Published online July 1, 2008
PEDIATRICS Vol. 122 No. 1 July 2008, pp. e232-e241 (doi:10.1542/peds.2007-3778)
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ARTICLE

Special Health Care Needs Among Children in the Child Welfare System

Heather Ringeisen, PhDa, Cecilia Casanueva, PhDa, Mathew Urato, PhDa and Theodore Cross, PhDb

a RTI International, Research Triangle Park, North Carolina
b Child and Family Research Center, School of Social Work, University of Illinois, Urbana-Champaign, Illinois


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The aim of this study was to determine levels of special health care need among children in the child welfare system and how these needs may affect children's functioning.

METHODS. Data were from the National Survey of Child and Adolescent Well-being, a national probability study of children investigated for child maltreatment. The sample consisted of 5496 children aged 0 to 15 years at baseline. For analysis, we used descriptive statistics to determine special health care needs and children's functioning from baseline to 3-year follow-up. Logistic regression was used to examine correlates of special health care needs.

RESULTS. At any point in the study period, approximately one third of the children were identified as having special health care needs. Overall, across 3 years of follow-up data, 50.3% of the children were identified as having special health care needs. Boys were significantly more likely than girls to have had special health care needs, and children aged 0 to 2 years at baseline were significantly less likely to have had special health care needs than older children. Adopted and foster children were significantly more likely to have had special health care needs than children never placed out of the home. The most commonly reported type of chronic health condition was asthma. The most commonly reported type of special need was a learning disability.

CONCLUSIONS. Special health care needs are prevalent among children in the child welfare system. Many children with special health care needs have cognitive, language, adaptive, social, or behavioral functional impairments. Mechanisms are needed to ensure that this vulnerable population has access to and receives coordinated health and related social services.

Key Words: child development • chronic conditions • maltreatment • special needs • survey

Abbreviations: SHCN—special health care need • CWS—child welfare system • NSCAW—National Survey of Child and Adolescent Well-being • MCHB—Maternal and Child Health Bureau • SSRS—Social Skills Rating System

It is estimated that from 13% to 19% of children in the US population have special health care needs (SHCNs).1–3 These children are at increased risk for chronic physical, developmental, behavioral, or emotional conditions requiring extensive health and related services.4 Meeting the needs of such children requires the coordination of community-based systems of care.5 For many children with SHCNs, the child welfare system (CWS) plays a critical role in this coordinated service array. Although children reported for maltreatment and involved with CWS are at heightened risk for SHCNs, there are no nationally representative data on the prevalence of SHCNs in this population. Several studies have broached SHCN among children in foster care,6–9 but the great majority of children involved in child maltreatment investigations continue to live at home with their biological parents; consequently, we lack information about them. To effectively coordinate care for children's SHCNs in the CWS population, we must know how frequently SHCNs occur, which children are most at risk for them, and how these needs may affect children's development and functioning.

Numerous reports detail the harmful effects of maltreatment on children's physical, neurologic, emotional, and social development,10–20 effects that can lead to SHCN. Thirty percent to 60% of children in foster care have been estimated to have chronic health conditions.7,21 When behavioral, emotional, and developmental concerns are taken into consideration, the estimated proportion of foster children with serious health care needs jumps to >80%.6,9 Furthermore, we know that children reported for maltreatment show greater rates of developmental and behavioral problems than children in the general US population.22,23 We examined the prevalence, characteristics, risk factors, and developmental concomitants of SHCNs in a nationally representative sample of children involved in CWS investigations of child maltreatment. This study considered the rates of these SHCNs over a 3-year period, and derived its data from the National Survey of Child and Adolescent Well-being (NSCAW), the first national probability study of children in the United States involved in CWS investigations. We examined how key subgroups in the population vary in their risk for having SHCNs: boys and girls, children in different age groups and racial and ethnic categories, children in and out of poverty, children in different placement settings, and children having experienced different forms of maltreatment. We also examined whether having a SHCN is related to children's developmental progress in several domains. The analyses offered here were to ascertain service needs among this vulnerable group of children.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
NSCAW is a national longitudinal study of the well-being of 5501 children aged ≤15 years who had contact with the CWS during a 15-month period starting October 1999. NSCAW used a national probability sampling strategy to select a total of 100 counties representing CWS agencies. The probability of county selection was proportional to the size of the CWS population of the county. Of the 100 counties sampled for the study, the NSCAW study collected child-level data on 92 counties. Eight counties were excluded, because regulations in these areas required that CWS personnel obtain active consent from potential participants before contacting them. The final sample of children was representative of the national population of children being investigated for allegations of child maltreatment. Caregiver and caseworker interviews, together with child assessments, were collected at baseline and at follow-ups conducted 1.5 and 3.0 years after the completion of the maltreatment investigation (additional information on NSCAW methodology is published elsewhere24).

