PEDIATRICS Vol. 106 No. 1 July 2000, pp. 59-66

Specialized Assessments for Children in Foster Care

Sarah McCue Horwitz, PhD^{*, , §}, Pamela Owens, MA, and Mark D. Simms, MD, MPH

From the ^* Department of Epidemiology and Public Health and  Child Study Center, Yale University School of Medicine, New Haven, Connecticut; ^§ Institution for Social and Policy Studies, Yale University, New Haven, Connecticut; and  Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.

	ABSTRACT

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Objective.  To investigate the differences in health problems identified and health services received by children newly entering foster care who participated in a comprehensive multidisciplinary program, compared with children newly entering foster care who received customary community-based services.

Methods.  Using a 2-group quasiexperimental design, 120 young children entering foster care were enrolled in a multidisciplinary intervention program (n = 62) or were followed by customary care providers (n = 58). An interview with the foster parent; a complete medical examination; and a battery of developmental, psychological, speech/language, and motor assessments were completed for each child at baseline. Children in both groups participated in follow-up assessments at 6 and 12 months.

Results.  No significant differences between the 2 groups existed in medical, educational, developmental, or mental health problems identified by foster mothers. However, children in the intervention group were more likely to be identified with developmental (56.5% vs 8.6%) and mental health problems (37.1% vs 13.8%) by providers than children in the comparison group. Children in the intervention group were also more likely to be referred for health services at baseline (71.0% vs 43.1%) and receive follow-up care at 6 and 12 months of age than children in the comparison group.

Conclusions.  Findings indicate that community providers identify medical and educational needs but do not recognize developmental and mental health needs of young children newly entering foster care. The discrepancies in the number of recommended services and follow-up care between the 2 groups make a case for the establishment of specialized services for children entering out-of-home care.  Key words:  foster care, health services.

Investigations over the past 20 years have highlighted the extent and seriousness of the physical and mental health problems experienced by children entering the foster care system.^1-15 Current estimates of mental health problems range from 30% to 80% with 40% to 80% of these children experiencing some chronic health problems, 43% showing growth abnormalities, and 33% having untreated health problems.^3,9,1012-15 As the magnitude of these problems has been recognized, various professional organizations have called for thorough and ongoing assessment and treatment of the health and mental health problems of children entering substitute care. In 1987, the Committee on Early Childhood, Adoption, and Dependent Care of the American Academy of Pediatrics produced a series of recommendations for the health assessment of children entering foster care.¹⁶ These recommendations were followed in 1988 by the Child Welfare League of America publication, Standards for Health Care Services for Children in Out-of-Home Care.¹⁷ Both of these documents and more recent recommendations by the American Academy of Pediatrics¹⁸ stress the need for comprehensive, continuous care by individuals who are familiar with the special health needs of these children. However, as pointed out in 1994 in an article by Simms and Halfon,¹⁹ there is little evidence that these extensively circulated recommendations have been implemented.

The question for those concerned with the health of these children is why health care for children in foster care continues to be so incomplete. Several explanations have been put forth, including the absence of interest and clear policies to address health care needs within many state child welfare agencies, the multiple possible financing streams and the move by states to manage their Medicaid programs, the lack of advocacy by consistent care providers, the complexity of services needed, and the general fragmentation of the medical care system.^19-23 To address the latter 2 concerns, complexity of needed services and fragmentation, several strategies have been proposed, such as, medical passports, centralized health management units within child welfare agencies, and a series of service delivery models to provide initial health care and ongoing monitoring to children in out-of-home care. These models range from highly centralized services to more decentralized models made up of providers from various agencies joining forces to provide care to children newly entering foster care.¹⁹ The question that has not been answered with any of these delivery models is whether differences exist in the problems identified and in the subsequent services received.

This study compared the scope of health problems identified, the number of and types of referrals, and the number of services received for young children newly entering foster care. One half of these children received care in a comprehensive foster care clinic staffed by a set of providers from 5 independent community agencies who were familiar with the special needs of children in foster care. The other half received the customary medical services available in the community in which their foster families lived. To our knowledge, this article represents 1 of the few evaluations of specialized health care services for foster children and is the only study we could identify with a comparison group.

