The Youngest Victims of Violence: Examining the Mental Health Needs of Young Children Who Are Involved in the Child Welfare and Juvenile Justice Systems
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- Whitted, K.S., Delavega, E. & Lennon-Dearing, R. Child Adolesc Soc Work J (2013) 30: 181. doi:10.1007/s10560-012-0286-9
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Children placed in the state’s custody due to neglect, abuse or maltreatment are one of America’s most vulnerable populations. Seventy-five percent of child victims of maltreatment are under the age of 12. Not only is their suffering a problem, these children are also at increased risk for delinquent behavior later in life. While research has documented the potential long-term consequences of child abuse and neglect, the mental health needs of young children involved in the foster care and juvenile justice systems have been largely overlooked. This study examined the social, emotional and behavioral difficulties of 670 children, age 3–11, who were involved in the child welfare and juvenile justice systems. Children in this study were living in residential treatment facilities, group homes, foster care homes or were receiving intensive home-based services. To assess the children’s mental health needs caregivers completed the parent form of the Strengths and Difficulties Questionnaire (Goodman, Journal of Child Psychology and Psychiatry 38:581–586, 1997). The findings indicated a high prevalence of mental health problems, with 81 % of the children in the sample having a total difficulties score in the borderline or abnormal range and 90 % of the children having borderline or abnormal scores on at least one of the subscales (conduct, emotional, peer or attention problems). When characteristics such as gender, race and age were considered significant differences were found among boys and girls, Caucasian and minority children, and age groups. The findings highlight the importance of mental health assessment and interventions that are gender and culturally sensitive and developmentally appropriate.
KeywordsThe Strengths and Difficulties Questionnaire (SDQ)Residential careFoster careJuvenile justiceSocial problemsBehavioral problemsEmotional problemsDevelopmental needsMental health
The Youngest Victims of Violence
Each year in the United States, there are over three million reports of child abuse made, and of these reports, approximately 24 % are substantiated (U.S. Department of Health and Human Services [USDHHS] 2008), resulting in more than 700,000 victimized children in the country. In 2008 there were an estimated 269,000 children living in foster care due to substantiated reports of maltreatment (USDHHS 2008). The majority of substantiated Child Protective Services (CPS) referrals involved very young children. In fact, USDHHS (2008) statistics show that over 32 % of all victims of maltreatment were younger than 3 years old and 42.5 % of victims are between the ages 4 and 11. These numbers indicate that 75 % of children who were confirmed by CPS as being victims of maltreatment were under age 12. While these statistics are alarmingly high, our inability to respond to the mental health needs of young children in substitute care is even more disturbing.
The number of children in state custody who have mental health problems is staggering. It has been estimated that up to 80 % of children who enter foster care have serious problems with mental health (Simms et al. 2000), as compared to 18–22 % of children diagnosed with mental health problems in the general population (Roberts et al. 1998). Yet, only 23 % of children who are in foster care for at least 12 months received mental health services (National Survey of Child and Adolescent Well-Being 2003).
When the mental health needs of children are not addressed, the impact of maltreatment is often devastating and long lasting (Anda et al. 2006; Colman and Widom 2004; Edwards et al. 2005). Children who have been abused and neglected are more vulnerable to post-traumatic stress disorder, attention deficit hyperactivity disorder, conduct disorder, and learning and memory difficulties (Anda et al. 2007; Dallam 2001; Perry 2001).
The developmental consequences are even more severe when abuse and neglect is experienced at a very young age. The Centers for Disease Control and Prevention (CDC 2012) report that maltreatment during infancy or early childhood can interfere with brain development, which, in turn, can cause physical, mental, and emotional problems such as sleep disturbances, panic disorder, and attention deficit hyperactivity disorder. These difficulties often manifest in the form of behavior problems and subsequently, the child’s inability to relate to peers and adults.