Participants
We focused on 5496 children for whom we had valid caregiver data on SHCNs. Only 5 children were excluded because of missing data. At any follow-up, attrition was <20% of the sample size at baseline.

Procedures
Baseline interviews and assessments were conducted an average of 4 months after the closing of the CWS investigation for maltreatment (mean: 3.9 months; median: 3.7 months [range: 1.3–10.4 months]). Interviews with the children's caregivers were conducted in English (96%) or Spanish at the children's homes by means of computer-assisted personal interviewing. Caregivers received an honorarium of approximately $40 for their participation in each interview. NSCAW also conducted 1-hour computer-assisted personal interviewing sessions with the CWS caseworkers, who were instructed to consult the case record as needed during the interview. The data analyzed here came from child assessments, caregiver interviews, and caseworker interviews.

Institutional Review Board Approval
NSCAW, the consent protocols, and this study received institutional review board approval from RTI International and the Office of Management and Budget.

Measures
Demographics
Caregivers were asked about their child's gender, child's age, child's race/ethnicity, family income, and number of adults and children in the household. Family income and number of adults and children in the household were used to determine at baseline poverty level according to the US Census Bureau guidelines.25

Maltreatment Characteristics
The most serious type of maltreatment was assessed by asking the caseworkers the following question in the baseline interview: "Of the types of abuse or neglect that were reported, please tell me the type that you felt was the most serious (physical maltreatment, sexual maltreatment, emotional maltreatment, physical neglect [failure to provide], neglect [lack of supervision], abandonment, moral/legal maltreatment, educational maltreatment, exploitation, and other)."

Substantiation
"Substantiation" denotes the official decision of the CWS service that the maltreatment allegations are valid. Caseworkers indicated whether the evidence of maltreatment was substantiated, indicated, or neither substantiated or indicated. "Indicated' is a case disposition used in some states when the caseworker judges that evidence of maltreatment exists but not enough to substantiate the allegation. Only when caseworkers chose the response option "substantiated" were children classified as such.

Child's Living Arrangements
At each follow-up, a child's current living arrangement was obtained from caregivers or from caseworkers if necessary. If the caregiver or the caseworker reported that the child was at some point placed out of home, then the child was coded as "yes" for having an out-of-home placement history. At the final follow-up, children were currently classified as one of the following: (1) living in-home with biological parents or other preinvestigation caregivers, with no out-of-home placement history; (2) living at home with biological parents or other preinvestigation caregivers with an out-of-home placement history; (3) living at home with adoptive parents (among adopted children, only 29 children [0.5%] were never placed out of home); (4) living in kinship care (children cared for by relatives, including grandmothers, sisters, and aunts, including 58 children [1.0%] who were never placed out of the home of their kin); or (5) living in foster care. Children lacking 3-year follow-up data on living arrangements were classified from the most recent follow-up period with available data.

SHCNs
NSCAW includes 2 indicators of SHCNs: the presence of a chronic health condition and the presence of a "special need." Each of these indicators is based on caregiver report. To closely approximate the Maternal and Child Health Bureau (MCHB) definition1 of SHCNs, we deemed both caregiver reports of chronic health conditions and caregiver reports of special needs to indicate SHCNs; however, we also examined chronic health conditions and special needs separately to discuss differences by type of need (physical health versus developmental and/or behavioral needs; Table 1).


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  		TABLE 1 Sociodemographic Characteristics of Young Children Reported to the CWS

 
Chronic Health Conditions
At each interview, caregivers were asked whether their child had any health problems that "last a long time or come back again and again." If "yes," caregivers were asked to name them. Caregivers could report >1 problem; the list of chronic conditions reported by caregivers is presented in Table 2. To ensure a narrow and accurate definition of "chronic health conditions," we excluded caregiver responses not included among those listed in Table 2 (eg, those coded by the interviewer as "other").


