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To comprehensively assess family services, health, and health care outcomes for US children in kinship care vs foster care.
A 3-year prospective cohort study.
National Survey of Child and Adolescent Well-Being.
The sample consisted of 1308 US children entering out-of-home care following reported maltreatment.
Kinship care vs foster care.
Main Outcome Measures
Baseline caregivers' support services and the children's behavioral, mental health, and health service use outcomes 3 years after placement.
Kinship caregivers were more likely than foster caregivers to have a low socioeconomic status but reported significantly fewer support services (caregiver subsidies, parent training, peer support, and respite care). Kinship care was associated with a lower risk ratio (RR) of continuing behavioral problems (RR = 0.59; 95% confidence interval [CI], 0.41-0.80), low social skills (RR = 0.61; 95% CI, 0.40-0.87), mental health therapy use (RR = 0.45; 95% CI, 0.27-0.73), and psychotropic medication use (RR = 0.46; 95% CI, 0.24-0.82) but higher risk of substance use (RR = 1.88; 95% CI, 0.92-3.20) and pregnancy (RR = 4.78; 95% CI, 1.07-17.11).
Kinship caregivers received fewer support services than foster caregivers. Children in kinship care fared better with behavioral and social skills problems, mental health therapy use, and psychotropic medication use. Adolescents in kinship care may be at higher risk for substance use and pregnancy.
More than 125 000 US children live in out-of-home kinship care.1 Although most children in state conservatorship (out-of-home care) live in nonrelative foster homes, the number of children placed in kinship care has increased dramatically owing to the increasing demand for out-of-home placement and a decline in the number of nonrelative foster homes.2-4 In addition, the Fostering Connections to Success and Increasing Adoptions Act of 2008,5 which aims to improve outcomes of children entering out-of-home care, supports the placement of children in kinship care by requiring the child welfare system (CWS) to increase efforts to find and notify relatives when children are removed from the care of their parents.
Despite the move toward kinship care, the evidence for improved outcomes of children in kinship care vs foster care has been conflicting. While children in kinship care experience greater placement stability and improved behavioral outcomes compared with children in foster care,6-10 studies have not demonstrated significant differences in adult functioning between the 2 groups.10,11 Children in kinship care may also receive fewer health care services than children in foster care despite a high prevalence of health care needs.12-15 In addition, concerns remain regarding the lower level of child welfare supervision and caregiver support in the kinship environment16-18 and the decreased likelihood for permanency when compared with foster care.6
The conflicting evidence underscores the need for a more in-depth examination of health and health care outcomes of children in kinship care vs foster care. Comprehensive analyses of national data have not been available to determine whether differences in health and health care outcomes exist for children in kinship care. The aim of this study therefore was to compare behavioral and mental health outcomes as well as health care access and use of health services for US children placed in kinship care vs foster care 3 years after placement. A secondary aim of this study was to compare differences in caregiver support services at the time of placement in kinship care vs foster care.
The data source was the National Survey of Child and Adolescent Well-Being (NSCAW), a nationally representative survey conducted by the US Department of Health and Human Services on the well-being of children in the US CWS. Subjects were 0- to 14-year-olds randomly selected following reported maltreatment from 92 child welfare agencies across the country from October 1999 to December 2000. Of the 8961 children selected, 5501 child-caregiver dyads participated in baseline interviews (61.4% response rate). After obtaining informed consent from the nonparental caregiver who knew the most about the child's health and obtaining assent from children aged 7 years or older, face-to-face interviews and assessments were conducted 2 to 6 months after reported maltreatment. All out-of-home caregivers would have taken over care of the children within this period. Interviews included an extensive battery of survey questions and instruments that were tailored to the age of the child and the type of caregiver (out-of-home vs parental). Follow-up interviews were conducted in a similar fashion 3 years later. The primary caseworkers were also interviewed to determine abuse history and placement details at baseline and 3 years after the initial report (additional details on NSCAW methods are provided elsewhere19).
