Behavior Problems and Placement Change in a National Child Welfare Sample: A Prospective Study

NEW RESEARCH

Behavior Problems and Placement Changein a National Child Welfare Sample:

A Prospective StudyGregory A. Aarons, Ph.D., Sigrid James, Ph.D., Amy R. Monn, B.A.,

Ramesh Raghavan, M.D., Ph.D., Rebecca S. Wells, Ph.D., Laurel K. Leslie, M.D., M.P.H.

Objective: There is ongoing debate regarding the impact of youth behavior problems onplacement change in child welfare compared to the impact of placement change on behaviorproblems. Existing studies provide support for both perspectives. The purpose of this studywas to prospectively examine the relations of behavior problems and placement change in anationally representative sample of youths in the National Survey of Child and AdolescentWell-Being. Method: The sample consisted of 500 youths in the child welfare system without-of-home placements over the course of the National Survey of Child and AdolescentWell-Being study. We used a prospective cross-lag design and path analysis to examinereciprocal effects of behavior problems and placement change, testing an overall model andmodels examining effects of age and gender. Results: In the overall model, out of a total ofeight path coefficients, behavior problems significantly predicted placement changes for threepaths and placement change predicted behavior problems for one path. Internalizing andexternalizing behavior problems at baseline predicted placement change between baseline and18 months. Behavior problems at an older age and externalizing behavior at 18 months appearto confer an increased risk of placement change. Of note, among female subjects, placementchanges later in the study predicted subsequent internalizing and externalizing behaviorproblems. Conclusions: In keeping with recommendations from a number of professionalbodies, we suggest that initial and ongoing screening for internalizing and externalizingbehavior problems be instituted as part of standard practice for youths entering or transition-ing in the child welfare system. J. Am. Acad. Child Adolesc. Psychiatry, 2010;49(1):70–80. Key Words: mental health, child, adolescent, child welfare, placement change

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F or more than a quarter century, child wel-fare policy and practice have aimed toachieve permanency and placement stabil-

ity for abused and neglected children removedfrom their primary caretaker and placed intoout-of-home care. Despite these efforts, a signif-icant number of children in out-of-home carehave continued to experience extended stays incare and repeated placement changes.1 TheAdoption and Safe Families Act of 19972 placedrenewed emphasis on permanency and adoptionand encouraged expansion of “state standards toensure quality services for children in foster

This article is discussed in an editorial by Dr. Schuyler W.

iHenderson on page 11.

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are.”2 The Fostering Connections to Success andncreasing Adoptions Act of 20083 further re-ewed emphasis on “child safety, permanency,nd well being.” In addition, states have beenequired to collect and report data on placementtability. Although more than 80% of states meetlacement stability performance standards forhorter periods in care, the percentage decreasesignificantly when children stay in care longer.4

here is further indication from regional studieshat 25% to 50% of children experience more thanwo placements while in out-of-home care, andhat about 10% to 15% experience very highumbers of placement changes.5-7 Such instabil-

ty is almost universally considered to be harm-ul.8

Empirical studies have for some time exam-

AL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 49 NUMBER 1 JANUARY 2010

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BEHAVIOR PROBLEMS AND PLACEMENT CHANGE

bility.7,9-13 Four variables have consistently beenlinked to a higher number of placement changes:higher levels of behavioral or emotional prob-lems, older age of the child, extended stays incare, and placement type (e.g., children in kin-ship care tend to experience fewer placementchanges compared to children in group home orresidential care).7,9,11,14,15 Findings regarding theassociation between placement instability andother factors, such as gender and race/ethnicityof the child, characteristics of the biological fam-ily, or caseworker characteristics have remainedequivocal.10,13,16,17

Of particular interest to mental health provid-ers is the relation between placement instabilityand behavior problems given growing evidenceof the prevalence of emotional and behavioralproblems among children in foster care.18,19 Moststudies investigating this relation have beencross-sectional, precluding definitive inferencesabout the directionality of effects. Assignment ofplacement change as an independent or a depen-dent variable has been conceptually driven andguided by two basic hypotheses: children expe-rience placement instability because of their at-tributes on entering care (e.g., the presence ofbehavior problems leads to a higher risk ofplacement changes) and placement instabilitycauses poor outcomes, including increased levelsof behavior problems. This latter hypothesis isgrounded in attachment theory and argues thatfrequent placement change undermines chil-dren’s ability to build stable relationships,20 ulti-mately leading to adverse outcomes in the shortand long term. This research suggests a need forthe child welfare system to improve well-beingoutcomes by prioritizing services and interven-tions aimed at stabilizing children’s out-of-homecare experience.