	METHODS

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The data for these analyses came from a 2-group quasiexperimental design evaluation of the effectiveness of a specialized set of services designed to provide a baseline, multidisciplinary health and mental health assessment as well as ongoing monitoring for young children entering foster care in 1 Connecticut town. The Foster Care Clinic (FCC) is a community-based multidisciplinary clinic started in 1985 by 1 of the authors (M.D.S.).³ At the time of the evaluation, the clinic provided comprehensive baseline evaluations to young children entering out-of-home care and, through biannual reevaluations, monitored the health and mental health status of these children and facilitated their entry into appropriate services. The coordinated efforts of several independent community agencies, the public school system, and the State Department of Social Services created a de facto system of care for this unique group of children.

From February 1, 1992 through July 31, 1993, 100% of young children (11-74 months of age) entering foster care in region V in Connecticut were enrolled in the evaluation. This was the first episode of substitute care for these children, although by the time they were evaluated for this study, some children had changed placements. All children placed in care through the Waterbury office of the Department of Children and Families (DCF) and living in the Waterbury area were enrolled in the intervention group. Within 60 days of placement, these children received a baseline health, mental health, and developmental assessment in the FCC (n = 62; 53 [85.5%] seen at FCC at 30 days). The FCC visit consisted of an interview with the foster parent, usually the foster mother, as well as a complete medical examination, developmental assessment, psychological assessment, speech and language assessment, and motor evaluation. The examinations were completed by providers from community agencies and referrals for services were made back to these agencies. The payment for this comprehensive evaluation was generated through Medicaid.

During the same 18-month period, all young children (11-74 months of age) placed into substitute care in the same region but through the Danbury/Torrington office of the Department of Children and Families served as the comparison group (n = 58). The foster parents of these children received the same interview within their homes administered by trained interviewers rather than at the FCC, and children were assessed for the same developmental, psychological, speech/language, and motor skills using the same battery of instruments used in the FCC. One hundred percent of the comparison families and children were evaluated using the FCC instruments within 30 days of placement. The results of these assessments were not provided to either the children's social services workers or their medical providers. Foster parents and social workers were asked about any medical, psychological, and developmental services these children had received while in care, and then records were obtained by project staff from the office/agency where children had received care for each encounter. Recommendations for additional services were collected from the records obtained from community providers. Of the 58 young children enrolled in the comparison group, 36 (62.1%) received some medical, developmental, or psychological service assessment within the initial 60 days of placement. These services were part of the customary care received by children in foster care and were not the result of the study's assessment procedures.

Intervention and comparison group children were followed up at 6 and 12 months postbaseline. Follow-up rates were excellent with 57 of the intervention (92%) and 53 of the comparison children (95%) followed up at 6 months, and 56 of the intervention children (90%) and 54 of the comparison children (93%) followed up at 12 months. All study procedures were approved by the Human Investigation Committee of the Yale University School of Medicine.

Measures

The contents of the baseline, 6-, and 12-month assessments are displayed in Table 1. The intake forms of the Department of Children and Families supplied information on the demographics of the child, the child's family of origin, reason for placement, and other social services history. The foster parent interview collected demographic information on the foster family, a measure of children's mental health, the Child Behavior Checklist (CBCL),²⁴ the Family Environment Scale,²⁵ and the Home Survey of the Early Screening Profile (ESP).²⁶

CBCL The CBCL is designed to record in a standardized format the behavioral problems and social competencies of children 4 through 16 years of age, as reported by their parents or by a parent surrogate. More recently, the CBCL has been developed and standardized for children as young as 18 months of age.^27-29 Each of the 113 behavior problem items is scored on a 3-step response scale.

C-GAS The physician conducting the FCC health evaluation examination rated the child using the C-GAS. The C-GAS is a 1-dimensional assessment scale that summarizes many different aspects of the patient's social and psychiatric functioning. Scores on the C-GAS range from 1, representing the most seriously impaired child, to 100, representing the healthiest child. Scores above 70 are designated as indicating normal function. The instrument contains behaviorally oriented descriptions at each anchor point, which depict behaviors and life situations applicable to children.³¹