From the 5501 children in the NSCAW sample, 1308 children were included in the analyses based on placement in out-of-home kinship care and nonrelative foster homes as reported by the caregiver at baseline interviews. At the 3-year follow-up, 88.5% of the kinship group and 85.5% of the foster care group completed follow-up interviews and assessments.
Baseline independent variables determined through caregiver interviews included the child's age (categorized into ages 0-2, 3-5, 6-10, and ≥11 years), sex, race/ethnicity, and the caregiver's age (categorized into ages <35, 35-54, and ≥55 years), race/ethnicity, marital status, educational attainment, employment status, and income. Baseline child behavioral problems were assessed by the caregiver using the Child Behavior Checklist (CBCL)20 for children aged 2 years or older and the National Survey of Youth early temperament score21 for children younger than 2 years using previously established methods.22 A child was identified as having behavioral problems if the total standardized score of the CBCL (including internalizing and externalizing problems) was above the established borderline or clinical range or if the standardized early temperament score was 1 or more SDs from the normed mean in the negative hedonic and difficult domains. In addition, whether a household had multiple children (defined as >3) was also included as an independent variable.
Caseworkers were asked to identify whether the reported maltreatment was substantiated after investigation and the single most serious type of maltreatment: physical abuse, sexual abuse, neglect/abandonment, or other (including exploitation and emotional, educational, or moral/legal maltreatment). Substantiation depended on local child welfare practices and the availability of sufficient evidence for child maltreatment; therefore, certain high-risk cases resulting in out-of-home placement might not have been classified as substantiated.
Caregivers were interviewed regarding the services received from the CWS and the community, including financial support (Temporary Assistance for Needy Families and caregiver subsidies), parent education and training, peer support groups, and respite care. Caregivers were also asked whether they had input into the service plan, which specifies services to the child and family for achieving permanency goals on entering the CWS.
Placement stability and permanency were examined at the 3-year follow-up by determining the total number of placements and days in out-of-home care and whether the child was with a permanent caregiver (including reunification with a biological parent, adoption, or permanent custody).
For all children, behavioral problems and social skills problems were based on assessments by caregivers using the CBCL and the parent form of the Social Skills Rating System,23 which has a 58% correlation with the CBCL. Behavioral problems and social skills problems were based on standard clinical threshold scores for the CBCL and Social Skills Rating System, respectively. In addition, adolescents aged 11 years or older were directly questioned regarding risk-taking behavior, including pregnancy, substance use, and delinquency. Adolescents were asked, “In the past 30 days, how many days did you [drink alcohol, smoke a cigarette, chew tobacco, use pot, sniff glue to get high, use hard drugs, take a pill without a prescription]?” A response of 1 day or more to any of the substances was considered substance use. Pregnancy was determined by asking the youth whether he or she had ever “gotten someone pregnant” or been pregnant. A self-reported delinquency scale addressed delinquent acts in areas of felony assault, felony theft, robbery, fraud, minor theft, illegal services, public disorder, status offenses, and property damage. Youths were dichotomized into having no acts vs 1 or more acts in any area in the last 6 months.
Mental health outcomes included the prevalence of depression, posttraumatic stress disorder, psychotropic medication use, and outpatient mental health therapy use. The diagnosis of depression was determined using standard clinical threshold scores for the Child Depression Inventory,24 a self-report inventory normed for children aged 7 years or older that measures cognitive, affective, and behavioral signs of depression. The diagnosis of posttraumatic stress disorder was given if the total standardized score of the Trauma Symptoms Checklist for Children,25 a self-report instrument normed for children aged 8 years or older, was at the established clinical range. Psychotropic medication use was determined by asking the caregiver whether the child was “currently taking any prescription medication for emotional, behavioral, learning, attentional, or substance abuse problems.” Outpatient mental health therapy included therapy for substance use or emotional and/or behavioral problems through a mental health center, drug and/or alcohol clinic, private professional, in-home counseling, school counseling, or primary care physician.