Many children in foster care have higher levels of chronic behavior and emotional problems, medical, learning, or mental health conditions that negatively impact their ability to relate to others (Kortenkamp and Ehrele 2002). Maltreated children have difficulty regulating their own emotions and understanding the emotions of others (Maughan and Cicchetti 2002). They do not understand how their actions influence others and they are unable to anticipate the consequences of their behavior. Lacking these skills, many children have lifelong difficulties with social relationships with both peers and adults (Colman and Widom 2004; Darwish et al. 2001; Morrison et al. 1999; Shields and Cicchetti 2001). Often a vicious cycle is set in place, as the child is rejected by peers, has difficulty with authority figures, and is constantly in trouble at home and at school. When a child has experienced a number of failed or painful relationships, the child may learn to disregard the values and beliefs of others. When this occurs the child has difficulty adapting to and following the rules of society. These children are often described as being angry, violent and aggressive and eventually are diagnosed with oppositional defiant disorders, conduct disorders or antisocial personality disorders. This is particularly troubling because behavior problems identified during childhood are strong predictors of delinquency during adolescence and of adult incarceration (Broidy et al. 2003).
Delinquent Behavior in Childhood
Children who experience maltreatment are at increased risk of engaging in delinquent behavior. In fact, Ryan and Testa (2005) found that delinquency rates were nearly twice as high when youth had been victims of maltreatment. Although maltreatment does not inevitably lead to delinquency, the research suggests that a high number of children that leave the foster care system become involved in the juvenile justice system (Langsford et al. 2007; Ryan and Testa 2005; Widom and Maxfield 2001).
The prevalence of mental health disorders among children involved in the juvenile justice system is also staggering. Recent statistics report that as many as 70 % of youth involved in the juvenile justice system have a diagnosable mental health disorder (Shufelt and Cocozza 2006; Wasserman et al. 2002; Teplin et al. 2002) and of the children who have a diagnosable mental health disorder, 79 % met criteria for two or more diagnoses. Over 60 % of these children were diagnosed with three or more mental health disorders (Shufelt and Cocozza 2006). Ultimately, abuse and neglect impact not just the child and family, society as a whole is impacted due to the burden it places on the health care, human services, and educational systems (Child Welfare Information Gateway 2008a).
To what extent do young children living in out of home placements have social, emotional or behavioral problems?
How do the social, emotional and behavioral problems of children living in out of home placements differ among boys and girls?
How do the social, emotional and behavioral problems of children living in out of home placements differ among Caucasian and minority children?
How do the social, emotional and behavioral problems of children living in out of home placements differ across developmental age groups (3–7 and 8–11)?
Participants in this study consisted of children who were living in residential treatment facilities, group homes, foster homes, or were receiving intensive home-based services and considered to be at high risk for becoming involved with the foster care or juvenile justice systems. Data were collected from a large non-profit agency in the Southeastern United States that serves the behavioral health needs of children referred by the juvenile justice and child welfare systems.
Frequencies and percentages in sample
Young children in sample
8–11 year olds
Percentage of children with SDQ scores in the borderline or abnormal range
The Strengths and Difficulties Questionnaire (SDQ; Goodman 1997) was used in this study. The SDQ is a brief behavioral screening questionnaire that gives reliable information about children’s emotional health, conduct problems, hyperactivity, peer relationship problems and prosocial behavior. The scale items were selected on the basis of the diagnostic categories of the DSM-IV and ICD-10 (Mark and Buck 2006). The questionnaire consists of 25 items divided between five subscales of five items each; (a) emotional symptoms (e.g., often seems worried, often unhappy, depressed or tearful), (b) conduct problems (e.g., often lies or cheats, often fights with other youth or bullies them), (c) hyperactivity (e.g., constantly fidgeting or squirming, easily distracted, concentration wanders), (d) peer problems (e.g., has at least one good friend, generally liked by other youth), and (e) prosocial behavior (e.g., considerate of other people’s feelings, kind to younger children). The questionnaire has several forms; youth (over the age of 11), parent, and teacher reports (Goodman 1997). This study used the parent report form of the SDQ.