At this point, there is support for both hypoth-eses, that behavioral problems predict out-of-home placements and that out-of-home place-ments predict subsequent behavior problems.Studies have found higher levels of behaviorproblems, in particular externalizing problems,to be one of the most consistent predictors offrequent placement changes.7,9,11,13-15,21,22 Fewerstudies have attempted to examine whetherplacement changes cause behavior problems, andthese have produced inconsistent findings. Sev-eral studies have demonstrated that a highernumber of placement changes is associated with

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

earch on preschoolers in foster care has reportedo variation in child outcomes by placement

ength or number of placements.28,29

Determining the precise relation between be-avior problems and placement changes has re-ained difficult given methodologic con-

traints.30 A few studies have tried to addresshese constraints and disentangle the complexelation between behavior problems and place-ent changes. Two studies deserve further atten-

ion. Newton et al.25 tried to specifically disen-angle the relation between behavior problemsnd placement change, using child welfare ad-inistrative and clinical survey data in an 18-onth longitudinal foster care cohort study. The

esearchers divided their sample of 415 subjectsnto two groups. One group scored below bor-erline cutpoints on the three Child Behaviorhecklist (CBCL31) broad-band scales (internaliz-

ng, externalizing, and total behavior problems);he second group scored above at least oneutpoint. The study generated several importantndings: externalizing behavior problems are aignificant predictor of a higher number of place-ent changes; frequent placement changes con-

ribute to increased internalizing and externaliz-ng behavior problems; and a high number oflacement changes adversely affected childrenho initially did not score above the borderline

utpoint. Results have suggested that behaviorroblems should be conceptualized as a causend as an effect of placement disruptions. An-ther recent study by Rubin et al.26 used datarom the National Survey on Child and Adoles-ent Well-Being (NSCAW), a prospective na-ional study, to examine the independent impactf placement stability on behavioral outcomes,ontrolling for baseline attributes. Using a pro-ensity score-matching approach, the investiga-

ors found that children experiencing instabilityn foster care were more likely to have behaviorroblems regardless of their initial risk level.owever, the study did not use all waves of data,

ncluded youths younger than 2 years at baselinewith temperament as a proxy for behavior prob-ems), and used categorical, rather than continu-us, measurements of placement stability (i.e.,arly stability, late stability, unstable).

The present study used a prospective cross-lagodeling approach to further disentangle the

omplex relation between placement change andehavior problems. Using data from the

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children and families involved with the childwelfare system, our analyses capitalize on theavailability of placement and clinical survey datacollected at several data points over a 36-monthperiod. Beyond examining the relation betweenplacement change and behavior problems, thisstudy also investigates how age and gendermoderate this relation. These extensions clarifythe applicability of findings to children in devel-opmentally distinct age groups and across boysand girls, in whom behavioral problems oftenemerge in different ways.

METHODOverviewThe NSCAW was authorized under the Personal Re-sponsibility and Work Opportunity Reconciliation Actof 199632 and is the first national prospective study toexamine the experiences of children and families in-volved with the child welfare system. NSCAW used astratified two-stage cluster sampling strategy to select100 primary sampling units (PSUs) from a nationalsampling frame, with the probability of PSU selectionproportional to the size of the PSU’s service popula-tion. Of the 100 PSUs identified by the samplingstrategy, the NSCAW study ultimately collected child-level data in 92 PSUs representing 96 counties in 36states. The NSCAW study has involved four waves ofdata collection to date (baseline, 12 months, 18 months,and 36 months), with 12 months being limited tocaseworker (nonclinical) data. The sampling approachused in the study generated national estimates for thefull population of children and families entering thechild welfare system.33 Unless otherwise indicated, allparameters presented in this article are weighted in thestatistical analyses.

