摘要：Objectives. We sought to examine the extent to which children in the child welfare system receive mental health care consistent with national standards. Methods. We used data from 4 waves (3 years of follow-up) of the National Survey of Child and Adolescent Well-Being, the nation's first longitudinal study of children in the child welfare system, and the Area Resource File to examine rates of screening, assessment, and referral to mental health services among 3802 youths presenting to child welfare agencies. Weighted population-averaged logistic regression models were used to identify variables associated with standards-consistent care. Results. Only half of all children in the sample received care consistent with any 1 national standard, and less than one tenth received care consistent with all of them. Older children, those exhibiting externalizing behaviors, and those placed in foster care had, on average, higher odds of receiving care consistent with national standards. Conclusions. Adverse consequences of childhood disadvantage cannot be reduced unless greater collaboration occurs between child welfare and mental health agencies. Current changes to Medicaid regulations that weaken entitlements to screening and assessment may also worsen mental health disparities among these vulnerable children. Ensuring that children in the child welfare system receive high-quality mental health services has been a policy priority for the past 2 decades, and professional organizations have proposed standards of care specifically tailored for this population. However, there is no information on the extent to which children in the child welfare system actually receive care that is consistent with these national standards. Attention to standards-consistent mental health care is important because children in the child welfare system have very high needs for mental health services. Nearly half of all children coming into contact with child welfare agencies nationally have clinically significant emotional or behavioral problems, 1 and 40% to 60% of children in the child welfare system may have a psychiatric diagnosis. 2 Local and regional studies have also documented high rates of problems across several domains among these children. 3 – 5 Children in foster care have between 10 and 20 times the rate of utilization of mental health services when compared with children maintained within their homes, 6 – 8 and national estimates suggest that the point prevalence of psychotropic medication use is 13.5% 9 —far above the 4% seen among privately insured children 10 and the 5% to 6% seen among Medicaid-enrolled children. 11 , 12 Given this magnitude of service use and the unique vulnerabilities of children in child welfare, the Child Welfare League of America proposed standards for the provision of health and mental health services for children in foster care in 1988. 13 The American Academy of Pediatrics proposed similar standards in 1994 and in 2002, 14 , 15 as did the American Academy of Child and Adolescent Psychiatry in 2001. 16 , 17 These recommendations are highly convergent with regard to mental health care and suggest that all children should receive a mental health screening when placed into foster care, a subsequent comprehensive mental health assessment by a mental health professional within a month of being placed into foster care, and a systematic, coordinated approach to the delivery of services to meet children's ongoing mental health needs. These standards since have been operationalized for use by child welfare agencies and extended to children who are not placed in foster care. For example, the Council on Accreditation, presumably informed by the literature documenting significant mental health needs among non–foster-care child welfare populations, 1 evaluates child protective services agencies on their case-management abilities, including needs assessment and the provision of counseling and intensive mental health services. 18 These standards govern processes of care—not quality of clinical care—and are primarily designed to assist child welfare agencies in implementing organizational structures and processes that can improve child well-being. Passage of the 1997 Adoption and Safe Families Act 19–21 provided additional federal impetus to standards development, and states are currently evaluated on the extent to which children “receive adequate services to meet their … mental health needs.” 22 Despite professional consensus and federal legislation and regulation, there is little information on whether children in the child welfare system actually receive care that is consistent with these standards. In 2002, Halfon et al. reported on the overall inadequacy of services available to children in foster care 23 ; a key informant survey of state and county mental health agencies found that only one third of all mental health agency respondents reported being aware of these standards 24 ; and another study found that fewer than half of all counties had policies regarding mental health assessments for children in child welfare. 25 However, there was no information obtained at the child level to determine whether this lack of knowledge and policymaking adversely affects the care received by individual children. In an attempt to quantify the extent to which children in the child welfare system receive mental health services consistent with national standards, we analyzed data from the first national study of children coming into contact with child welfare agencies—the National Survey of Child and Adolescent Well-Being (NSCAW). We conducted longitudinal data analyses to estimate the prevalence of standards-consistent care among this national sample and identify child-, caregiver-, and caseworker-level characteristics that place children at most risk for receiving care inconsistent with these national standards. Through these analyses we attempt to provide policy guidance for child welfare and child mental health policymakers to better construct systems of care for these highly vulnerable children.
