Juha Mikkonen, Dennis Raphael
A document like this one, accessible and presenting the spectrum of existing inequities in health, will promote awareness and informed debate, and I welcome its publication. Following years of a move towards the ideology of individualism, a growing number of Canadians are anxious to reconnect with the concept of a just society and the sense of solidarity it envisions. Health inequities are not a problem just of the poor. It is our challenge and it is about public policies and political choices and our commitments to making these happen.
An Ounce of Prevention Revisited. A Review of Health Promotion and Selected Outcomes for Children and Youth in BC Schools
Provincial Health Officer
Research consistently shows that health and education are inextricably linked. Those with better education are healthier than those with less education. Most students in BC are progressing well through the education system, which bodes well for their future, but females consistently do better than
males in most aspects. There are others who do not do well, and they require additional assistance at school in order to succeed and make a successful transition into adulthood.
Julia Brasileiro, Laura Widman, Sunshine Spiva, & Kate Norwalk
Youth in foster care are a vulnerable group of adolescents that experience worse sexual health outcomes, including higher rates of STIs, HIV, and early and repeat pregnancy, compared to youth not in foster care. Caregivers of youth in foster care may play a critical role in improving the sexual health of youth in their care. However, many caregivers of youth in foster care do not talk to youth about sexual health, and few studies have directly asked caregivers about the trainings they may need to provide better sex education to youth. This exploratory study examined the training needs of caregivers of youth in foster care. Participants were a state-wide sample of 347 caregivers of youth in foster care in North Carolina, United States, who completed an online survey that asked about training needs. Almost half (49.0%) of participants state that they do not feel fully prepared to parent youth in foster care. Seventy-two percent of participants indicated they would like to receive more training on at least one of the three topics relevant to adolescent relationships and sexual health. By topic, the percentage of participants who desired more information included: peer pressure and friendships (48.1%); sexuality and sexual risk reduction (e.g. healthy relationships, pregnancy, STIs) (43.8%); and puberty and physical development (40.3%). Another area that most participants expressed a desire for more training was adolescent technology use (56.2%) – which is relevant to adolescent relationships and sexuality given a rise in the use of technology-based platforms to meet relationship partners, look at pornography, and share sexual messages and photos. Many caregivers desire additional training on how to engage with youth about sexuality and sexual risk reduction. Training caregivers of youth in foster care may be an effective strategy for improving the sexual health outcomes of this vulnerable population of youth.
Shifting from Receiver to Provider: Aging Out of Semi-Institutional Child Welfare Settings with Serious Mental Health Diagnoses
Vanessa V. Klodnick, Rebecca P. Johnson, Cory Morris, Deborah A. Cohen, Beth Sapiro, Ava Schneider, Marc A. Fagan
Youth who age out of group homes and transitional living programs with serious mental health needs can abruptly lose critical supports, including housing and mental health treatment access. Little is known about how these particularly vulnerable youth navigate these large shifts in support. Twenty youth diagnosed with serious mental health conditions completed three in-depth interviews (within four-months of planned emancipation and at six- and 12-months post-emancipation). Brief monthly check-ins prevented attrition. Participants transitioned from a receiver/complier role in a mental health treatment context pre-emancipation to a provider/exchanger role in a poverty context post-emancipation. Independence was short-lived post-emancipation; temporary emancipation funds and disability benefits provided a brief cushion. Participants were unprepared for navigation of mutual social support exchanges. Child welfare providers who aim to prepare youth for independence post-emancipation must better understand the social context youth age into, as well as youth’s desired and required resource exchanges.
Sarah McKenna, Michael Donnelly, Ifeoma N. Onyeka, Dermot O’Reilly, Aideen Maguire
Purpose: This is the first comprehensive review of empirical research that investigated the association between receipt of child welfare services and adult mental health outcomes. The review summarised the results of studies about mental health outcomes of adults with a history of child welfare involvement.
Methods: A scoping review methodology was used to search five electronic databases (MEDLINE, EMBASE, PsychINFO, IBSS, Social Policy and Practice). Studies were included if they examined any child welfare exposure (including receipt of services while remaining at home/being placed in care) and adult mental health status.
