For Better or Worse? Change in Service Use by Children Investigated by Child Welfare Over a Decade

Published:February 03, 2016DOI:



      Children, particularly minority children, referred to child welfare because of suspected maltreatment are vulnerable and need many services. We sought to assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased.


      We used 2 national data sets (the National Survey of Child and Adolescent Well-Being [NSCAW] I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), and dental services and overall service use.


      In NSCAW II more children were young, had lower Child Behavior Checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services, and a decrease in MH services on the bivariate level (all P < .01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children, and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities.


      These data showed no change in MH services over time for children referred for child welfare evaluation, but improvement in dental services was noted. Racial and ethnic disparities persist. Decrease in MH services occurred predominantly among children whose MH symptoms were below the clinical range.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Simms M.D.
        • Dubowitz H.
        • Szilagyi M.A.
        Health care needs of children in foster care.
        Pediatrics. 2000; 106: 909-918
        • Hochstadt N.J.
        • Jauses P.K.
        • Zimo D.A.
        • et al.
        The medical and psychosocial needs of children entering foster care.
        Child Abuse Negl. 1987; 11: 53-62
        • Leslie L.K.
        • Hurlburt M.S.
        • Landsverk J.
        • et al.
        Comprehensive assessments for children entering foster care: a national perspective.
        Pediatrics. 2003; 112: 134-142
        • Committee on Early Childhood, Adoption, and Dependent Care
        Health care of young children in foster care.
        Pediatrics. 2002; 109: 536-541
      1. ChildHelp. Child abuse statistics and facts. Available at: Accessed August 4, 2015.

        • Stein R.E.K.
        • Hurlburt M.S.
        • Heneghan A.
        • et al.
        Health status and type of out-of-home placement: informal kinship care in an investigated sample.
        Acad Pediatr. 2014; 14: 559-564
        • Stein R.E.K.
        • Hurlburt M.S.
        • Heneghan A.
        • et al.
        Chronic conditions among children investigated by child welfare.
        Pediatrics. 2013; 131: 455-462
        • Horwitz S.M.
        • Hurlburt M.S.
        • Heneghan A.
        • et al.
        Mental health problems in young children investigated by US child welfare agencies.
        J Am Acad Child Adolesc Psychiatry. 2012; 51: 572-581
        • Burns B.J.
        • Phillips S.D.
        • Wagner H.R.
        • et al.
        Mental health need and access to mental health services by youth involved with child welfare: a national survey.
        J Am Acad Child Adolesc Psychiatry. 2004; 43: 960-970
      2. Council on Accreditation. Accreditation standards—public agencies. 8th ed. Available at: Accessed November 10, 2011.

      3. Adoption and Safe Families Act. PL 105-89. 111 S 2115, amending 42 USC x671–675.

      4. Administration for Children and Families; US Department of Health and Human Services. Procedures manual. Available at: Accessed August 21, 2011.

        • Kosanovich A.
        • Joseph R.M.
        Child welfare consent decrees: analysis of thirty-five court actions from 1995–2005. Child Welfare League of America.
        (Available at:) (Accessed August 21, 2011)
        • Romanelli L.H.
        • Hoagwood K.E.
        • Kaplan S.J.
        • et al.
        • Child Welfare–Mental Health Best Practices Group
        Best practices for mental health in child welfare: parent support and youth empowerment guidelines.
        Child Welfare. 2009; 88: 189-212
        • Leslie L.K.
        • Landsverk J.
        • Ezzet-Lofstrom R.
        • et al.
        Children in foster care: factors influencing outpatient mental health service use.
        Child Abuse Negl. 2000; 24: 465-476
        • Garland A.F.
        • Landsverk J.A.
        • Lau A.S.
        Racial/ethnic disparities in mental health service use among children in foster care.
        Child Youth Serv Rev. 2003; 25: 492-507
        • Stahmer A.C.
        • Leslie L.K.
        • Hurlburt M.
        • et al.
        Developmental and behavioral needs and service use for young children in child welfare.
        Pediatrics. 2005; 116: 891-900
        • Hurlburt M.S.
        • Leslie L.K.
        • Landsverk J.
        • et al.
        Contextual predictors of mental health service use among children open to child welfare.
        Arch Gen Psychiatry. 2004; 61: 1217-1224
      5. Health equity and children's rights. Policy statement.
        Pediatrics. 2010; 125: 838-849
        • Lillie-Blanton M.
        • Maleque S.
        • Miller W.
        Reducing racial, ethnic, and socioeconomic disparities in health care: opportunities in national health reform.
        J Law Med Ethics. 2008; 36: 693-702
      6. US Department of Health and Human Services; Administration for Children and Families. About TANF. Available at: Accessed August 14, 2013.