SampleIn participating counties, 5,501 children were selectedfrom among the population of children from birth to15 years old (one youth was 16 years old at the time ofthe baseline interview), for whom an investigation ofabuse or neglect had been opened by the child welfaresystem during a 15-month period beginning in Octo-ber 1999. Approval for this study was given by the USOffice of Management and the Budget and the institu-tional review boards of the Research Triangle Institute,University of California at Berkeley, Children’s Hospi-tal in San Diego, and numerous state or county insti-tutional review boards representing PSUs involvedwith the study. The sample for the present analysesincludes those children who were 2 to 15 years old atbaseline (children younger than 2 years were excluded

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roblems were not available) and had been in out-of-ome care for the entire 36-month study period. Thisielded a final sample of 500 youths 2 to 15 years old.hese 500 youths represent a subsample of the largerroup of youths who experienced any out-of-hometays within the 36-month study period (n � 1,298).

e compared selected youths (n � 500) to those notelected (n � 728) and found no differences by age,ender, or race/ethnicity. This subsample was choseno control for variability in placement histories (e.g.,ifferent times of entry, variability in length of stay,eentry, etc.).

roceduresield representatives conducted face-to-face inter-iews with child welfare workers and caregivers (in-luding youth data) and entered all data directly intoaptop computers. Baseline interviews with social

orkers were completed an average of 5.1 monthsfter the onset of the child welfare investigation (SD �.1 months) and caregiver interviews were completedn average 5.5 months after the investigation (SD � 2.5onths). Eighteen-month and 36-month follow-up in-

erviews with caregivers were conducted an average of0.5 (SD � 2.8) and 36.8 (SD � 2.7) months, respec-ively, after the onset of the child welfare investigation.he present study focuses on youth data from baseline,8 months, and 36 months.

easurementsemographics. Child age, gender, and race/ethnicityere collected as part of the initial case identificationrocedures and confirmed by caregiver and childelfare worker interviews. Based on major develop-ental stages of childhood, we categorized age into

hree groups: 2 to 5 years (young children), 6 to 10ears (middle childhood), and 11 years and olderadolescents).

umber of Placements. Placement history data wererovided by caseworkers’ review of a child’s casehart. Placement into out-of-home care was defined asny removal from home with at least one overnighttay in a relative or nonrelative foster care placement,roup home or residential treatment facility, shelter oretention setting, or inpatient psychiatric care. To beounted as a placement change, the child’s physicalocation of residence needed to have changed. Theseata allowed us to construct a count of the number oflacement changes between each assessment time.

ehavioral Problems. The CBCL, a widely used andsychometrically established measure,31 was used to

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the clinical range for youth. Two caregiver report formsof the CBCL were used, one for children 2 to 3 years oldand another for children 4 to 18 years old. We used theaccepted clinical cutoff T score (�64) to assess the pres-ence of clinically meaningful behavior problems.

AnalysesWe conducted a series of cross-lag path analysescontrolling for the nested design of the NSCAW studyand applied sampling weights to allow generalizationback to the population of youths in child welfare withat least one out-of-home placement. The level of ag-gregation was the PSU (k � 92). The cross-lag path-analytic approach has the advantage of testing thesequential relations of the key variables in the model(i.e., behavior problems and placement changes) re-flecting the longitudinal design of the study and thepotential bidirectionality of effects (i.e., the effects ofbehavior problems on subsequent placement changesand the effects of placement changes on subsequentbehavior problems). Figure 1 shows the general cross-lag path-analytic model to be tested. We conducted aseries of analyses to examine global effects of behaviorproblems on placement change and placement changeon behavior problems and two sets of multigroupanalyses to examine potential moderator effects (i.e.,age and gender) of behavior problems and placementchanges. Missing data were estimated using full-infor-mation maximum likelihood estimation.34 To assesspotential bias given that we used a subsample of theout-of-home population, we compared results for oursample to results for the subsample in the context ofthe full sample and found very slight and nonsignifi-cant differences in standard errors (SEs). Thus weproceeded with our analyses as planned. We alsoconducted analyses comparing youths with two orfewer placement changes to those with three or moreplacement changes, and results did not indicate a bias

FIGURE 1 Path-analytic model of reciprocal effects of bproblems were assessed at baseline, 18 months, and 36