Results: In total 4591 records were retrieved, of which 55 met the eligibility criteria. Overall, receipt of child welfare services was associated with an increased risk of adult mental ill-health, suicide attempt and completed suicide. Results regarding potential moderating factors, such as gender and care-related experiences, were mixed. Relatively few studies investigated the reasons for requiring child welfare services, the experience of abuse or neglect or the adult outcomes of child welfare service users who remained in their own homes. Mental ill-health was defined and measured heterogeneously and details about the nature and type of welfare service utilisation were lacking.
Conclusion: There is a need for detailed, longitudinal studies to better understand the relative contribution of pre-existing adversity versus experiences during and after exposure to child welfare services on adult mental health outcomes. More standardised measures of mental ill-health and greater detail from authors on specific care exposure are also needed.
Comparing Outcomes of Children and Youth with Fetal Alcohol Spectrum Disorder (FASD) in the Child Welfare System to Those in Other Living Situations in Canada: Results from the Canadian National FASD Database
Jessica Burns, Dorothy E. Badry, Kelly D. Harding, Nicole Roberts, Kathy Unsworth and Jocelyn L. Cook
Aims: The current study aimed to explore differences in adverse outcomes between youth and adolescents with fetal alcohol spectrum disorder (FASD) living in child welfare care (i.e., foster care or group home) with those living with their biological parent(s) or with adoptive or other family member(s) in Canada.
Methods: Data gathered from the Canadian National FASD Database were used for analysis. A total of 665 youth and adolescents with a clinical diagnosis of FASD under the age of 18 living in child welfare care, with biological, adoptive or other family members, were included in the sample. Key areas examined included living situation, legal problems, experience of sexual or physical abuse, mental health (anxiety, conduct disorder, mood disorder and post-traumatic stress disorder) and suicidal ideation. Descriptive statistics and chi-square comparisons were utilized to explore these differences.
Results: Results revealed a significantly higher rate of reported sexual and physical abuse among individuals in child welfare care compared with those living with biological parents or with adoptive or other family member(s). Rates of difficulty with the law were also higher among those in child welfare care compared with adoptive/ other family members. Conversely, the rate of mood disorders was significantly higher among those living with adoptive/other family members compared with child welfare care. Results highlight similar rates of reported suicidal ideation/attempts across all living situations, as well as mental health concerns.
The Impact of Adverse Childhood Experiences on Sexual Well-Being Among Youth Formerly in the Foster Care System
Richard A. Brandon-Friedman, J. Dennis Fortenberry
This study evaluates the impact of broad and singular measures of adverse childhood experiences (ACE) and severity of sexual abuse on sexual well-being among youth formerly in the foster care system (YFFC). Divorce, alcohol/drug use within the home, the presence of mental illness or a family member suicide attempt, and sexual abuse severity increased odds of negative sexual outcomes and predicted lower sexual well-being. Overall ACE levels negative impacted outcomes, but positively impacted sexual well-being. Research must move beyond summative ACE measures to examine impact of types of ACEs and sexual abuse severity on sexual well- being and sexual health outcomes for YFFC.
The Relationship Between Child Protection Contact and Mental Health Outcomes Among Canadian Adults With a Child Abuse History
Tracie O. Afifi, Jill McTavish, Sarah Turner, Harriet L. MacMillan, C. Nadine Wathen
Despite being a primary response to child abuse, it is currently unknown whether contact with child protection services (CPS) does more good than harm. The aim of the current study was to examine whether contact with CPS is associated with improved mental health outcomes among adult respondents who reported experiencing child abuse, after adjusting for sociodemographic factors and abuse severity. The data were drawn from the 2012 Canadian Community Health Survey-Mental Health (CCHS-2012), which used a multistage stratified cluster design (household-level response rate = 79.8%). Included in this study were individuals aged 18 years and older living in the 10 Canadian provinces (N = 23,395). Child abuse included physical abuse, sexual abuse, and exposure to intimate partner violence (IPV). Mental health outcomes included lifetime mental disorders, lifetime and past year suicidal ideation, plans, and attempts, and current psychological well-being and functioning and distress. All models were adjusted for sociodemographic factors and severity of child abuse. For the majority of outcomes, there were no statistically significant differences between adults with a child abuse history who had CPS contact compared to those without CPS contact. However, those with CPS contact were more likely to report lifetime suicide attempts. These findings suggest that CPS contact is not associated with improved mental health outcomes. Implications are discussed.