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  		TABLE 2 Specific Chronic Health Conditions and Special Needs at Baseline and Follow-up

 
Special Needs
At each interview, caregivers were asked if they had ever been told by an educational or health professional, or told since the last interview, that their child has "learning problems, special needs or developmental disabilities." If "yes" to either of these questions, caregivers were asked to describe these problems. Developmental problems deriving from special needs described by caregivers are presented in Table 2. The special needs questions in NSCAW were designed to correspond with disability categories under the Individuals With Disabilities Act. For the chronic health condition questions, the wording denoted a chronic health condition prevalent at the time of the interview; special needs questions included both prevalence and incidence (ie, whether a special need was reported since the previous interview).

With these data and capitalizing on the multiple waves of data collection by NSCAW at baseline, at 1.5-year follow-up, and at 3.0-year follow-up, 2 kinds of variables were calculated to indicate whether children were reported to have each condition. First created were variables for whether children reportedly had had any condition during the period since the previous data collection, up to and including the time of the follow-up interview. A variable was also created for whether the children had ever had any condition.

Child Functioning
Data on child functioning came from the field representative's direct assessment of the child at the 3-year follow-up in 6 areas: cognitive development, language, adaptation, behavior, social skills, and academic problems.

To measure cognitive development, NSCAW used the cognitive domain of the Battelle Developmental Inventory, which assesses perceptual discrimination, memory, reasoning, academic skills, and conceptual development for children 0 to 4 years old26; it used the Kaufmann Brief Intelligence Test for children ≥4 years of age.27 The Kaufmann Brief Intelligence Test is a brief, individually administered measure of verbal and nonverbal intelligence. We used the standard score for vocabulary, matrices, and total IQ composite.27 The Preschool Language Scale-3 was used to measure language development for children ≤6 years, 11 months old. The auditory comprehension subscale measures receptive communication skills; the expressive communication subscale measures expressive communication skills with tasks that focus on social communication and vocal development.28 A total language score combines these 2 subscales.

NSCAW used the daily living skills items from the Vineland Adaptive Behavior Scale Screener to measure adaptive problems. These items assess personal care skills (eg, how the child eats), domestic skills (eg, how the child performs household tasks), and community skills (eg, child's knowledge of safety).29

NSCAW used the Child Behavior Checklist and Teacher's Report Form to measure behavioral problems.30 These checklists are designed to assess children's social competencies and problem behaviors.30 For each item, the child's caregiver indicates how well the behavior describes the child, either at the time of assessment or within the previous 6 months. For this research, the Child Behavior Checklist and Teacher's Report Form total problem standardized scores were used to measure the behavioral well-being of children. In keeping with recommended procedures for classifying the total problem scale,30,31 total problem standardized scores were classified as normal (<60), borderline, (60–63), or clinical (>63).

NSCAW used the Social Skills Rating System (SSRS) to measure caregiver perception of the social skills of children between the ages of 3 and 18 years.32 Separate versions have been developed for preschool, elementary school, and secondary school. The SSRS assesses social skills in 4 domains (cooperation, assertion, responsibility, and self-control) and provides standard scores for the total and individual domains. Total scores were categorized as suggested in the SSRS manual: fewer social skills (<85), average social skills (85–115), or more social skills (>115).32

The reading and math subtests of the Woodcock-McGrew-Werder Mini-Battery of Achievement were used to assess academic problems of children aged ≥6 years. Standardized scores were calculated from a normative mean of 100, with an SD of 15.33

Analyses
All of the analyses were conducted with weighted data to take into account the complex sampling design of NSCAW. The SUDAAN statistical package 9.0.1 was used.34 Thus, all of the percentages were adjusted (weighted) for sampling probabilities, although we also report unweighted sample sizes. We report the percentages of children with any chronic health condition, special need, or either of the 2 (SHCN). We also report respective percentages of children with any of 22 specific chronic health conditions and respective percentages of those with any of 11 specific special needs. Because of the sampling design of NSCAW, all of the percentages represent point estimates of the percentage in the population of children involved in CWS investigations. Also reported are SEs, which provide an opportunity to construct confidence intervals around these percentages.