Measures of health care access and utilization were evaluated by asking caregivers about health insurance status and whether the child was up to date with immunizations. Caregivers were also asked about health services received during the past 18 months, including vision and hearing screening, dental care visits, and emergency department use or hospitalization for illness or injury.
Descriptive analyses using Pearson χ2 tests compared baseline child and caregiver characteristics. Unadjusted associations between initial placement setting and baseline caregiver services as well as initial placement setting and outcomes at the 3-year follow-up were expressed as risk ratios to reflect more accurate estimates of associations that better represent the true relative risks.26,27 The reference group for all analyses was children initially in foster care.
Multivariable analyses of health and health care outcomes at the 3-year follow-up controlled for the child's race/ethnicity, age, and other characteristics significantly associated (P < .05) with initial placement setting (child's sex, baseline behavioral problems, number of children in the household, maltreatment substantiation, and caregiver's age, marital status, educational attainment, employment status, and income). Placement stability (whether the child was with a permanent caregiver and the total number of placements) was also controlled for when evaluating health and health care outcomes at the 3-year follow-up.
We used SAS version 9.1 statistical software (SAS Institute, Inc, Cary, North Carolina) for all analyses. Analyses were conducted with sampling weights to allow for generalization to the entire population of US children in the CWS. This study was approved by the institutional review board of the University of Texas Southwestern Medical Center.
Of the 1308 children in our study sample, 572 were in kinship care and 736 were in foster care. There was no significant difference in the age distribution or race/ethnicity of the children at the time of placement (Table 1). Children in kinship care compared with children in foster care were more likely to be female and to live in households with more than 3 children, but they were less likely to have behavioral problems at baseline (34.1% vs 46.9%, respectively; P = .04). Neglect/abandonment was the predominant form of reported maltreatment for children in both kinship and foster care; however, a greater proportion of all maltreatment cases was substantiated among those placed in foster care (69.5%) than in kinship care (54.2%).
Kinship caregivers were older and substantially more likely to be single than foster caregivers (Table 1). Kinship caregivers were 4 times more likely to have not graduated high school and about 3 times more likely to have an annual household income less than $20 000. They were also more likely to be unemployed. No significant differences were noted in caregiver race/ethnicity or health status.
Kinship caregivers compared with foster caregivers were 0.4 times as likely to receive any form of financial support to care for the child (29.7% vs 83.1%, respectively) (Table 2). Temporary Assistance for Needy Families was the predominant form of financial support for kinship caregivers. Conversely, foster caregivers mostly received financial support through caregiver subsidies. Kinship caregivers were about 4 times less likely than foster caregivers to receive any form of parent training (16.4% vs 70.1%, respectively). Compared with foster caregivers, kinship caregivers were about 7 times less likely to have peer support groups or respite care; only 5.2% and 4.9% of kinship caregivers reported having these respective services. Kinship caregivers were also 0.75 times as likely as foster caregivers to have had input into the service plans (49.5% vs 66.0%, respectively).
At the 3-year follow-up, children in kinship care were more likely than children in foster care to be with a permanent caregiver (71.0% vs 56.4%, respectively); however, there were no significant intergroup differences in the mean number of placements and median number of days in out-of-home care (Table 3). Children in kinship care compared with children in foster care had 0.6 times the risk of behavioral problems (30.2% vs 53.1%, respectively) and social skills problems (23.6% vs 40.1%, respectively), even after adjusting for potential confounders. Adolescents in kinship care compared with adolescents in foster care had nearly 7 times the risk of pregnancy (12.6% vs 1.9%, respectively) and 2 times the risk of substance use (34.6% vs 16.9%, respectively). When accounting for potential confounders, the risk of pregnancy remained significantly greater for adolescents in kinship care than in foster care (adjusted risk ratio = 4.78; 95% confidence interval, 1.07-17.11); however, the risk of substance use did not remain statistically significant (adjusted risk ratio = 1.88; 95% confidence interval, 0.92-3.20). The rates of clinical depression and posttraumatic stress disorder did not significantly differ between the 2 groups; however, children in kinship care compared with children in foster care had half the risk of outpatient mental health therapy (19.7% vs 40.0%, respectively) and psychotropic medication use (13.6% vs 27.6%, respectively). The risks remained similar after adjustments for confounders. There were no significant intergroup differences in other measures of health care access and utilization.