Examining the Association Between Suicidal Behaviours and Referral for Mental Health Services Among Children Involved in the Child Welfare System in Ontario, Canada
Philip Baiden, Barbara Fallon
Although various studies have investigated factors associated with mental health service utilization, few studies have examined factors associated with referral for mental health services among maltreated children. The objective of this study was to examine the association between suicidal thoughts and self-harming behavior and referral for mental health services among children involved in the Child Welfare System in Ontario, Canada. Data for this study were obtained from the Ontario Incidence Study of Reported Child Abuse and Neglect 2013. An estimate 57,798 child maltreatment investigations was analyzed using binary logistic regression with referral for mental health service as the outcome variable. Of the 57,798 cases, 4709 (8.1%), were referred for mental health services. More than seven out of ten maltreated children who engaged in self-harming behavior and two out of three maltreated children who expressed suicidal thoughts were not referred for mental health services. In the multivariate logistic regression model, children who expressed suicidal thoughts had 2.39 times higher odds of being referred for mental health services compared to children with no suicidal thoughts (AOR = 2.39, 99% C.I. 2.05–2.77) and children who engaged in self-harming behavior had 1.44 times higher odds of being referred for mental health services compared to children who did not engage in self-harming behavior (AOR = 1.44, 99% C.I. 1.24–1.67), both after controlling for child demographic characteristics, maltreatment characteristics, and child functioning concerns. Given that referral is the initial step towards mental health service utilization, it is important that child welfare workers receive the necessary training so as to carefully assess and refer children in care who expressed suicidal thoughts or engaged in self-harming behavior for appropriate mental health services. The paper discusses the results and their implications for child welfare policy and practice.
Rebecca Rebbe, Paula S. Nurius, Mark E. Courtney, Kym R. Ahrens
Objective: Former youth in foster care (YFC) are at greater risk of chronic health conditions than their peers. Although research in general population samples has shown a dose-response relationship between adverse childhood experiences (ACEs) and adult health outcomes, few studies have conducted similar analyses in highly stress-exposed populations such as YFC. In this study we used person-centered latent class analysis methods to examine the relationship between different profiles of ACE exposures and divergent health trajectories among this high-risk population.
Methods: Data are from longitudinal research that followed transition-age YFC from age 17 to 26 (N = 732). Using 3 subgroups previously identified by their ACEs histories-complex, environmental, and lower adversity groups-we applied group mean statistics to test for differences between the groups for physical and sexual health outcomes in young adulthood.
Results: In contrast to previous research that showed that the environmental group was at the highest risk of criminal behavior outcomes, for most of the physical and sexual health risk outcomes evaluated in this study, the complex adversity group had the highest risk.
Conclusions: This study shows that there are subgroups of YFC, which each have a distinct profile of risk in young adulthood, with the complex group being at highest risk of the physical and sexual health risk outcomes evaluated. Findings strongly suggest the need for targeted strategies to promote screening for ACEs and chronic health conditions, linkage to adult health care, and continuity of care for adolescents and young adults in foster care to offset these trajectories.
Adverse Childhood Experiences Among Children Placed in and Adopted From Foster Care: Evidence from a Nationally Representative Survey
Kristin Turney, Christopher Wildeman
Despite good reason to believe that children in foster care are disproportionately exposed to adverse childhood experiences (ACEs), relatively little research considers exposure to ACEs among this group of vulnerable children. In this article, we use data from the 2011–2012 National Survey of Children’s Health (NSCH), a nationally representative sample of non-institutionalized children ages 0–17 in the United States, to estimate the association between foster care placement and exposure to an array of ACEs. In adjusted logistic regression models, we find that children placed in foster care or adopted from foster care, compared to their counterparts, were more likely to experience parental divorce or separation, parental death, parental incarceration, parental abuse, violence exposure, household member mental illness, and household member substance abuse. These children were also more likely to experience ACEs than children across different thresholds of socioeconomic disadvantage (e.g., children in households with incomes below the poverty line) and across different family structures (e.g., children in single-mother families). These results advance our understanding of how children in foster care, an already vulnerable population, are disproportionately exposed to ACEs. This exposure, given the link between ACEs and health, may have implications for children’s health and wellbeing throughout the life course.
Rebecca Rebbe, Paula S. Nurius, Kym R. Ahrens, Mark E. Courtney
Research has demonstrated that youth who age out, or emancipate, from foster care face deleterious outcomes across a variety of domains in early adulthood. This article builds on this knowledge base by investigating the role of adverse childhood experience accumulation and composition on these outcomes. A latent class analysis was performed to identify three subgroups: Complex Adversity, Environmental Adversity, and Lower Adversity. Differences are found amongst the classes in terms of young adult outcomes in terms of socio-economic outcomes, psychosocial problems, and criminal behaviors. The results indicate that not only does the accumulation of adversity matter, but so does the composition of the adversity. These results have implications for policymakers, the numerous service providers and systems that interact with foster youth, and for future research.