Subscale and total SDQ mean scores (SD) and comparisons by gender, race and age group
Subscales of SDQ
Total difficulties score
Cut point (borderline–abnormal)
Children in community ages 4–17
An examination of the psychometric properties of the SDQ (Stone et al. 2010) found internal consistency reliability estimates for the parent report form were: emotional symptoms, α = 0.66; conduct problems, α = 0.58; hyperactivity, α = 0.76; peer problems, α = 0.53; prosocial behaviors, α = 0.67; and total difficulties score, α = 0.80. Concurrent validity was found between the SDQ total difficulties score and the Child Behavior Check List (CBCL) total scales, (weighted) r = .76 (Stone et al. 2010). The SDQ is in the public domain and can be accessed at: http://www.sdqinfo.org.
To address the first research question, the authors conducted frequency tables. Research questions two, three and four looked at the effects of gender, race, and age on the dependent variables (emotional symptoms subscale, conduct problems subscale, hyperactivity subscale, peer problems subscale, and total difficulties score), the authors conducted t tests and χ2 analyses. In addition, we calculated the risk ratio of having borderline/abnormal scores on each of the dependent variables (emotional symptoms, conduct problems, hyperactivity symptoms, peer problems, and total difficulties score) by gender, race, and age group. Preliminary statistics comprising correlations and regressions suggested that multivariate analyses were not appropriate except in the case of gender and two of the subscales: emotional symptoms and hyperactivity. As a result, the researchers did not conduct multivariate statistics. Data were analyzed in SPSS version 20.0. Significance levels were determined to be equal to or <0.05.
Among the children in this study, 81.2 % (n = 544) had total difficulties scores in the borderline or abnormal range. Over 90 % of the children (n = 618) had scores in the borderline or abnormal range in at least one of the subscales. The most frequently observed problem domain was the conduct problems subscale in which 84 % (n = 563) of the children had scores in the borderline or abnormal range. In addition, nearly 75 % (n = 498) of the children in this study had scores in the borderline or abnormal range on the hyperactivity subscale, over 68 % (n = 460) on the peer problems subscale and over 57 % (n = 387) on the emotional symptoms subscale (see Table 1 for complete frequencies). Results indicate that this population has significantly higher proportions of borderline/abnormal scores on all subscales and on the total difficulties scale than children in the community (see Table 2). One interesting finding is that the conduct problems subscale and the hyperactivity subscale are the most highly correlated (r = 0.597, p = 0.000) among the subscales, suggesting that perhaps what is interpreted as conduct problems may instead be undiagnosed attention deficit hyperactivity disorder (ADHD).
T test results (see Table 2) show significant race and age-group differences on the emotional symptoms subscale, significant gender and race differences on the hyperactivity scale, and significant gender, race, and age-group differences on the conduct problems subscale, the peer problems subscale, and the total difficulties score. Means and standard deviations (see Table 2) suggest that in general males have worse scores than females on all scales except on the emotional symptoms subscale, Caucasians have higher scores than minority children on all scales, and children older than 8 have higher scores on all scales than younger children. It is important to note that while no significant differences were found between genders on the emotional symptoms subscales, females have higher means (4.32) than males (4.06); and that males have higher means (5.59) than females (5.01) on the conduct problems scale (t = −2.366, p < 0.05), suggesting that females are internalizing their problems while males are both internalizing and externalizing them. It is also interesting to note that no statistically significant differences were found among younger and older children on the hyperactivity subscale.
χ2 and percentage of children with borderline or abnormal SDQ scores by gender, race and age group
Percentage of children with borderline or abnormal scores in sample
Total difficulties scale
Consistent with other research, this study found that the mental health needs of children involved in the child welfare and juvenile justice systems were astonishingly high (Shufelt and Cocozza 2006; Simms et al. 2000; Wasserman et al. 2002; Teplin et al. 2002). The present study found that upon admission to a behavioral health service provider agency, over 81 % of the children had a total difficulties score that was in the borderline or abnormal range. A striking 84 % of these children had conduct problems, more than 74 % of the children had hyperactivity scores in the borderline or abnormal range, and over 50 % had peer problems and emotional symptoms subscale scores in the borderline or abnormal range. There were also significant differences in the psychological, social and behavioral needs of boys and girls, of Caucasian and minority children, and of children in different age groups. The implications of these differences will be discussed in the following sections.