The study findings reveal that children in kinship care are substantially more likely to live in poor households and to be cared for by caregivers who are older, single, unemployed, and not high school graduates. These nationally representative findings are consistent with prior smaller regional studies16-18 and emphasize that kinship caregivers have a substantial need for support services. Despite the need for support services,2,17 kinship caregivers were found to be substantially less likely than foster caregivers to receive financial support, parent training, peer support groups, and respite care. In addition, kinship caregivers were less likely than foster caregivers to have input into service plans, which specify the services to families on entering the CWS. Caregivers' input into service plans may help agencies serve kinship families more effectively and efficiently.
Financial support for kinship families has traditionally come from Temporary Assistance for Needy Families state funds, which are generally less than Title IV-E foster care payments (caregiver subsidies) and have work requirements and time limits.28 Changing state policies have greatly influenced the payment amounts and the ability of relative caregivers to access these funds.28,29 In addition, requirements to meet foster care licensing standards to obtain caregiver subsidies have limited the amount of financial support available to relative caregivers. Study findings emphasize the need for state policy changes on the way funds are distributed to kinship caregivers and the need for greater assistance to caregivers to obtain currently available financial support. Additional avenues to assist kinship families might include peer support groups and respite care30 through use of wraparound programs and kinship navigator programs, which are intended to link relative caregivers to a broad range of services and supports.5
Children in kinship care were significantly more likely to be with a permanent caregiver at the 3-year follow-up. While this finding is consistent with prior studies reporting the stability of kinship placements,6-8 children in kinship care continue to have prolonged courses in out-of-home care. Kinship guardianship assistance programs offer financial support to relative caregivers interested in permanent custody.5 Implementation of these programs may decrease the duration that children in kinship care remain in state custody and may further improve placement stability and permanency.
Compared with children in foster care, children in kinship care had significantly lower risks of behavioral problems and poor social skills at the 3-year follow-up. These nationally representative findings on the behavioral outcomes of kinship care vs foster care are consistent with prior studies.8-10 The prevalence of behavioral problems for children in foster care increased over time, from 46.9% at baseline to 53.1% at the 3-year follow-up. Conversely, children in kinship care did not experience such an increase in the prevalence of behavioral problems (from 34.1% at baseline to 30.2% at the 3-year follow-up). The findings suggest that increased placement of children with behavioral problems in kinship care may be beneficial to help prevent escalation of behavioral problems.
A troublesome finding is the higher risk of substance use and pregnancy in youths in kinship care compared with youths in foster care. High rates of substance use and pregnancy among adolescents in the CWS have been noted previously31,32; study findings highlight the need for increased attention to substance use and pregnancy in youths in kinship care. The lower prevalence of these risk-taking behaviors in youths in foster care might relate to the higher degree of agency and caregiver supervision. Health care providers caring for youths in kinship care should increase efforts to screen youths and caregivers for high-risk behaviors33 and to educate them about pregnancy prevention. Greater adult mentorship of youths in kinship care might also reduce these high-risk behaviors and improve adult outcomes for these youths.34,35
Kinship care is also associated with lower risks of outpatient mental health service use and psychotropic medication use. Caution should be used when interpreting these findings, however, because the prevalence of mental health problems such as depression and posttraumatic stress disorder was not significantly different between the 2 groups at the 3-year follow-up. Additional studies are needed to confirm whether children in kinship care experience better mental health outcomes than children in foster care10 or whether barriers to mental health care access are more prevalent for children in kinship care than for children in foster care.36,37
Certain study limitations should be noted. The main independent variable was initial placement in kinship care vs foster care; changes in placement settings were not analyzed in this study. This approach is most relevant to child welfare policy on where to place children initially, once they are removed from the home. The impact, however, of the duration in each of these placement settings and of the final placement setting on child well-being outcomes requires additional research.