Pearson {chi}2 analyses were used to test differences in the rates of chronic health conditions and special needs by child demographic characteristics, living arrangement, and maltreatment characteristics. To examine the unique effects of key variables on SHCN rates, controlling for other covariates, we conducted 3 logistic regression analyses. These analyses modeled ever having a chronic health condition, ever having a special need, and ever having SHCNs. The reference group for all of the analyses consisted of children who were never identified as having SHCNs; so, for example, children with chronic health conditions were compared with children who had never been identified as having SHCNs. Consequently, this analysis excluded children with special needs, and the total number for this model was 3161. The other models were constructed similarly.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Children
Approximately half of the children were boys and half were girls. The mean age of the children was 7 years. Child age was fairly evenly distributed across the range from 0 to 14 years. White children made up the largest group, followed by black and Hispanic children. Almost half were living at or below the federal poverty line. For the majority of children, the main type of maltreatment was neglect (lack of supervision: 25.2%; failure to provide: 18.0%), followed by physical abuse (25.2%). Most children's cases were not substantiated (73.8%). At the 3-year follow-up or at the time of the last contact, almost three fourths of the children had never been placed out of the home, and no other living-arrangement category included >9.9% of the children (Table 1).

SHCNs, Chronic Health Conditions, and Special Needs
Caregivers reported that 50.3% of the children had ≥1 SHCN at some point during the 3-year study period (Table 1). At baseline, 35.1% of children were reported to have had SHCNs. Thirty-one percent were reported to have had SHCNs at the 1.5-year follow-up, and 33.5% were reported to have had SHCNs at the 3.0-year follow-up. Boys were significantly more likely than girls to have had SHCNs, and children aged 0 to 2 years at baseline were significantly less likely to have had SHCNs than older children. Adopted and foster children were significantly more likely to have had SHCNs than children in other living arrangements.

As for chronic health conditions, 27.9% of children had ever had one. There were no differences in ever having a chronic condition by any of the variables presented in Table 1, except for child's age: children aged 0 to 2 years at baseline were significantly more likely to have had a chronic health condition than children aged 6 to 10 years at baseline.

As reported by caregivers, 33.2% of children had a special need either currently or in the past. There were significant differences in having a special need by gender, age, poverty, and living arrangement. Boys were significantly more likely than girls to have a special need, and children aged 0 to 2 years at baseline were significantly less likely to have a special need, compared with every other age group. Children living at or below the poverty level at baseline were significantly more likely than children living above the poverty level at baseline to have had a special need. Finally, adopted and foster children were more likely than children living at home to have had special needs.

Specific Chronic Health Conditions and Special Needs
Table 2 shows the respective percentages of children having any 1 of 33 specific SHCNs at baseline, 1.5-year, and 3.0-year follow-ups. These SHCNs are organized by chronic health condition and by special need. This table also shows the percentages of children who ever had each of these conditions at any point in time. At any point during the 3-year study period, between 14.9% and 19.2% of children reportedly had a chronic health condition. The most commonly reported condition was asthma (8.0% and 8.5% at any given point). Overall, 12.8% of all of the children were reported to have had the condition over the course of 3 years. Other conditions less frequently reported over the course of 3 years included repeated ear infections (5.2%), other respiratory problems (4.7%), severe allergies (4.2%), epilepsy (1.9%), and eczema or other skin disease (2.0%).

At any point during the 3-year study period, between 20.2% and 22.2% of children reportedly had a special need. The most common special need was a learning disability (10.4% and 13.7% at any given point). Overall, 20.6% of all of the children had learning disabilities over the course of 3 years. Other commonly reported conditions over the 3-year study period included 14.1% of children with emotional disturbance, 12.3% with speech impairment, 2.4% with mental retardation, 2.0% with hearing impairment, 1.3% with autism, and 1.2% with vision impairment.

Developmental Concomitants of Chronic Health Conditions and Special Needs
To ascertain how having SHCNs was related to development, children with chronic health conditions, special needs, or both were compared on 7 different types of developmental problems with children who never had any form of SHCN. Table 3 shows the percentages of children in the clinical range (defined as having a score at or below –2 SD of the normative mean) at the 3-year follow-up. Children with a chronic health condition were significantly more likely than children without SHCNs to have a score in the clinical range in the cognitive, adaptive, behavioral, social skill, and math and reading areas. Overall, 53.5% of children with chronic health conditions had a problem in ≥1 of these areas compared with 29.1% of children without SHCNs.