ESP The ESP, published by American Guidance Service, is a compilation of items from very well-known instruments, the Kaufman Assessment Battery for Children, Home Observation for Measurement of the Environment, and Bruininks-Oseretsky. It is a nationally normed screened battery for young children (2-7 years of age) that is easy to administer, requires only 30 minutes to complete, and correlates well with similar instruments.²⁶ It was developed to distinguish children who are potentially at risk for developmental and educational problems and to assist in planning any further diagnostic assessments that might be necessary. Preliminary data suggest excellent internal consistency of the various subscales (.89-.95) with the exception of the motor subscale, which ranges from .60 to .78. Test-retest reliability of profile and subscale standard scores are all above .80 with the exception of motor, which is .70. Interrater reliability for the various subscales ranged from .80 to .99. Looking at the concurrent validity of the battery, the cognitive language profile correlates .84 with the Stanford Binet composite score, .83 with the Kaufman Assessment Battery for Children standard score for achievement, and .62 with the Battelle Developmental Inventory Screening Test total score. There were moderate correlations between the Motor Profile and the Bruininks-Oseretsky (.66 with battery standard score). In general, compared with measures of achievement, the correlations are moderate to high.²⁶

Peabody Picture Vocabulary Test (PPVT) The PPVT is designed to measure receptive vocabulary and, in effect, demonstrates acquisition. This widely used measure was standardized on a representative sample of US children and youth. The split-half reliabilities ranged from .67 to .88 on form L (the form used in this study) depending on the age of the child, whereas the test-retest coefficients using alternative forms ranged from .73 to .92 with a median of .82. The PPVT correlates well (.70) with other vocabulary measures (eg, Stanford Binet Vocabulary Subtest), demonstrating its validity.³² It is recommended for children 21/2 years of age and older.

Vineland Adaptive Behavior Scales The Vineland is a measure of adaptive behavior, which is broadly defined as meeting age and culturally appropriate standards of personal independence and social sufficiency. It is developmental in nature and increases in complexity as a function of age (age range: birth to 18 years 11 months). Recently, attention has been focused on adaptive behavior as a dimension of functioning that may be particularly helpful in differentiating psychologically disturbed children from normal peers.³³ Given the adaptations required of a child in foster care, this measure may be a crucial factor in a successful foster placement. We did not use the entire Vineland because of its length but rather a 40-item subset of this instrument that was developed in conjunction with the Yale Child Epidemiologic Catchment Area Methodologic Project. The screener correlates .98 with the entire Vineland (S. S. Sparrow, personal communication, 1998).

Data Analysis

All data analyses were completed using SAS, Version 6.12 (SAS, Cary, NC). After a careful review of the data to identify any out of range values or inconsistencies, all standardized scales were constructed according to the scoring directions. Once the data management tasks were completed, all univariable and bivariable analyses were performed to characterize experiences of the children before coming into care, examine the interrelationships among developmental, behavioral, and physical health problems, and examine the comparability of the intervention and comparison groups.

The form of a particular bivariable analysis was dictated by the structure of the variables being compared. For continuous outcome variables, correlations and regression analyses were used. Multifactor-stratified analyses used Mantel-Haenszel techniques. For analyses with categorical outcome variables, logistic regression and polycotomous logistic regression were used. Any baseline sociodemographic differences between the 2 groups were controlled in these analyses.

	RESULTS

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Table 2 displays the baseline sociodemographic, social services, developmental, physical health, and mental health characteristics of study children. Both intervention and comparison children were fairly evenly divided by gender, with children in the intervention group being both younger and more often of Hispanic ethnicity. Children in the intervention group were more commonly placed for reason of neglect (50% vs 36%), whereas those in the comparison group were placed more commonly for being at risk for abuse and/or neglect (35.5% intervention vs 62.1% comparison; P = .004). The 2 groups were similar in the number of foster homes before this placement, whether the biological mother was known to social services, and the foster mother's assessment of the foster child's health and medical conditions. Interestingly, at baseline, foster children in the comparison group were more likely to have had a health care, developmental, or educational service since living in the foster home where the interview occurred, compared with the children in the intervention group (62.1% vs 38.7%; P = .011). There were no statistically significant differences between intervention and comparison children in mental health as measured by the CBCL; functioning as measured by the Vineland; cognitive, language, or motor ability as measured by the ESP; or receptive vocabulary as measured by the PPVT.

Examining the baseline sociodemographic characteristics of the foster families (Table 3), we find that the foster families of the intervention group are more likely to have 6 to 8 household members rather than 5 or 9 members, have less well-educated foster mothers (high school: 54.9% intervention and 82.8% comparison; P = .001), and more mothers who have been fostering for >3 years (56.5% intervention vs 43.1% comparison; P = .021). Intervention mothers are also somewhat less likely to be working and have lower household incomes.