Kristin Turney, Christopher Wildeman
BACKGROUND AND OBJECTIVES: Each year, nearly 1% of US children spend time in foster care, with 6% of US children placed in foster care at least once between their birth and 18th birthday. Although a large literature considers the consequences of foster care placement for children’s wellbeing, no study has used a nationally representative sample of US children to compare the mental and physical health of children placed in foster care to the health of children not placed in foster care.
METHODS: We used data from the 2011–2012 National Survey of Children’s Health, a nationally representative sample of noninstitutionalized children in the United States, and logistic regression models to compare parent-reported mental and physical health outcomes of children placed in foster care to outcomes of children not placed in foster care, children adopted from foster care, children across specific family types (eg, single-mother households), and children in economically disadvantaged families.
RESULTS: We find that children in foster care are in poor mental and physical health relative to children in the general population, children across specific family types, and children in economically disadvantaged families. Some differences are explained by adjusting for children’s demographic characteristics, and nearly all differences are explained by also adjusting for the current home environment. Additionally, children adopted from foster care, compared with children in foster care, have significantly higher odds of having some health problems.
CONCLUSIONS: Children in foster care are a vulnerable population in poor health, partially as a result of their early life circumstances.
Developmental Patterns of Adverse Childhood Experiences and Current Symptoms and Impairment in Youth Referred for Trauma-Specific Services
Damion J. Grasso, Carly B. Dierkhising, Christopher E. Branson, Julian D. Ford, Robert Lee
By the time children reach adolescence, most have experienced at least one type of severe adversity and many have been exposed to multiple types. However, whether patterns of adverse childhood experiences are consistent or change across developmental epochs in childhood is not known. Retrospective reports of adverse potentially traumatic childhood experiences in 3 distinct developmental epochs (early childhood, 0- to 5-years-old; middle childhood, 6- to 12-years-old; and adolescence, 13- to 18-years-old) were obtained from adolescents (N = 3485) referred to providers in the National Child Traumatic Stress Network (NCTSN) for trauma-focused assessment and treatment. Results from latent class analysis (LCA) revealed increasingly complex patterns of adverse/traumatic experiences in middle childhood and adolescence compared to early childhood. Depending upon the specific developmental epoch assessed, different patterns of adverse/traumatic experiences were associated with gender and with adolescent psychopathology (e.g., internalizing/externalizing behavior problems), and juvenile justice involvement. A multiply exposed subgroup that had severe problems in adolescence was evident in each of the 3 epochs, but their specific types of adverse/traumatic experiences differed depending upon the developmental epoch. Implications for research and clinical practice are identified.
Resmiye Oral, Marizen Ramirez, Carol Coohey, Stephanie Nakada, Amy Walz, Angela Kuntz, Jenna Benoit, Corinne Peek-Asa
Adverse childhood experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care (TIC) in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity, and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.
Adverse Chilldhood Experiences and Psychosocial Well-Being of Women Who Were in Foster Care as Children
Delilah Bruskas, Dale H. Tessin
Background and Objective: Research has shown that many children in foster care later have psychosocial problems as adults; this is often attributed to cumulative adversities and a lack of supportive caregivers. The risk factors associated with foster care, such as maternal separation and multiple placements, often counteract many protective factors that can ameliorate the effects of childhood adversities. This study assessed the relationship between adverse childhood experiences (ACEs) and psychosocial well-being in women who were in foster care as children.
Methods: A total of 101 women aged 18–71 years (mean, 36.83 [12.95] years) completed an anonymous online survey based on the 10-item ACE Questionnaire, the Sense of Coherence questionnaire, and the General Health Questionnaire.
Results: More than 56% of respondents were identified as experiencing current psychological distress. Sense of coherence scores (mean, 54.26 [15.35]) showed a significant inverse association with both General Health Questionnaire (mean, 14.83 [5.88]) and ACE (mean, 5.68 [2.90]) scores (r = −0.64 and −0.31, respectively) and 97% reported at least 1 ACE, 70% reported ≥ 5 and 33% reported ≥ 8. Linear regressions indicated that ACEs reported to occur before foster care were associated with lower levels of sense of coherence (8%) and higher levels of psychological distress (6%). Physical neglect and living in a dysfunctional household (parental loss, maternal abuse, or household member associated with substance abuse or prison) significantly decreased during foster care by 16 and 19 percentage points, respectively. Rates of emotional and physical abuse did not change.