        • Horwitz S.M.
        • Kerker B.D.
        Impediments to employment under welfare reform: the importance of physical health and psychosocial characteristics.
        Women Health. 2001; 32: 101-117
        • Schott L.
        • Mann C.
        Assuring That Eligible Families Receive Medicaid When TANF Assistance is Denied or Terminated.
        Center on Budget and Policy Priorities, Washington, DC1998 (Available at:) (Accessed July 28, 2014)
        • Johnson N.
        • Oliff P.
        • William E.
        An Update on State Budget Cuts.
        Center on Budget and Policy Priorities, Washington, DC2011 (Available at:) (Accessed March 30, 2012)
        • Goldhaber-Fiebert J.D.
        • Babirez K.S.
        • Garfield R.L.
        • et al.
        Explaining variations in state foster care maintenance rates and implications for implementing new evidence-based practices.
        Child Youth Serv Rev. 2014; 39: 183-206
        • Dowd K.
        • Dolan M.
        • Wallin J.
        • et al.
        National Survey of Child and Adolescent Well-Being II: Combined Waves 1–2 Data File User's Manual, Restricted Release Version.
        Cornell University, National Data Archive on Child Abuse and Neglect, Ithaca, NY2011
        • Achenbach T.M.
        • Rescorla L.A.
        Manual for the ASEBA Preschool Forms and Profiles.
        University of Vermont, Research Center for Children, Youth, & Families, Burlington, Vt2000
        • Achenbach T.M.
        • Rescorla L.A.
        Manual for the ASEBA School-Age Forms and Profiles.
        University of Vermont, Research Center for Children, Youth, & Families, Burlington, Vt2001
        • Research Triangle Institute
        SUDAAN User's Manual: Release 10.0.
        ([computer program]) Research Triangle Institute, Research Triangle Park, NC2008
        • Department of Health and Human Services
        Oral Health in America: A Report of the Surgeon General—Executive Summary.
        National Institute of Dental and Craniofacial Research, National Institutes of Health, US Dept of Health and Human Services, Rockville, Md2000 (Available at:) (Accessed August 5, 2013)
      7. Medicaid. Dental care for Medicaid and CHIP enrollees. Available at: Accessed August 5, 2013.

      8. Centers for Medicare and Medicaid Services; Center for Medicaid, CHIP and Survey and Certification. Medicaid/CHIP oral health services fact sheet. Available at:

        • Bogges K.A.
        • Edelstein B.L.
        Oral health in women during preconception and pregnancy: implications for birth outcomes and infant oral health.
        Matern Child Health J. 2006; 10: S169-S174
        • Perou R.
        • Bitsko R.H.
        • Blumberg S.J.
        • et al.
        Mental health surveillance among children—United States, 2005–2011.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 1-35
        • Olfson M.
        • Blanco C.
        • Wang S.
        • et al.
        National trends in mental health care of children, adolescents, and adults by office-based physicians.
        JAMA Psychiatry. 2014; 71: 81-90
        • Angold A.
        • Costello E.J.
        • Farmer E.M.
        • et al.
        Impaired but undiagnosed.
        J Am Acad Child Adolesc Psychiatry. 1999; 38: 129-137
        • Hoagwood K.
        • Burns B.J.
        • Kiser L.
        • et al.
        Evidence-based practice in child and adolescent mental health services.
        Psychiatr Serv. 2001; 52: 1179-1189
        • Stein R.E.K.
        • Storfer-Isser A.
        • Kerker B.D.
        • et al.
        Beyond ADHD: how well are we doing?.
        Acad Pediatr. 2016; 16: 115-121
        • Horwitz S.M.
        • Hurlburt M.S.
        • Zhang J.
        Patterns and predictors of mental health services use by children in contact with the child welfare system.
        in: Webb M.B. Dowd K. Jones Harden B. Landsverk J. Testa M. Child Welfare and Child Well-being—New Perspectives From the National Survey of Child and Adolescent Well-being. Oxford University Press, New York, NY2010: 279-329
        • Thomas J.F.
        • Temple J.R.
        • Perez N.
        • et al.
        Ethnic and gender disparities in needed adolescent mental health care use.
        J Health Care Poor Underserved. 2011; 22: 101-110