Examining data on health, developmental, educational, and mental health issues from the foster mothers, FCC, social services records, and community providers, we find that, since entering foster care, similar numbers of children in both groups were identified as having problems by their foster mothers (Table 4). For educational problems, foster mothers were asked, "Do you expect [child] to have problems in school?" Approximately one third of the children were identified as having medical problems (37.1% intervention and 36.2% comparison; P = .919). Of children in the intervention groups, 33.9% were judged to have educational problems versus 44.8% in the comparison group (P = .219), with similar percentages of children in each group having developmental (eg, speech, motor, and language) issues (22.6% intervention vs 17.2% comparison; P = .465), and mental health problems (29.0% intervention vs 31.0% comparison; P = .811).

Interestingly, although there were no differences between the 2 groups in the percentages of children identified with problems by their foster mothers, the number of children identified with problems by providers was dramatically different with the exception of medical and educational problems. Children seen in the FCC were much more likely to be identified with developmental (56.5% intervention vs 8.6% comparison; P = .004) and mental health problems (37.1% intervention vs 13.8% comparison; P = .001). However, when we examined whether FCC providers or community practitioners were more likely to agree with foster mothers on children's problems, there were no differences. In fact, neither set of providers showed agreement with the foster mothers' identification of children's problems (data not shown).

The number and percentage of children who were referred for additional services also varied significantly between the 2 sites. Between 25% and 40% of the children with medical problems in each group were referred for further services (26.3% intervention vs 40.9% comparison; P = .326). However, the rates of referrals for educational, developmental, and mental health services were much higher in the intervention group, compared with the comparison group. When providers referred children for educational problems, these referrals consisted primarily of requests for pupil placement team evaluations for possible special education services. All 5 of the children referred for educational problems by providers were >3 years of age. Forty-four of the 62 intervention group children (71.0%) and 25 of the 58 comparison group children (43.1%) had at least 1 service referral recommended at baseline (P = .002). At 6 months of follow-up, of the 44 intervention children who had a service referral, 30 (68.2%) had received the service, whereas only 11 of the 25 comparison children (44%) had received the recommended service (P = .049). At 12 months, the intervention children continued to have better follow-up of recommended services (34/44; 77.3%) compared with comparison children (15/25; 60.0%), but the difference was no longer statistically significant.

Table 5 displays the results of the multivariate model examining predictors of receipt of services among the 69 children who had at least 1 referral for a service. The model demonstrates that children who were seen in the FCC were younger, had >1 foster home before the 1 where they were living at the time of the baseline examination, had a provider-identified physical health problem, and were rated as having fair or poor mental health status by their foster mothers were more likely to receive referral services. Specifically, children whose initial assessments were in the FCC were 3.67 times more likely to receive recommended services, compared with children who received customary services in the community.

When we examined the interrelations among types of problems and reason for placement, we found that regardless of the type of problem, children at risk for abuse and neglect were identified with more problems than those placed for substantiated neglect or abuse (data not shown). Children with medical problems were not statistically significantly more likely to have mental health and educational problems (Table 6). However, mental health problems and educational/developmental problems frequently cooccurred, as did lower adaptive functioning and educational/developmental problems. More children scored low on the Vineland than would be expected in a sample of children drawn from the community.

	DISCUSSION

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Results from this evaluation of the effectiveness of a specialized set of evaluation and monitoring services for children entering foster care in 1 Connecticut region, clearly point to the multiple health (developmental, educational, and mental) needs of even very young children who are newly entering foster care. Using psychometrically sound assessment instruments, we found that children seen in the specialized clinic for children in foster care (FCC) are identified with medical and educational problems at rates similar to children in foster care who are seen by nonspecialized health care providers available in the communities where their foster parents reside. This finding lends support to the notion that medical and educational providers have been sensitized to the special needs of children entering foster care. However, the extreme differences in rates of identification of developmental and mental health problems despite similar rates of these problems identified by foster mothers on psychometrically sound assessment instruments (ie, CBCL and Vineland) strongly indicate that community providers do not recognize these problems and that centralized services are necessary to assure identification of the full range of problems experienced by young children entering foster care. This is particularly important because foster mothers who have limited experience with a child in their care may not be aware of the full range of children's problems. Identification and treatment of these problems are critical because they have been shown to affect the amount of time a child spends in foster care and the likelihood that he or she will experience stable living situations.³⁴