The findings in the present study were consistent with other research that found the mental health needs of maltreated children differ among females and males (Maschi et al. 2008). There were significant differences among boys and girls on the total difficulties score and on the conduct, hyperactivity, and on the peer problems subscales, with boys having higher scores on the total difficulties scale and all three of these subscales (see Table 3). These findings were consistent with other research that shows that, in general, boys exhibit more externalizing problems than girls (Crijnen et al. 1999).
We did not find a statistically significant difference among boys and girls on the emotional symptoms subscale. This finding suggests that boys and girls in this study experienced similar rates of internalizing problems. Since a number of studies show that among children exposed to trauma, girls exhibit more internalizing behaviors and boys exhibit more external behaviors in response to stress and trauma (Eschenbeck et al. 2007), these findings were surprising. The results also show that boys exhibit hyperactivity to a greater degree than girls, that is, that boys tend to exhibit observable symptoms, hyperactivity, and general misconduct. Taken together, these findings suggest that boys may be externalizing and internalizing symptoms, whereas girls are more likely to internalize than to externalize. The implications of this include the need for interventions that address the emotional needs of boys even as their behavior problems are addressed. Furthermore, it is possible that the behavioral problems boys exhibit are manifestations of emotional trauma. If the emotional trauma of boys is not addressed, behavioral interventions may not be effective. These findings suggest that additional research needs to be directed at understanding how social, emotional and behavioral problems manifest among pre-adolescent boys and girls who are involved in the child welfare and juvenile justice systems.
There were significant differences between Caucasian and minority children on the total difficulties scale and on the four subscales, emotional symptoms, conduct problems, peer problems and hyperactivity, with Caucasian children having significantly higher scores. The risk ratio also shows that the greatest differences on the scales were based on race. These findings were unexpected in their direction and were contrary to findings from the National Health Interview Survey (NHIS), a large national study, which uses the SDQ to assess the mental health functioning of children and adolescents in the general population. The NHIS found that social, emotional and behavioral disturbances were overrepresented among African American youth (Mark and Buck 2006). In fact, findings from this study were contrary to a number of studies that found that African American youth were more likely than Caucasian youth to have been given diagnosis of ADHD (Yeh et al. 2002) and to have been diagnosed with conduct disorder or a disruptive behavioral disorder (Delbello et al. 2001; Mak and Rosenblatt 2002; Nguyen et al. 2007; Yeh et al. 2002). In a longitudinal study of maltreated children aged 7–12 years old, African American youth’s internalizing symptoms and externalizing behaviors were consistently higher than their Caucasian counterparts (Hatcher et al. 2009). In addition, African American youth are more likely to be diagnosed with depression (Stiffman et al. 1992; Delbello et al. 2001).
Interestingly, the findings from this study suggested that minority children were less likely than Caucasian youth to exhibit emotional symptoms. These findings point to the need to better explore plausible explanations for these differences and to examine how these differences may require different assessment and intervention approaches. The researchers propose that minority children are referred to either child welfare or juvenile justice when exhibiting lower levels of symptoms, as scores for minority children were significantly lower on every subscale and on the total difficulties scale; this may be the result of lower societal tolerance to normal behaviors among minority children among service providers in this geographical area.
Age Group Differences
There were also significant differences in the age group comparisons on the total difficulties score and three of the subscales. Children in the older 8–11 age group had significantly higher mean scores on the emotional symptoms, conduct, and peer problems subscales. This is consistent with previous research showing age to be positively correlated with behavioral problems (Mak and Rosenblatt 2002; Nguyen et al. 2007). Although that children’s social, emotional and behavioral problems may increase with age, and the literature consistently shows that behavioral problems are more amenable to intervention when they are addressed early on, yet the mental health needs of children involved in the child welfare and juvenile justice systems often go unaddressed (National Survey of Child and Adolescent Well-Being 2003). In fact, the literature that addresses the mental health needs of pre-adolescent children living in out of home placements due to abuse or neglect or due to their unruly or delinquent behaviors is scant. Clearly, more attention to better understand and address the needs of this vulnerable population of children is warranted.
Unfortunately, for many children, by the time they enter the juvenile justice system their behaviors are entrenched and difficult to change. Dodge (1993) has suggested that if behavior problems are not addressed by the end of the third grade, the behaviors should be treated as a chronic condition, hopefully kept in check with interventions. There is a large body of literature that suggests that intervention efforts that are implemented early on are the most effective means to address children’s psychological and behavioral problems.