BehaviorProblems at Baseline

PlacementChanges

Baseline – 18 Months

for either group. For the overall analysis and analyses c

xamining effects of age and gender, we report overallodel fit, path coefficients, and significance level. We

escribe path coefficients and refer to effect sizes toescribe the magnitude of effects, characterizing val-es of 0.1 as “small,” values of 0.30 as “medium,” and.5 as “large.”35

ESULTSable 1 presents descriptive data for the studyample. As shown, the sample was predomi-antly non-Hispanic African American, although

here was some variability in race/ethnicity. Ta-le 2 presents the proportion of youths with at

east one placement change by study period, age,nd gender. As shown, the proportion of youthsith at least one placement change was lower in

he later period of the study.

verall Modelwo separate path-analytic models were esti-ated to examine overall effects for externalizing

nd internalizing behavior problems. In Figures 2o 4, the path coefficients are arranged withxternalizing behavior problem coefficients la-eled with the superscript “ext” and the coeffi-ients for internalizing behavior problems la-eled with the superscript “int”. As shown inigure 2, externalizing and internalizing behav-

or problems at baseline significantly predictedlacement changes from baseline to 18 monthsith medium effect sizes. Externalizing behaviorroblems assessed at 18 months significantlyredicted placement changes from 18 to 36onths with a small effect size. Placement

vior problems and placement changes. Behaviorhs.

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significantly predict externalizing or internaliz-ing behavior problems at 18 months. Placementchanges from 18 to 36 months significantly pre-dicted externalizing behavior problems at 36months (medium effect size).

Moderated ModelsWe next conducted separate multi-group pathanalyses to determine if age or gender had animpact on the relation between behavior prob-lems and placement changes. This approach al-lows for simultaneous estimation of path coeffi-cients for each level of the moderator variables ofinterest: age (2–5 years, 6–10 years, and �11years at baseline) and gender (male, female).

Age. We conducted two multigroup path-ana-lytic models (one for externalizing problems andthe other for internalizing problems), simulta-neously estimating path coefficients for each ofthe three age groups (2–5 years, 6–10 years, and

TABLE 1 Sample Demographics

% Mean (SE)

Age at baseline, y2–5 25.6 3.42 (0.22)6–10 50.9 8.39 (0.21)�11 23.5 12.97 (0.16)

GenderMale 48.7Female 51.3

RaceBlack 49.2White 32.2Hispanic 13.3Other 5.3

CBCL T scores (�64)CBCL externalizing (baseline) 33.9CBCL externalizing (18 mo) 29.1CBCL externalizing (36 mo) 27.3CBCL internalizing (baseline) 21.6CBCL internalizing (18 mo) 16.9CBCL internalizing (36 mo) 20.8

No. of OOH placementsNo. of OOH from baseline to

18 mo1.92 (0.15)

No. of OOH from 18 to 36mo

0.28 (0.06)

Note: N � 500. CBCL � Child Behavior Checklist; OOH � out-of-home placement; T score � standardized Child Behavior Checklistscore.

�11 years at baseline). Figure 3 shows results for

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hese models. As in the previous model, the pathoefficients are arranged so that the top rowndicates externalizing problem coefficients andhe bottom row internalizing problem coeffi-ients. The coefficients read from left to right: 2 to

years/6 to 10 years/11 years and older ataseline. Thus at 18 months age groups were 4 toyears, 8 to 12 years, and 13 years and older and

t 36 months were 5 to 9, 9 to 13, and 14 years andlder. However, we refer to the groups based onheir ages at baseline. Externalizing and internal-zing behavior problems at baseline predictedlacement changes from baseline to 18 months

or 6- to 10-year-old children, and externalizingroblems predicted placement changes for those1 years and older; we found no significantffects for the youngest age group. Externalizingehavior problems at 18 months significantlyredicted placement changes from 18 to 36onths for externalizing problems for those 11

ears and older (small to medium effect size).lacement changes from baseline to 18 monthsid not significantly predict behavior problems

or externalizing or internalizing problems forny of the age groups. Placement changes from8 to 36 months significantly predicted external-zing behavior problems at 36 months for the 6-o 10-year age group (small effect size).

ender. The final set of analyses examinedhether the relation of behavior problems andlacement change varied by gender. As shown

n Figure 4, externalizing behavior problemst baseline significantly predicted placementhanges from baseline to 18 months for boys andirls, whereas for internalizing behavior prob-

ems this path was significant only for boys (all

ABLE 2 Proportion of Youths With at Least Onelacement Change by Study Period, Age, and Gender

Study Period, %

Baseline-18 mo 18-36 mo

Age at baseline, y2–5 22.3 5.76–10 51.5 9.8�11 26.2 36.7

GenderMale 44.2 17.9Female 55.8 14.4

Note: N � 500.