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  		TABLE 3 Developmental Problems at 3-Year Follow-up, According to Chronic Condition, Special Needs, and SHCNs (Ever)

 
Children with a special need were significantly more likely than children without SHCNs to have any of the developmental problems. More than half (50.7%) of the children with special needs had a clinically significant score for behavioral problems. Overall, 62.8% of children with special needs had ≥1 of these developmental problems compared with 29.1% of children without an SHCN. Predictably, then, the same pattern of statistical significance was observed when we compared children having either form of SHCN with children without an SHCN. Overall, 56.1% of children with either form of SHCN had ≥1 of the 7 developmental problems.

Statistical Models Predicting Chronic Health Conditions and Special Needs
Table 4 reports results of the 3 multiple logistic regression models capturing associations of the child's age, gender, race and ethnicity, poverty level, living arrangements at last follow-up, most serious type of maltreatment, and substantiation status with the child's ever having a chronic health condition, ever having special needs, and ever having SHCNs. The adjusted odds of a child ever having a chronic health condition were ~1.6 times greater for boys than for girls. No other variable was associated with ever having a chronic health condition. Gender, age at baseline, poverty level at baseline, and living arrangement were associated with ever having special needs and with ever having SHCNs. Boys' odds of ever having a special need were 2.1 times the girls' odds of ever having special needs. Similarly, the odds of boys ever having SHCNs were 1.8 as great as for girls. For children aged 0 to 2 years at baseline, the odds of ever having a special need were 0.36 as great as the odds for youths 11 to 14 years old at baseline. For the 0- to 2-year-olds at baseline, the odds of ever having SHCNs were 0.62 as great as the odds for the 11- to 14-year-olds at baseline. Children living at or below the federal poverty level at baseline had odds ~1.5 times as great as the odds of ever having special needs as children above the poverty level, and they had comparable odds of ever having SHCNs. Adopted children had 3.3 times the odds of ever having special needs and had 2.6 times the odds of ever having SHCNs as children living at home without an out-of-home placement history. Foster children had 2.3 times the odds of ever having special needs and had 2.1 times the odds of ever having SHCNs as children in the home who had never been placed out of the home. It is noteworthy that children with an investigation for maltreatment that was not substantiated were as likely as those whose alleged maltreatment was substantiated to have SHCNs.


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  		TABLE 4 Multiple Logistic Regression Analysis of Ever Having a Chronic Health Condition and Ever Having Special Needs

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
NSCAW has yielded the first national data on the proportion and characteristics of children with SHCNs in the population of children involved in CWS investigations of child maltreatment. The survey has shown that, at any point in time, approximately one third of children were identified as having SHCNs. Overall, across 3 years of follow-up data, 50.3% of children were identified as having SHCNs. The estimates in this study of the extent of SHCNs among children involved in CWS child maltreatment investigations offer several advances beyond previous research: (1) an expansion of the research base to include CWS-involved children outside foster care; (2) an examination of SHCNs within a sample of CWS-involved children that is nationally representative; (3) a description of condition-specific prevalence estimates for a variety of SHCNs; and (4) an examination of specific risk factors and functional characteristics associated with 2 primary types of SHCNs (ie, chronic health conditions and developmental and behavioral needs).

NSCAW estimates that between 31.0% and 35.1% of children have a SHCN at any given follow-up period over the course of 3 years. These estimates substantially exceed the estimate of 12.8% for the US general population of noninstitutionalized children in 2001, based on the National Survey of Children With Special Health Care Needs.3 Our estimate also exceeds that of 18.0% from the 1994 National Health Interview Survey on Disability,2 that of 17.6% from the 2003 National Survey of Children's Health, and that of 18.8% to 19.3% from the four 2001–2004 Medical Expenditures Panel surveys.1

Especially high rates of SHCNs in this target population seem to stem from the preponderance of developmental and behavioral needs. Children in the CWS show much higher rates of special needs than children in the general US population. The problems identified here as "special needs" correspond with disability categories under the federal Individuals with Disabilities Act and are consequently considered relevant for special education evaluation or service referral. Thirty-three percent of children were reported by caregivers to have ever had a special need during the 3 years after a CWS investigation for alleged child maltreatment. At any given time, between 20.2% and 22.2% of all children were reported to have such a need. These rates of observed special needs substantially exceed the 12.8% of all US students (6–21 years) who received special education services in 2005.35 Most commonly, children in the CWS were reported over the course of 3 years to have a learning disability (21%), emotional disturbance (14%), or speech impairment (12%). At the national level, it is estimated that 8% of children have ever had a learning disability.36 It has also been estimated that, at any given point in time, ~6% of US children have needs consistent with a serious emotional disturbance,37 whereas 5% to 9% have speech and/or language impairment.5 In each case, these estimates are lower than those found here for children investigated for child maltreatment.

