Examining the social, emotional and behavioral needs of youth involved in the child welfare and juvenile justice systems.
This study assesses the social, emotional and behavioral symptoms
of 2,575 youth who were receiving behavioral health services from a
private provider agency, either in an out of home placement (e.g.,
foster care home, a group home or a residential treatment facility) or
in their own home (through the In-Home Services Program). The findings
suggest the prevalence of symptoms in each of the domains (i.e., conduct
problems, emotional problems, ADHD, and peer problems) were relatively
high compared to the general population. Over 50% of the youth had
conduct problems in the borderline or abnormal range, more than 35% had
hyperactivity and peer problems subscale scores in the borderline or
abnormal range, and almost 25% of the youth reported symptoms of
emotional problems in the borderline or abnormal range. Youth's
social, emotional and behavioral problems varied by gender,
race/ethnicity and age group.
Key Words: The Strengths and Difficulties Questionnaire (SQD), Residential Care, Foster Care, Juvenile Justice, Social Problems, Behavioral Problems, Emotional Problems, Mental Health
Child welfare (Psychological aspects)
Juvenile justice, Administration of (Social aspects)
Juvenile justice, Administration of (Psychological aspects)
Emotional problems of children (Research)
Child mental health (Research)
Adolescent psychology (Research)
|Publication:||Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739|
|Issue:||Date: Fall, 2011 Source Volume: 34 Source Issue: 2|
|Topic:||Event Code: 290 Public affairs; 310 Science & research|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
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.
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
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.
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).
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
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.
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.
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.
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.
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.
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.
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.
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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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.
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