youth of different races, genders
and ages. This information is needed to better inform intervention and
prevention efforts aimed at reducing both the shortterm and long-term
social, emotional and behavioral problems of youth involved in the child
welfare and juvenile justice systems. Hopefully, with a better
understanding of the mental health needs of youth who are involved in
these two systems, intervention and prevention efforts can be developed
that effectively meet the needs of this vulnerable population of youth.
ACKNOWLEDGEMENTS
We thank Youth Villages for providing the data for this study. We
would also like to thank Sarah Hurley for her assistance in reviewing
data sources and for helping us to better understand the treatment needs
and placement decisions among youth with serious emotional disturbances.
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SUSAN NEELY-BARNES
KATHERYN WHITTED
University of Memphis
Table 1.
Sample Demographics
Race Male (%) Female (%) Total (%)
African American 23.9 14.3 38.2
White 35.0 23.2 58.2
Latino 1.9 0.9 2.9
Other 0.3 0.4 0.6
Total (n = 2,531) 61.2 38.8 100
Table 2.
Subscale and Total SDQ Mean Scores by Gender, Race,
and Age Group
Emotional Conduct Hyperactivity
Cut 6 4 6
point
Gender
Males 3.19 (2.42) 3.86 (2.21) 4.91 (2.49)
(n=1541)
Females 4.41 (2.55) 3.82 (2.17) 4.83 (1.90)
(n=974)
Race
African- 3.26 (2.44) 3.64 (2.13) 4.38 (2.43)
Amer.
(n=968)
Latino 3.12 (2.37) 3.49 (2.06) 4.63 (2.05)
(n=73)
White 3.96 (2.59) 3.99 (2.23) 5.41 (2.42)
(n=1474)
Age
Group
Under 15 3.81 (2.53) 4.11 (2.22) 5.26 (2.52)
years
(n=1129)
15 years 3.55 (2.55) 3.63 (2.15) 4.77 (2.39)
and up
(n=1386)
Total 3.66 (2.55) 3.84 (2.19) 4.99 (2.46)
Peer
Problems Total SDQ
Cut 4 16
point
Gender
Males 2.96 (1.96) 14.99 (6.48)
(n=1541)
Females 2.92 (2.00) 16.24 (6.40)
(n=974)
Race
African- 2.91 (1.85) 14.19 (6.23)
Amer.
(n=968)
Latino 2.85 (1.95) 14.07 (5.30)
(n=73)
White 2.97 (2.06) 16.32 (6.55)
(n=1474)
Age
Group
Under 15 2.99 (1.99) 16.15 (6.66)
years
(n=1129)
15 years 2.91 (1.96) 14.84 (6.28)
and up
(n=1386)
Total 2.95 (1.98) 15.43 (6.48)
Table 3
Three-way MANOVA of SDQ Subscales
Emotional Conduct
F df P F df p
Corrected Model 23.65 9 <.001 5.832 9 <.001
Intercept 1140.32 1 <.001 1535.39 1 <.001
Gender 30.29 1 <.001 .39 1 .53
Race 20.54 (a) 2 <.001 5.70 (b) 2 .003
Age 7.42 1 .01 5.53 1 .02
Gender*race .05 2 .95 2.32 2 .10
Gender*age 6.20 1 .01 1.03 1 .31
Race*Age 2.02 2 .13 .36 2 .70
Hyperactivity Peer Problems
F df p F df p
Corrected Model 15.638 9 <.001 1.28 9 .24
Intercept 2132.06 1 <.001 1135.33 1 <.001
Gender .91 1 .34 .24 1 .62
Race 42.96 (a) 2 <.001 .19 2 .83
Age 14.12 1 <.001 .69 1 .41
Gender*race 1.80 2 .17 1.28 2 .28
Gender*age .13 1 .72 .02 1 .89
Race*Age 1.66 2 .19 3.27 2 .04
Totsl SDQ
Corrected Model F df p
Intercept 13.87 9 <.001
Gender 2960.38 1 <.001
Race 8.01 1 .004
Age 26.79 (a) 2 <.001
Gender*race 12.44 1 .01
Gender*age 1.64 2 .19
Race*Age .54 1 .46
(a) The White youth had significantly higher scores than the
African-American and Latino youth. (b) The White youth had
significantly higher scores than the African-American
youth.