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medium effect sizes). Externalizing behaviorproblems at 18 months significantly predictedplacement changes from 18 to 36 months for boysand girls (medium to small effects), but therewere no significant effects for internalizing prob-lems. Placement changes from baseline to 18months predicted increased internalizing prob-lems at 18 months only for boys (small effect).Placement changes from 18 to 36 months signif-icantly predicted externalizing and internalizing

FIGURE 2 Overall model of Child Behavior Checklist efrom baseline to 36 months (n � 500, out-of-home only).Comparative Fit Index � 0.998, Tucker-Lewis Index � 0.standardized root mean square residual � 0.025. InternaFit Index � 0.99, Tucker-Lewis Index � 0.968, root meamean square residual � 0.023. Significance tests two-tai

BehaviorProblems

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Placement ChangeBaseline -18 Months

ext .48***Int .37***

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FIGURE 3 Behavior problems and placement changescoefficients: age 2 to 5 years (n � 122)/age 6 to 10 yeaExternalizing behavior problems (ext): �2 � 16.222, p �� 0.868, root mean square error of approximation � 0.Internalizing behavior problems (int): �2 � 7.747, p � .51.035, root mean square error of approximation � 0.00Significance tests two-tailed: *p � .05, **p � .01, ***p �

BehaviorProblems

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Age 2-5 / 6-10 / 11+ext .78***/.35*/.36***int . 25 / .44**/.31**

Age 2-5 / 6-10 / 11+ext -.13/.47***/.33***int .19 / .36* /.11

Age 2-5 /6-ext .05/.1int . 20/.0

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ehavior problems at 36 months but only for girlsmedium to large effects).

ISCUSSIONhe present study used a unique national longi-

udinal sample of children in child welfare toetermine the extent to which behavior problemsredicted placement changes and placementhanges predicted behavior problems over time.

alizing/internalizing disorder and placement changesrnalizing problems (ext): �2 � 3.188, p � .3635,root mean square error of approximation � 0.011,g problems (int): �2 � 3.957, p � .2662, Comparativeare error of approximation � 0.025, standardized root

*p � .05, **p � .01, ***p � .001.

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ext.41***int.52***

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ge from baseline to 36 months (n � 500). Order of� 195)/age 11 years and older (n � 183).

24, Comparative Fit Index � 0.96, Tucker-Lewis Indexstandardized root mean square residual � 0.042.

, Comparative Fit Index � 1.000, Tucker-Lewis Index �andardized root mean square residual � 0.028.1.

BehaviorProblems

at 36 Months

Age 2-5 / 6-10 / 11+ext .096 /.54***/.46***int . 69***/.58***/.31*

Age 2-5 / 6-10 / 11+ext .10/.24/.25***int -.02 /.10/.06

Age 2-5 / 6-10 / 11+ext .081/.20*/.19int . 01/.15 /.24

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Specifically, in the overall sample, externalizingand internalizing problems at baseline predictedplacement changes during the period from base-line to 18 months and externalizing problems at18 months predicted placement changes duringthe 18- to 36-month period. There was no signif-icant association in the overall sample betweenplacement change from baseline to 18 monthsand behavior problems at 18 months. However,placement changes from 18 to 36 months pre-dicted externalizing behavior problems at 36months.

The general patterns found in the overall modelheld when separate multigroup analyses consid-ered effects of youth age and gender, althoughsome exceptions emerged. For example, baselinebehavior problems in preschoolers did not influ-ence placement changes and this finding is consis-tent with at least one previous study.28,29 In fact, theone age group for which externalizing behaviorsconsistently predicted placement changes wasyouth who were 11 years or older at baseline. Inregard to placement change predicting subsequentbehavior problems, only placement changes duringthe 18- to 36-month period predicted higher rates ofexternalizing problems for 6- to 10-year-old chil-dren (age at baseline). In regard to gender differ-ences, externalizing and internalizing behaviorproblems at baseline predicted placement changesfor boys at 18 months, whereas only externalizingbehavior problems at baseline predicted placement

