All Things Permanent: Exits to Permanency at 36-Months

Richard P. BarthSenior Fulbright Specialist

School of Social WorkUniversity of MarylandBaltimore, MD 21201

rbarth@ssw.umaryland.edu

Paper presented to the 7th Looking After Children Conference

Sydney AustraliaAugust 16, 2006

First National Random Sample Study Of CWS

• Extended Research Team includes:– Research Triangle Institute– University of North Carolina– Caliber Associates– San Diego Children’s Hospital,

CASRC– CSRD, Pitt Medical Center– Duke Medical Center– National Data Archive on Child Abuse

and Neglect, Cornell– 92 Local Child Welfare Agencies – Admin. For Children and Families– Children and Families

NSCAW Cohort at Baseline

Total6,231

Enter through investigation

5,504

No services1,725

Ongoing services3,779

In home2,312

Out-of-home1467

Other gateways600

Long-term foster care

727

Data Collection TimelineTarget population: Children Target population: Children involved in investigations involved in investigations closed between October 1, 1999 closed between October 1, 1999 and December 31, 2000and December 31, 2000

Wave 1: Wave 1: BaselineBaselineNov, 1999 – Apr, 2001Nov, 1999 – Apr, 2001

Wave 2: Wave 2: 12 Month Follow-up12 Month Follow-upOct , 2000 – Apr, 2002Oct , 2000 – Apr, 2002

Wave 3: Wave 3: 18 Month Follow-up18 Month Follow-upApr, 2001 – Sept, 2002Apr, 2001 – Sept, 2002

1999 ‘ 2000 ‘ ‘ ‘ ‘ 2001 ‘ ‘ ‘ ‘ 2002 ‘ ‘ ‘ ‘ 2003 ‘ ‘ ‘ ‘ 20041999 ‘ 2000 ‘ ‘ ‘ ‘ 2001 ‘ ‘ ‘ ‘ 2002 ‘ ‘ ‘ ‘ 2003 ‘ ‘ ‘ ‘ 2004

Wave 4: Wave 4: 36 Month Follow-up36 Month Follow-upOct, 2002 – Apr 30, 2004Oct, 2002 – Apr 30, 2004

Placement Dynamics: The 5 Rs

• Reunification

• Reabuse after Reunification

• Reentry

• Replacement (placement instability)

One phenomena or many?

Reinvolvement

Common Dimensions

• Very age dependent• Must factor in caregiver behavior problems

and maltreatment type• Dependent on child behavior• Determined by child welfare services

response of service and surveillance• Depends on type of first placement• Shaped by experience of children and

youth in care

Reunification from OOHC at 36-Months

• Built on existing literature and Wildfire’s reunification work at 18-months

• Interactions were comprehensively tested• Unknown/missing group was included in models

– Findings are suggestive, only, because of data-driven approach and many significant tests

SAMPLE

1288 children entered foster care at baseline or within 6 months

Children 0-2

• Only family cumulative risk was associated with reunification

• However, statistically significant interactions include:

1) Newborns with family DV had higher rates of reunification than non-DV 2) Prior CWS for white children predicts slower reunification 3) Young children in kinship care and sexually abused children had slowest reunification rate.

Children 3-5

• Slower reunification rates for: - children w/ initial placement of in-home - children w/ a high family cumulative risk

• Faster reunification for children where: - trouble paying for basic necessities vs. no trouble

• Noteworthy interactions: 1) Hispanic and Other with high CBCLs had faster

2) Nonurban w/ physical abuse, reunification rate 100%

faster than nonurban children w/ other maltreatment types

3) Substance abuse and recent arrest history unknown

reunification rate far slower than no hx of arrests or SA

Children 6-10

• Cross-cutting relationship b/t primary maltreatment type and reunification rate

• Slowing reunification rate for children w/ borderline or clinical behavior problems

• Significant interactions: 1) Urban children initially placed at home had more rapid reunification than children initially receiving

services in-home 2) Nonurban children initially placed in kinship care had very slow reunifications 3) Children w/o high family risk but w/ SA had slower reunification rates than those w/ no SA

Children 11 and Older• Reunification rates faster for children whose primary

caregiver had recent arrest history than children whose PC had no arrest history

• Slower reunification rate for children whose family had trouble paying for basic necessities

• Interactions of value: 1) Being female & not visiting with mother yields slower

reunification than frequent visiting (did not hold for males) 2) White youth w/ physical abuse faster reunification than

other maltreatment types 3) Children who initially received foster care & no prior

CWS had faster reunification rate

Significant Reunification Main EffectsGender *Race *Urbanicity **Initial placement type *** *Prior CWS involvement * *Family cumulative risk ** *** *Primary maltreatment type ** + *Domestic violence at time of investigation *CBCL Total Score (borderline/clinical) N.A. * **Substance abuse of primary or secondary caregiver *Primary caregiver's recent history of arrests *Family trouble to pay basic necessities * * +Child placed in new neighborhood N.A. N.A. N.A. +Child's frequency to see mother N.A. N.A. N.A. ***Self-reported delinquent behavior N.A. N.A. N.A.