The behaviors children exhibit do not go unnoticed by adults who interact with these children on a day-to-day basis. The children’s foster/adoptive parents, teachers, caseworkers and therapist often struggle to find ways to help the children who are entrusted in their care. Yet, far too often the mental health needs of young children are not diagnosed or treated until they become older and their behaviors escalate. Mental health problems are not identified or addressed until a child has experienced a long list of failed placements, treatment programs, and intervention strategies. Fortunately, efforts to better meet the mental health needs of children in state custody have been addressed by a number of recent policy and legislative initiatives.
Of interest here is the fact that no significant differences were found among younger and somewhat older (but still preteen) children on the hyperactivity subscale, although younger children show slightly lower scores. The authors hypothesize that this is because ADHD tends to persist into adulthood (Young et al. 2011), and thus not change much throughout childhood. It is therefore not surprising that hyperactivity symptoms were found to be similar between upper elementary and lower elementary children.
An Integrated System of Service Delivery
A multisystems approach is needed to better meet the mental health needs of children in custody of the child welfare system or the juvenile justice system. Although the point of entry into state custody may differ, the literature suggests that from a clinical standpoint, the needs of these youth 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 and Weinberg 2010). “Systems of Care” is a promising evidence-based approach to cross-agency coordination of services for child welfare-involved children that features multiagency sharing of resources and responsibilities and makes use of full participation of professionals, families and youth, and community stakeholders as active partners (Child Welfare Information Gateway 2008b). Individualized, strengths-based care acknowledges each child and family’s unique set of strengths and challenges while addressing culture, language, ethnicity, gender, age, religious background, and class (Child Welfare Information Gateway 2008b). Social work has particular interest in insuring that children receive the best, most comprehensive services to address their multiple needs. The authors believe that the “Systems of Care” approach is best suited to serve the mental health needs (among others) of this population.
Although this study included a large sample of children from several states, several limitations should be noted. First, the behavioral difficulties were reported by the parent/caregiver only and no independent clinical assessment was provided. Therefore, it is possible that parents over-reported or under-reported their child’s social, emotional, or behavioral difficulties. However, previous research using the SDQ has indicated relatively good reliability and validity of the parent-report version of this instrument (Goodman 2001).
Second, the participants in this study consisted of children who were referred for behavioral health services through both the child welfare and the juvenile justice systems. Because many of the children are involved in both the juvenile justice and the child welfare systems and may 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 children 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 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 and Sickmund 2006).
Third, this study consisted of children 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 children 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 children receiving services through other provider agencies should be carefully considered.
Finally, this study did not investigate the historical data of the children or important demographic information about the children’s family of origin (marital status of the biological parents, socioeconomic status of the biological parents, whether the children’s biological parents had legal custody of their child) nor was the child’s service history examined. For example, the number of times the children had previously been in foster care, whether the children 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 children who have a history that includes a number of risk factors would likely have resulted in these children having higher scores on the SDQ. However, no statistical analysis was employed to test these assumptions.
When the state intervenes against an abusive or negligent parent and assumes custody of a minor child, the state becomes responsible for that child’s well being. The best interests of any child must also include the responsibility of meeting their developmental, social, emotional, and behavioral needs. Children who have come to be in the state’s care and custody have a right to inclusive mental healthcare screening, assessment and treatment services.
The literature that addresses the mental health needs of pre-adolescent children is scant, particularly as it relates to young children in foster care and residential treatment. This descriptive study suggests that mental health difficulties may differ when race, gender and age among young children referred by the juvenile justice or child welfare systems for residential care are considered. The findings point to the need for further research aimed at better understanding how race, gender and age influence assessment of children’s emotional symptoms, conduct problems, hyperactivity, and peer relationship problems. Clearly, more work needs to be undertaken in an effort to develop sound treatment approaches that are developmentally appropriate, culturally sensitive and gender specific to the mental health needs of young victims of violence and neglect—young children who are involved in the nation’s child welfare and juvenile justice systems.