FIGURE 4 Behavior problems and placement changescoefficients � male (n � 237)/female (n � 263). ExternaComparative Fit Index � 0.966, Tucker-Lewis Index � 0.standardized root mean square residual � 0.033. InternaComparative Fit Index � 0.981, Tucker-Lewis Index � 0.standardized root mean square residual � 0.026. Signifi

BehaviorProblems

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Male / Femaleext .56***/.43*Int .24 /.46**

Male / Femaleext .34***/.31** int .38***/.15

Male / Fext .12/.1int .20***

changes for girls. o

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Although slightly more consistent effects wereeen for the effect of youth behavior problems onubsequent placement changes, there were aumber of reciprocal effects. For example, in theverall sample, we found a significant effect forlacement changes from 18 to 36 months toredict externalizing behavior problems at 36onths. The analyses examining gender effects

uggested that boys and girls may have differenttrengths of associations of the placementhanges on behavior problems, with boys evi-encing larger effect sizes for externalizing and

nternalizing problems from baseline to 18onths predicting behavior problems at 18onths, whereas girls exhibited larger effects for

xternalizing and internalizing problems at 36onths.Our analyses support the hypothesis that be-

avior problems can affect placement changesnd support the hypothesis that placementhanges can lead to behavior problems. Thus, weecommend focusing on helping children man-ge their behavior, providing training for care-ivers to respond effectively to child behavioralroblems, and the development of strategies to

ncrease placement stability.The fact that placement changes were associ-

ted only with subsequent behavioral problemsor middle childhood and adolescence may re-ect developmental challenges for youths and

he need for caregivers to effectively manage

ender from baseline to 36 months (n � 500). Order ofg behavior problems (ext): �2 � 10.859, p � .0928,root mean square error of approximation � 0.057,g behavior problems (int): �2 � 8.137, p � .2282,root mean square error of approximation � 0.038,

e tests two-tailed: *p � .05, **p � .01, ***p � .001.

BehaviorProblems

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Male / Femaleext .50***/.31*int .61***/.35*

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refers to ages at baseline, this group was 6 to 10years old at baseline and 8 to 12 years old by 18months. If parenting is less effective for theseolder children, a consequence may be more act-ing-out by children. In addition, a number ofinfluences could affect youth behavior. For exam-ple, 8- to 12-year-old children are likely to beincreasingly exposed to preteen and teenage rolemodeling, which may lead to behavior that chal-lenges caregiver parenting skills. It is more diffi-cult to speculate about potential factors thatmight explain why placement changes were as-sociated with externalizing problems for middlechildhood but not for adolescence, a period gen-erally considered to be even more challenging.One possibility is that adolescents’ stronger peeraffiliations may buffer them from the effects ofplacement instability; however, placementchanges often imply concomitant neighborhoodand school changes, which could undermine peernetworks. Still this discussion must be temperedwith the finding that even some coefficients withmoderate effect sizes were not statistically signif-icant, likely due to the small samples withinsome of the age groups. Thus, further work isneeded to better understand the reliability andmechanisms of these effects.

The finding that placement changes did notpredict externalizing problems for boys appearsto contradict the finding of Ryan and Testa36 thatplacement instability increased the risk of delin-quency for boys. For girls, the behavioral conse-quences of placement changes appeared toemerge more slowly with medium to large ef-fects. This finding warrants further exploration.For example, girls may respond to placementdisruption differently than boys; however, themechanisms by which this occurs remain to beidentified. Other potential moderators of the re-lation between behavior problems and placementchange might also be explored in future studies.For example, placement duration or receipt ofmental health services might influence these re-lations.37

Although we did find that placement changespredicted subsequent behavioral problems, theseeffects were less consistent relative to behaviorproblems predicting placement changes. Theremay be a number of reasons for this. First, weused a subsample of children who had experi-enced continuous placement in out-of-home care.However, our sample could differ from the larger

n ways not assessed in this study. Second, inontrast to studies by Rubin et al.26 and Newtont al.,25 we used a prospective design assessingehavior problems and placement changes atultiple time points. This allowed us to examine

he sequencing of behavior problems and place-ent changes. Third, other studies examining the

mpact of placement change focused on otherutcomes such as educational performance23,27

r used samples with characteristics differentrom ours (e.g., young adopted children).24

Another possible reason for variability in as-ociations between placement changes and be-avioral problems could be that new caregiversay be less likely to detect behavioral problems

especially internalizing problems) than caregiv-rs who have had children in their homes foronger periods. Future research could test thispeculation, at least for youth 11 years and older,y comparing youth self-reports to caregivereports across multiple points in time.