National estimates of specific chronic health conditions are limited; however, they do exist for the most common chronic illnesses in the general population and in our study. A recent national study estimated that 13% of all children (younger than age 18 years) had at some point in their lives suffered from asthma.38 Within the NSCAW target population, the most commonly reported chronic health condition was also asthma (13%). Similarly, the prevalence of other chronic health conditions, like severe allergies, was comparable to that found in the general population.38 Although it is beyond the scope of this study to examine service use, a critical issue for the CWS is ensuring that children with asthma and other chronic health conditions have such needs addressed by relevant health service systems.

This study is also the first to demonstrate the developmental impact of SHCNs in this target population. Our data suggest that the children with SHCNs in this sample were at substantially high risk for a variety of cognitive and behavioral impairments. Functional problems were found consistently across the 2 main types of SHCNs examined: chronic health conditions and special needs. Consequently, our data point to the importance of early health and special education services in general. The early identification of SHCNs may offer the opportunity to foster positive functioning or simultaneously identify co-occurring problems.

Boys, older children, children living in poverty, adopted children, and children in foster care were all more likely than their counterparts to be reported as having SHCNs. A higher rate of special needs among school-aged youth was attributable partly to the definition of the term "special needs." Caregivers were specifically asked if an "educational" or other professional had identified such a need in their child. The findings regarding gender, age, and poverty resemble those of van Dyck et al3 and Newacheck et al,2 although these studies found significant differences by race and ethnicity that were not found in our study. Previous studies have found high rates of SHCNs among children placed in out-of-home care.6,7,9 This study supports previous findings that children with a history of out-of-home placement (adopted and foster care) are at particular risk for both chronic health problems and special needs.6,7,9

Adopted and foster care children may be at increased risk because of a greater prevalence of biological or environmental risk factors. These children may also be more likely than others to have their needs identified or reported because of health screenings provided by CWS or because adoptive and foster parents may be more alert to health conditions and better able to access pediatric care than other caregivers. The rates of SHCNs among children living with adoptive or foster parents do indicate a need to prioritize resources to enable families to cope with their child's chronic health, developmental, or behavioral needs. Although further examining these links between out-of-home placement history and SHCNs exceeds the scope of this study, such links raise important questions on which to base future investigation. Such research could more clearly delineate service priorities for various populations of children with a history of CWS involvement.

It is noteworthy that SCHNs did not vary by the substantiation status of the maltreatment allegation. This finding is consistent with previous studies showing that children in unsubstantiated cases do not differ from children in substantiated cases in the degree to which their development or health is compromised.39–41

Several limitations qualify our conclusions. First, the data to determine SHCNs came from caregivers' reports, not medical charts; consequently, they do not necessarily correspond with medical diagnoses, or they may be subject to response and recall bias. Moreover, although caregivers were asked to report only on conditions that "last a long time or come back again and again," some could have mistakenly reported presence of a chronic condition on the basis of only 1 or a few, or relatively mild, episodes of acute discomforts, like respiratory problems, recurring ear infection, or eczema. A second limitation concerns ways we may be underestimating the rate of SHCNs in the population of children involved in CWS investigations. First, some caregivers may have had limited insight into their children's health problems and special needs; second, the definition of SHCNs used in our study is more restrictive than the MCHB definition, which is a critical issue in the estimation of prevalence.1,42,43 Our definition did not include children "at risk" for SHCN, and we had no information about the requirement or need for "health and related services of a type or amount beyond that required by children generally."4 The analyses of functional impairments associated with the SHCN in this sample, however, suggest that our definition has identified a group of children whose needs match at least the spirit of the MCHB definition. Moreover, regardless of whether such a match exists, SHCN estimates based on NSCAW are likely smaller than estimates from research by using the full MCHB definition.