The finding that many fewer comparison group children identified with problems by community providers are recommended for follow-up services also argues for the establishment of specialized services for these children. Given the demands on health providers and the often time-intensive nature of referrals for specialized services, it may be that community-based providers without a specific mandate to monitor these children chose to refer only those children with the most severe problems. Further, the finding that children in the intervention group receive more of the recommended services at both the 6- and 12-month follow-ups reinforces the need to develop effective means to monitor the health, mental health, and educational services children receive while they reside in foster homes.¹⁹ Given the size of the case loads assigned to foster care case workers (in region V in Connecticut the range is 28-30) and the ineffectiveness of administrative interventions that are commonly thought to improve service delivery (each child in the State of Connecticut has a medical passport and a sophisticated Management Information Service system is in place), states must seek ways other than administrative initiatives to ensure that children receive the complex multisystem services they require.

The multivariate analysis lends support to the premise that specialized service programs like the FCC are more likely to lead to receipt of services in children for whom a service is recommended. Part of the mandate of the FCC was the ongoing assessment of the health of children in foster care and, as part of that charge, referrals for specialized services were monitored. Adjusting for other correlates of receipt of services, including provider-identified medical conditions and foster mother-reported mental health status, children whose initial health assessments were completed in the FCC were significantly more likely to receive the recommended follow-up.

These data also show that children placed for reasons of abuse are not more likely to be identified with medical, mental health, or educational/developmental problems than children placed because of neglect or those who are at risk for abuse or neglect. Earlier work with children in foster care in Connecticut demonstrated that, regardless of the stated reason for placement, virtually all of the children were neglected and many were abused.³ In reality, these data show that regardless of reason for placement even very young children come into care with a myriad of problems and that many of these problems cooccur. It seems that educational and developmental issues often coincide with poor mental health and low adaptive behavior scores. This association in young children is important because the poor school functioning of children in foster care has long been recognized and evidence of this association at entry into care among very young children points to the importance of treating these problems if children are to succeed in school.³⁵

Whether children entering foster care have multiple needs is no longer in question. What remains to be addressed by policymakers is how to provide multiple complex services to these children in a timely and cost-efficient manner. As states continue to struggle with strategies to contain health care costs for the most vulnerable segments of the child population, policymakers must remain cognizant of the fact that provision of comprehensive health, mental health, developmental, and educational evaluations, although perhaps somewhat more expensive in the short-term, are necessary to ensure that the considerable problems these young children experience are identified and subsequently treated.³⁶ This study demonstrates that relatively simple, but well-coordinated community-based efforts to evaluate and treat children in foster care can improve the scope and delivery of services needed for this unique group of children.

	ACKNOWLEDGMENT

The support for this research was provided by Award MH48456 from the National Institute of Mental Health.

	FOOTNOTES

Received for publication Mar 8, 1999; accepted Sep 10, 1999.

Reprint requests to (S.M.H.) Yale University School of Medicine, Department of Epidemiology and Public Health, 60 College St, Box 208034, New Haven, CT 06520-8034. E-mail: patricia.krieger{at}yale.edu

	ABBREVIATIONS

FCC, Foster Care Clinic; DCF, Department of Children and Families; CBCL, Child Behavior Checklist; ESP, Early Screening Profile; C-GAS, Children's Global Assessment Scale; PPVT, Peabody Picture Vocabulary Test.