Some children may possess sufficient resil-ence to sustain functioning despite placementhanges. A recent qualitative study of formeroster youth with multiple placement movesighlighted a range of coping strategies utilizedy youth to adapt after a placement disruption.38

owever, our finding that placement changes at8 to 36 months predicted externalizing andnternalizing problems for girls suggests thathere may be gender-specific vulnerabilities rela-ive to the long-term effects of placementhanges. Thus, further study of gender differ-nces in the impact of placement instability onubsequent behavioral problems is clearly war-anted.

In addition, for children engaged in the childelfare system, the alternative to out-of-home

are may not always be greater stability. Forxample, chronic maltreating families tend toove more than other families23 and to experi-

nce changes in household composition (e.g.,ttendant to partner violence or a parent beingncarcerated) that may in some respects be ashallenging for children as placement in out-of-ome care. Indeed, there is some evidence thatouth who returned to their families after place-ent in foster care have more behavioral and

motional problems than youth who do not re-urn.39 Our findings combined with that of Eck-nrode et al.23 that foster care did not moderatehe effects of general placement mobility on

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home placements do not necessarily disadvan-tage children compared to other children in thechild welfare system.30

Our findings may also reflect the generallylow number of placement changes in this sample,which averaged lower than two from baseline to18 months and just over a quarter of one changefrom 18 to 36 months (Table 1). Previous researchhas linked worse outcomes with multiple place-ment changes,26,27,36,40 with the highest risks be-ing associated with having had a high number ofsuch moves.25,41 For example, Thornberry et al.41

found a greatly increased risk of delinquency foryouth with more than four placement changes.Thus, there may be a step function such thatfewer than one or two changes results in lowerrisk, whereas some number greater than twodoes increase risk. However, when we comparedyouths with up to two placement changes (about55% of our sample) to youths with three or moreplacement changes, we found no evidence of biasfor either group to be consistently more likely toexperience effects of placement change and sub-sequent behavior problems. Still, there may beother thresholds not identified in the presentstudy and this should be explored further.

It is possible that the effects of placementchanges are not entirely negative. Youths maychange placements due to a number events (e.g.,behavior problems, foster-parent or kinship careavailability, court rulings).11 Children removedfrom their homes of origin typically need to learna range of new behaviors and ways of interpret-ing others’ behaviors. For at least some of thesechildren, new homes may present new opportu-nities to relate effectively with caregivers, fostersiblings, and peers at school.38 Such experiencescould counteract stress or trauma attendant toplacement moves.

These data strongly suggest that behavior prob-lems evidenced in the period after an investigationand initial placement in out-of-home care affect thenumber of placement changes youth experience insubsequent months. Externalizing and internaliz-ing problems were found to affect placementchanges, but there was also overlap in symptomssuggesting even more complexity than that repre-sented in analyses presented in this report. Al-though beyond the purview of the present study, itis recommended that consideration of youth at-tachment to caregivers be a part of clinical inter-ventions at placement, placement change, and re-

78 www.jaacap.org

mprove the skills of foster parents.42 Foster-parentupports and training such as that providedhrough the Multidimensional Treatment Fosterare model43 may help to fulfill this need in childelfare systems.The costs associated with each placement

hange are another important concern and can beubstantial. Work in unit cost analysis done in thenited Kingdom should be replicated in the United

tates to provide a deeper understanding of thesessues.44 The additional complexity of behaviorroblems and the costs associated with placementhange support the importance of early identifica-ion and treatment of behavior problems within aonstrained period after placement in foster care.owever, improved screening will not resolve theroblem in the absence of effective interventionsith foster youth with behavior problems. Chil-ren with known behavior problems are difficult tolace in foster homes; and despite the growingvailability of treatment foster care, these programsan serve only a limited number of children. More-ver, the only evidence-based treatment fosterare model—Multidimensional Treatment Fosterare—is even less available.45 Foster caregivers

end to be undertrained in the management ofmotional and behavioral problems. How to effec-ively deal with foster youth who have been as-essed as presenting with emotional or behavioralroblems remains one of the main challenges of thehild welfare system.