Conclusion: The number of ACEs was associated with the level of psychological distress. Our findings suggest that children entering the foster care system are already vulnerable and at risk of experiencing ACEs during foster care and psychological distress during adulthood. Measures implemented to protect children must not cause more harm than good. Social services that preserve and strengthen the family unit and reduce the number of ACEs both before and during foster care are recommended. Social workers and clinicians who are trained to address and manage the unique developmental needs of children in foster care may help reduce the effects of ACEs and optimize developmental health.
Cheryl Zlotnick, Tammy W. Tam, Laurie A. Soman
Objective: We compared the prevalence rates of mental health and physical health problems between adults with histories of childhood foster care and those without.
Methods: We used 2003–2005 California Health Interview Survey data (n=70456) to test our hypothesis that adults with childhood histories of foster care will report higher rates of mental and physical health concerns, including those that affect the ability to work, than will those without.
Results: Adults with a history of childhood foster care had more than twice the odds of receiving Social Security Disability Insurance because they were unable to work owing to mental or physical health problems for the past year, even after stratifying by age and adjusting for demographic and socioeconomic characteristics.
Conclusions: Childhood foster care may be a sentinel event, signaling the increased risk of adulthood mental and physical health problems. A mental and physical health care delivery program that includes screening and treatment and ensures follow-up for children and youths who have had contact with the foster care system may decrease these individuals’ disproportionately high prevalence of poor outcomes throughout their adulthood.
Julia M. Pryce, Gina Miranda Samuels
This interpretive study examines how childhood history and the personal experience of being mothered impact the meaning attributed to motherhood among young mothers aging out of the child welfare system. Through the use of an interpretive approach, findings are derived from interviews with 15 females who reported an experience of pregnancy or parenting at the time of the interview. In the midst of the strain and challenge of motherhood, these young women report that motherhood has the potential to provide opportunities relevant to their own identity as well as to healing from their pasts. Findings aim to inform ways of understanding and responding to the unique and dual experience of mothering and aging out of the child welfare system.
Comparing Developmental Outcomes for Children in Care Outcomes for Children in Care with Those for Other Children in Canada
Robert J. Flynn, Chantal Biro
This study assessed the test±retest reliability and convergent validity of single items from the Assessment and Action Record (AAR), from Looking After Children (Ward, 1995). It also compared developmental outcomes of 43 children cared for by a Canadian child welfare agency and those of an approximate comparison group of 1,600 children from the National Longitudinal Survey of Children and Youth (Statistics Canada, 1995). High and low reliability and validity were found for different AAR items. The children in care had worse outcomes than the comparison children on indicators of educational success and negative behaviour, but not on measures of identity, social and family relationships, or prosocial behaviour.
Emerging Adulthood as a Critical Stage in the Life Course in Handbook of Life Course Health Development
Eds: Neal Halfon, Christopher B. Forrest, Richard M. Lerner, Elaine M. Faustman
This open access handbook synthesizes and analyzes the growing knowledge base on life course health development (LCHD) from the prenatal period through emerging adulthood, with implications for clinical practice and public health. It presents LCHD as an innovative field with a sound theoretical framework for understanding wellness and disease from a lifespan perspective, replacing previous medical, biopsychosocial, and early genomic models of health. Interdisciplinary chapters discuss major health concerns (diabetes, obesity), important less-studied conditions (hearing, kidney health), and large-scale issues (nutrition, adversity) from a lifespan viewpoint. In addition, chapters address methodological approaches and challenges by analyzing existing measures, studies, and surveys. The book concludes with the editors’ research agenda that proposes priorities for future LCHD research and its application to health care practice and health policy.
Topics featured in the Handbook include:
The prenatal period and its effect on child obesity and metabolic outcomes. Pregnancy complications and their effect on women’s cardiovascular health. A multi-level approach for obesity prevention in children. Application of the LCHD framework to autism spectrum disorder. Socioeconomic disadvantage and its influence on health development across the lifespan. The importance of nutrition to optimal health development across the lifespan.