	REFERENCES

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1. Moffatt MZEK, Peddie M, Stulginshas J, Pless IB, Steinmetz N Health care delivery to foster children: a study. Health Soc Work 1985; 9:71-96
2. Swire MR, Kavaler F The health status of foster children. Child Welfare 1977; 56:635-653 [Medline]
3. Simms MD The foster care clinic: a community program to identify treatment needs of children in foster care. J Dev Behav Pediatr 1989; 10:121-128 [Medline]
4. Hochstadt NJ, Jaudes PK, Zimo DA, Schachter J The medical and psychosocial needs of children entering foster care. Child Abuse Negl 1987; 2:53-62
5. Schor EL The foster care system and health status of foster children. Pediatrics 1982; 69:521-528 [Abstract/Free Full Text]
6. McIntyre A, Keesler TY Psychological disorders among foster children. J Clin Child Psychol 1986; 15:297-303 [CrossRef]
7. Klee L, Halfon N Mental health care for foster children in California. Child Abuse Negl 1987; 11:63-74 [CrossRef][Medline]
8. United States General Accounting Office. Foster Care: Health Needs of Many Young Children Are Unknown and Unmet. Washington, DC: US Government Printing Office; 1995
9. Szilagyi M The pediatrician and the child in foster care. Pediatr Rev 1998; 19:39-50 [Free Full Text]
10. Halfon N, Mendonca A, Berkowitz G Health status of children in foster care. Arch Pediatr Adolesc Med 1995; 149:386-392 [Abstract]
11. Combs-Orme T, Chernoff RG, Kager VA Utilization of health care by foster children: application of a theoretical model. Child Youth Serv Rev 1991; 13:113-129
12. Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A Assessing the health status of children entering foster care. Pediatrics 1994; 93:594-601 [Abstract/Free Full Text]
13. Schor EL Foster Care. Pediatr Rev 1989; 10:209-216 [Abstract/Free Full Text]
14. Stein E, Evans B, Mazumdar R, Rae-Grant N The mental health of children in foster care: a comparison with community and clinical samples. Can J Psychol 1996; 41:385-391
15. Halfon N, Berkowitz G, Klee L Children in foster care in California: an examination of Medicaid reimbursed health services utilization. Pediatrics 1992; 89:1230-1237 [Abstract/Free Full Text]
16. American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care Health care of foster children. Pediatrics 1987; 79:644-646 [Abstract/Free Full Text]
17. Child Welfare League of America. Standards for Health Care Services for Children in Out-of-Home Care. Washington, DC: Child Welfare League of America; 1988
18. American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care. Health Care of Children in Foster Care. 1994;93:335-338
19. Simms MD, Halfon N The health care needs of children in foster care: a research agenda. Child Welfare 1994; 73:505-523 [Medline]
20. Center for Health Policy Research. Children in Foster Care: A Vulnerable Population in Health Care Reform. Washington, DC: George Washington University; 1994:3
21. Halfon N, Klee L Health and development services for children with multiple needs: the child in foster care. Yale Law Policy Rev 1991; 9:1
22. Klee L, Soman LA, Halfon N Implementing critical health services for children in foster care. Child Welfare 1992; 71:99-111 [Medline]
23. Berkowitz G, Halfon N, Klee L Improving access to health care: case management for vulnerable children. Soc Work Health Care 1992; 17:101-123 [Medline]
24. Achenbach TM. Manual for the Child Behavior Checklist. Burlington, VT: University of Vermont; 1991
25. Moos RH, Moos BS. Family Environment Scale Manual. 2nd ed. Palo Alto, CA: Psychologists Press, Inc; 1986
26. Harrison PL. Early Screening Profiles. Circle Pines, MN: American Guidance Service; 1990
27. Achenbach TM, Edelbrock C, Howell C Empirically based assessment of the behavioral/emotional problems of 2- and 3-year-old children. J Abnorm Child Psychol 1987; 15:629-650 [CrossRef][Medline]
28. Bassuk EL, Weinreb LF, Dawson R, Perloff JN, Buckner JC Determinants of behavior in homeless and low-income housed preschool children. Pediatrics 1997; 98:92-100
29. Koot HM, VenDen Oord EJCG, Verhulst FC, Boomsma DI Behavioral and emotional problems in young preschoolers: cross-cultural testing of the validity of the Child Behavior Checklist/2-3. J Abnorm Child Psychol 1997; 25:183-196 [CrossRef][Medline]
30. Achenbach TM, Edelbrock C. Manual for the Child Behavior Checklist and Profile. Burlington, VT: University of Vermont; 1986
31. Shaffer D, Gould MS, Brasic J, Children's Global Assessment Scale (C-GAS). Arch Gen Psychiatry 1983; 40:1228-1231 [Abstract]
32. Dunn IM, Dunn IM. The Peabody Picture Vocabulary Test-Revised. Circle Pines, MN: American Guidance Service; 1981
33. Sparrow SS, Cicchetti DV Adaptive behavior and the psychologically disturbed child. J Special Educ 1987; 21:89-100
34. Horwitz SM, Simms MD, Farrington R The impact of developmental problems on young children's exists from foster care. J Dev Behav Pediatr 1994; 15:186-190
35. Stein E, Rae-Grant N, Ackland S, Avison W Psychiatric disorders of children in care: methodology and demographic correlates. Can J Psychiatry 1994; 39:341-347 [Medline]
36. Simms MD, Freundlich M, Battistelli ES, Kaufman ND Delivering health and mental health care services to children in family foster care after welfare and health care reform. Child Welfare 1999; 78:166-183 [Medline]