CWS Reinvolvement Following Reunification

• Studies have traditionally divided “recidivism” into two parts—– reabuse for in-home cases and

• cases in which a child goes directly from in-home services to foster care may not have reabuse reports and may not be counted

– reentry for reunification cases• In this analysis, we combined safety measures and

included any reinvolvement with CWS after reunification– This provides a more complete indicator of safety

concerns– This is compared to in-home cases

• We stratified by age group

REINVOLVEMENT AT 36-MONTHS

Total Child Age at Baseline[1]

0-2 3-5 6-10 11+

OOHC as First Placement and Reunified (n=336)

Post-Reunification Reinvolvement

117 (36%) 53 (37%) 13 (28%) 30 (55%) 21 (21%)

Reabuse Rpt of unknown outcome

10 (5%) 3 (3%) 1 (4%) 3 (5%) 3 (8%)

Unsub Reabuse Report 14 (28%) 5 (11%) 2 (31%) 6 (52%) 1 (5%)

Substantiated Reabuse Report 16 (8%) 8 (6%) 1 (1%) 5 (12%) 2 (8%)

Replacement into Foster Care 77 (59%) 37 (80%) 9 (65%) 16 (31%) 15 (79%)

No post-reunification reinvolvement

219 (64%) 107 (63%) 26 (72%) 48 (45%) 38 (79%)

Reinvolvement Summary• Overall, a minimum of one-third of NSCAW children

become “reinvolved” with CWS subsequent to the initial investigation.

• The proportions of reinvolved children was similar (33%) for children who were in-home at baseline and those who were reunified (36%).

• Some age groups had distinctive patterns:– 6- 10s had very high reinvolvement (55%) after

reunification but low reentry (31%) among those reinvolved

– 11+s had low post reunification reinvolvement (21%) but high reentry (79%) among those reinvolved

• Upon reinvolvement, the proportion of the reunified group that was subsequently replaced into foster care (59%) was higher than in the in-home group (38%).

Reentry to Foster Care

• Of the 710 children that were reunified with a parent or relative after an OOH placement, 22.1% subsequently reentered OOH care within the 36-month study period.

• Among children 0-6, 20.7% reentered OOH care– When reentry did occur, it was often soon after reunification--

28.4% of the reentries were in the first two months. – The average (SE) time for younger children to reenter OOH care

was 9.93 (2.6) months following reunification, with a median time to reentry of 4.7 months.

• Among older children ages 7+, 24.2% reentered. – The average time children ages 7 and older spent in OOH care

prior to reunification was 8.16 months (1.54) months. – The average time for older children to reenter OOH care was 8.2

(1.5) months, with a median time to reentry of 4.2 months. • Completed Cox Regression model for each age groups

– Predictors included some child-reported variables for older children

Reentry for 0-6 Year Olds:Bivariate• While most of the factors were not significantly related to the bivariate hazard of

reentry into OOH care, primary type of maltreatment was (p<.01). • Physical abuse was the reference group (HR=1.0).• Sexual abuse 15.4. • Neglect 7.2. • Other 2.6.

• High cumulative family risk associated with reentry (HR = 2.15).• More time in OOHC marginally associated with slower reentry (HR= .95; p < .11)

Multivariate• Initial placement (p < .001): In-home was reference group (HR = 1.0)

• Foster home 8.46 • Kinship care 12.33 • Group/residential 0.01

• Primary type of abuse: physical abuse was the reference (HR = 1.0) • Sexual abuse 16.13 • Neglect 6.94 • Other 4.06

• More time in OOH care prior to reunification (HR= 0.92; p < .07)

Reentry for 7+ Year Olds

Bivariate• Prior CWS involvement was strongly associated with reentry (HR=

3.75)• Any clinical score (HR= 3.22, p < .10) was marginally associated with

reentry

Multivariate• Prior CWS involvement was strongly associated with reentry (HR=

3.75)• Initial placement (p < .02):

– In-home (reference) 1.00 – Foster home 3.37  – Kinship care 0.28  – Group/residential 0.79 

• Time in OOH care prior to reunification 0.96 (p < .11)

Reentry Summary• Reentry correlates depend on age• Younger

– Maltreatment type (physically abused children are lower risk)

– Placement type (kinship and foster care associated with reentry)

– Hi Family Risk• Older

– Prior CWS involvement– Placement type (foster care associated with reentry but

kinship care seems protective)– Clinical scores (marginal)

• Both– Longer time prior to reunification

Placement Changes

• Among California children in substitute care:– Over 50% of children in non-kinship foster care had

at least 3 moves– Over 25% of children in kinship foster care had at

least 3 moves (Webster, Barth, & Needell, 2000)• In a study of a large Ohio county:

– 22% of children placed into substitute care had at least 3 moves (Usher, Randolph, & Gogan, 1999)

• 4 or more placement changes have iatrogenic effects on behavior problems (Newton, Litrownik, & Landsverk, 2000). The number could be lower, of course

Stayers Who are Movers

• All across the world, placement instability is viewed as a major and improvable problem

• A common conclusion is that children’s behavior problems explain their movement, yet what explains the variation in movement among children with behavior problems?