Some limitations of the present study should beoted. First, as noted above, our analysis is basedn a subsample of youth with extended stays inut-of-home care. This limits the generalizability ofur findings. Second, we did not examine the

mpact of different types of placement changes, andhere may be differential effects of placement tooster care versus congregate care. For example,lder age correlates with placements in congregateare settings, which may have a positive or nega-ive effect. Third, we did not stratify by the num-ers of placement changes experienced by youths.lthough there was a wide range of placement

hanges, the mean number of placement changesas low in this sample. Exploration of this issueas beyond the purview of the present study but is

n area for future research. Fourth, CBCL ratingsay have been made by different informants over

ime. Although some variability in respondent for aiven child may be present, the CBCL is a well-tandardized measurement that uses behaviorally

aacewicoswatwbtac

gate concern about this issue. Fifth, in some casesnonsignificant path coefficients were similar inmagnitude to statistically significant coefficients.This was likely due to small cells for particularsubgroups (e.g., age groups). Future studies shouldaddress this issue with larger samples to determineif similar effects are found to be statistically andclinically meaningful. Sixth, the variables used inthe present study did not fully mirror other studiesexamining similar issues. However, the presentstudy made use of all available waves of youthdata, and we included measurements of behaviorproblems and placement change and used the fullrange of the data, rather than using data-reductionapproaches that limit variability.

The present study’s findings suggest that somepractical steps could be taken. For example, initialscreening and assessment for emotional or behav-ioral problems to help caseworkers and serviceproviders to refer youths for services to address notonly emotional distress but also potential futureplacement disruptions among children in the childwelfare system and in foster care, in particular. Theneed for such surveillance has been asserted innational standards proposed by the Child WelfareLeague of America,46 the American Academy ofPediatrics,47,48 and the American Academy ofChild and Adolescent Psychiatry.49,50 These recom-mendations are highly convergent, suggesting thatall children in out-of-home placements should re-ceive mental health screening at the point of initialinvestigation or assessment followed by compre-hensive mental health assessment by a mentalhealth professional within a month if the assess-ment indicates behavioral problems. Such initial

and continuity of the foster care system in the United States. IntSoc Work. 1984;27(1):5-9.

t the time of transitions in living arrangementsnd referral to mental health services if a need isonfirmed. We suggest that these standards bextended to all youths involved with the childelfare system. Unfortunately, only a third of key

nformants in state and county mental health agen-ies report being aware of these standards, andnly about half of mental health agencies playignificant roles in the design of services to childelfare populations.51 Absent shared case-finding

nd coordinated service delivery mechanisms withheir respective mental health departments, child

elfare agencies may have difficulty achievingetter performance on placement standards onheir own, but effort is needed to more effectivelyddress the mental health needs of youths in thehild welfare system. &

Accepted September 28, 2009.

Dr. Aarons is with the University of California, San Diego, and theChild and Adolescent Services Research Center, Rady Children’sHospital, San Diego. Dr. James is with Loma Linda University. Ms.Monn is with the Institute of Child Development, University of Minne-sota. Dr. Raghavan is with Washington University, St. Louis. Dr. Wellsis with the University of North Carolina at Chapel Hill. Dr. Leslie is withthe Tufts Medical Center, Floating Hospital for Children, and TuftsClinical and Translational Science Institute.

This work was primarily supported by NIMH grant R01MH059672(PI: Landsverk) and in part by R01MH072961 (PI: Aarons).

We thank Jinjin Zhang, M.Sc., M.A., for conducting data analyses forthis study.

Disclosure: Drs. Aarons, James, Raghavan, Wells, and Leslie, and Ms.Monn report no biomedical financial interests or potential conflict ofinterest.

Correspondence to Dr. Gregory A. Aarons, University of California,San Diego, Department of Psychiatry, 9500 Gilman Drive (0812),La Jolla, CA, 92093-0812; email: gaarons@ucsd.edu

DOI: 10.1016/j.jaac.2009.09.005

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Behavior Problems and Placement Change in a National Child Welfare Sample: A Prospective Study

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