This study compared court-involved kinship care with foster care. The findings therefore may not generalize to kinship arrangements that are made without involvement of the CWS. With even less supervision and fewer resources available in these informal kinship arrangements, the well-being of children in these settings deserves more thorough investigation. Unfortunately, children in these arrangements are not readily identified in the NSCAW, which follows only children in contact with the CWS. Further research is needed on the impact of informal kinship arrangements on child well-being.
There are also potential confounders that may have affected study outcomes. Differences in outcomes may not be directly related to placement type but may be indirectly related to the reasons for the CWS selection of a particular placement type. There is a tendency for the CWS to place children with complex medical or behavioral problems in medical foster homes.38 We attempted to control for this by adding baseline behavioral problems into multivariable modeling. The lower socioeconomic status of kinship caregivers might also be a potential confounder. This was considered in multivariable modeling; however, a comparison of children in kinship care with other similarly socioeconomically disadvantaged children might help clarify the impact of maltreatment and kinship care.15
A final study limitation is the potential for reporting bias. The interviews were conducted with the caregiver who knew the most about the child's health care; however, given that these reports were not validated with medical records, there may have been underreporting or overreporting of the use of health services. Kinship caregivers or those who have known the child longer may be more aware of the child's medical history and use of health services. Conversely, foster caregivers may identify more behavioral problems.39 However, NSCAW attempts to address reporting bias by using variables obtained from different sources and by incorporating objective instruments.
The study results have several implications for policy and practice and may prove useful in implementing the Fostering Connections to Success and Increasing Adoptions Act of 2008,5 which aims to improve outcomes for children in foster care and to connect and support relative caregivers. Our findings indicate that kinship caregivers need greater support services. Opportunities to access these support services might be provided through kinship navigator programs, which provide opportunities for relative caregivers to easily access information regarding assistance and services available to them. The findings also indicate that kinship care may be associated with a reduced risk of ongoing behavioral and social skills problems and decreased use of mental health therapy and psychotropic medications. Conversely, adolescents in kinship care have higher odds of reported substance use and pregnancy. These findings suggest that increased supervision and monitoring of the kinship environment and increased caregiver support services are urgently needed to improve outcomes of children in kinship care.
Correspondence: Christina Sakai, MD, Division of General Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390.
Accepted for Publication: June 17, 2010.
Author Contributions: Dr Sakai had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sakai, Lin, and Flores. Acquisition of data: Sakai. Analysis and interpretation of data: Sakai, Lin, and Flores. Drafting of the manuscript: Sakai, Lin, and Flores. Critical revision of the manuscript for important intellectual content: Sakai, Lin, and Flores. Statistical analysis: Sakai, Lin, and Flores. Obtained funding: Flores. Administrative, technical, and material support: Sakai, Lin, and Flores. Study supervision: Sakai and Flores.
Financial Disclosure: None reported.
Disclaimer: The National Survey on Child and Adolescent Well-Being was developed under contract with the Administration on Children, Youth, and Families, US Department of Health and Human Services. The views expressed herein reflect solely the position of the authors and should not be construed to indicate the support or endorsement of its contents by the Administration on Children, Youth, and Families, US Department of Health and Human Services.
Previous Presentations: This paper was presented in part as a platform presentation in the American Academy of Pediatrics Presidential Plenary of the 2009 Annual Meeting of the Pediatric Academic Societies; May 3, 2009; Baltimore, Maryland; and as a poster at the 2009 Annual Meeting of AcademyHealth; June 20, 2009; Chicago, Illinois.
Sakai C, Lin H, Flores G. Health Outcomes and Family Services in Kinship CareAnalysis of a National Sample of Children in the Child Welfare System. Arch Pediatr Adolesc Med. 2011;165(2):159–165. doi:10.1001/archpediatrics.2010.277
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