• Placement dynamics are likely to differ by ages of children and their behavior problems

• NSCAW finds that 37% of children ages 2 – 3 and 54% of children ages 4 – 15 enter foster care with an EBD (ACF, 2005)

46%54

%

No EBD EBD

Predictors of Placement Change Among Children With Emotional-Behavioral Problems

What Do We Know?

• Traditionally, 2 sources considered:– Child-centered (e.g., behavior problems cause moves)– Environment-centered (e.g., needs of foster family)

• BUT newer sources have been brought to light:– Administrative reasons (James, 2004)

– Child’s expectations (Gilligan, 2000) – Sibling group stability (Leathers, 2005)

– Foster parent and child relationship (Dozier, Albus, Fisher, & Sepulveda, 2002)

This Study Focuses On Children With EBD

• Sample drawn from the National Survey of Child and Adolescent Well-Being (NSCAW)

• In substitute care at In substitute care at time of baselinetime of baseline

• Clinical level Child Clinical level Child Behavior Checklist Behavior Checklist (CBCL) on either (CBCL) on either Internalizing or Internalizing or Externalizing sub-Externalizing sub-scalesscales

• Between ages 2 and Between ages 2 and 14 years old14 years old Non-EBD <4 w/ EBD 4+ w/ EBD

326

128

224

N=664

Methodology & 1st Results

• All data analysis was carried out using SUDAAN to prevent bias of standard errors

• Poisson Regression was used to account for the nonlinear and autocorrelated nature of the data.

• Children with EBDs were 2 ½ times as likely as their non-EBD peers to experience at least four placement changes

Results of Comparisons

Children with EBDs had greater proportions of:

• Having special needs (strongest)

• Being in non-kinship home

• Not residing with siblings

• Appearing in criminal court

• Having depression• Being male (trend

towards significance)

High v. Low Movers:• Low movement children

were younger than their high movement peers

• Low movement children more likely to be in kinship foster care than their high movement peers

Number of Placements

EBD w/ <4 EBD w/ 4+ EBD non-EBD

Mean: 1.85 6.25 3.45 2.72

Median: 2 6 3 2

Having an EBD is associted with more placement moves, although there is also quite a bit of variation within the EBD population.

Placements in EBD Group

• Among children with EBDs, being depressed and not residing with a sibling group are associated with placement movement

• Other variables approaching statistical significance included:– Age > 10 years old– Having special needs– Child unsure or hopeless about reunification

Placements in non-EBD Group

• Among children without EBDs, only age is positively associated with placement movement

• Males were less likely to experience movements

• Having psychological trauma, a criminal court appearance, or having special needs approach statistical significance

Discussion

• Children with EBDs differ from their non-disordered peers and may be best studied separately

• Children with EBDs appear to experience more placement problems when separated from their sibling group and when depression is present

• Depression (and perhaps hopelessness about going home) in children may manifest as behavior problems (e.g., problems in following program rules)

Discussion

• These findings suggest that reducing placement moves among children without EBDs may require more attention to factors that we did not measure, including specific reason for placement movements (e.g., administrative moves), timing of symptoms and placement changes, children’s perspective on placement, and improved stratifications of participants

• Overall, some evidence suggests an increased focus on helping workers and caregivers to anticipate children’s specific needs and deploy responsive interventions promptly

Conclusions

• Safety and permanency have been the superordinate CWS goals

• Well-being is becoming more of an issue

• Instability is related to all three:– Unstable placements are more likely to

lead to running away and other threats to safety and well-being

– Permanency opportunities are lost with every placement move

So, What Can We Do?

• We can focus on children with behavior problems that are not, yet, in the extreme range and help them achieve stability with timely interventions (e.g. MTFC, next slides)

• We can keep youth in contact with their parents so that they do not become a fantasy.

• We can continue to keep families informed about their children so that they are more ready for a reunification

•Children whose foster parents participated in Project KEEP were almost twice as likely to leave foster care for reunification or adoption.

•Children whose foster parents were not using project KEEP were more likely to run away, disrupt, or have another negative exit from care.

Project KEEP: %of Exit Type by Group

Placement Moves: MTFC-P vs. Regular Foster Care

Figure 3. Survival Functions by Condition

Time in perm placement

40 30 20 10 0 -10

Cu

m S

urv

ival

1.1

1.0

.9

.8

.7

.6

.5

.4

Condition FCI FCI-censored FCC FCC-censored

(Fisher, Burraston, & Pears, 2005)

MTFC-P

RFC

Effect Of Prior Out-of-home Placements On Placement Failures, MTFC-P vs. Regular Foster

Care

(Fisher, Burraston, & Pears, 2005)

RFC

MTFC-P

Reinvolvement as a Standard

• Reentry and reabuse combined…• Placement moves are another type of

reinvolvement--of the child welfare worker in implementing the change– Counts of reinvolvement would provide a

balanced administrative indicator of the process of care

– These need to be examined for each age group