The third limitation of this study stems from the time reference periods used in the NSCAW SHCN questions. In NSCAW follow-up interviews, caregivers were asked to identify special needs arising only since the previous interview period. By contrast, for chronic conditions, caregivers were asked at each follow-up if their child had a chronic health problem. It is, therefore, possible that caregivers failed to report a special need at a follow-up wave if they had reported it previously, even if the child still had the special need. It was for this reason, as well as to broaden somewhat the scope of our SHCN definition, that we examined the presence of chronic health conditions and special needs both separately and together, as well as over the course of 3 years.

Despite these limitations, this study demonstrates the need to conduct more in-depth community studies of children with SHCNs who are involved with the CWS. NSCAW continues to be a resource to any qualified researcher.44 Moreover, data collection will begin in 2008 for a new NSCAW cohort, which will provide more fully detailed information about the health and early intervention services that children receive. It will also permit the use of a more comprehensive definition of SHCNs, because it will include the Questionnaire for Identifying Children With Chronic Conditions-Revised.45


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Many children who come in contact with the CWS have SHCNs. The risk for SHCNs increases with a history of out-of-home placement, regardless of whether the placement is adoptive or foster care. Children reported to CWS for maltreatment are in a limited way already involved in the social services system; however, the high rates of SHCNs, the diversity of specific conditions, and the associated functional impairments evinced by this study will require a substantial investment by health, mental health, and education systems in partnership with CWS. Consequently, these data support the framework of the 2003 Child Abuse and Prevention Treatment Act, calling for service integration across systems to address the problem of child abuse and neglect. These findings also support the inclusion of comprehensive health screening procedures as a routine part of CWS service plans, particularly for children in out-of-home placements.5 Inattention to the health, developmental, and behavioral needs of children involved in maltreatment investigations not only may compound the immediate effects of abuse, neglect, and deprivation but also may increase the risk of future long-term impairment for these children.


   FOOTNOTES
 
Accepted Feb 8, 2008.

Address correspondence to Heather Ringeisen, PhD, RTI International, 3040 Cornwallis Rd, PO Box 12194, Research Triangle Park, NC 27709-2194. E-mail: hringeisen{at}rti.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Previous research suggests that children in foster care are at increased risk for SHCNs. However, there are no nationally representative data on the prevalence of SHCNs among maltreated children.

 

What This Study Adds

This study longitudinally examines SHCNs among a nationally representative sample of children involved in the child welfare system. This study offers a description of condition-specific prevalence estimates and an examination of specific risk factors and functional characteristics associated withSHCNs.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Bethell CD, Read D, Blumberg SJ, Newacheck PW. What is the prevalence of children with special health care needs? Toward an understanding of variations in findings and methods across three national surveys. Matern Child Health J.2008; 12 (1):1 –14[CrossRef][ISI][Medline]
  2. Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic profile of children with special health care needs. Pediatrics.1998; 102 (1 pt 1):117 –123[Abstract/Free Full Text]
  3. van Dyck PC, Kogan MD, McPherson MG, Weissman GR, Newacheck PW. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med.2004; 158 (9):884 –890[Abstract/Free Full Text]
  4. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics.1998; 102 (1 pt 1):137 –139[Free Full Text]
  5. American Academy of Pediatrics, Committee on Early Childhood and Dependent Care. Health care of young children in foster care. Pediatrics.2002; 109 (3):536 –541[Abstract/Free Full Text]
  6. Halfon N, Mendonca A, Berkowitz G. Health status of children in foster care. Arch Pediatr Adolesc Med.1995; 149 (4):386 –392[Abstract]
  7. Jee SH, Barth RP, Szilagzyi MA, et al. Factors associated with chronic conditions among children in foster care. J Health Care Poor Underserved.2006; 17 (2):328 –341[CrossRef][ISI][Medline]
  8. Leslie LK, Gordon JN, Ganger W, Gist K. Developmental delay in young children in child welfare by initial placement type. Infant Ment Health J.2002; 23 (5):496 –516[CrossRef][ISI]
  9. Leslie LK, Gordon JN, Meneken L, et al. The physical, developmental and mental health needs of young children in child welfare by initial placement type. J Dev Behav Pediatr.2005; 26 (3):177 –179[CrossRef][ISI][Medline]
  10. Perry BD. Incubated in terror: neurodevelopmental factors in the "cycle of violence." In: Osofsky J, ed. Children in a Violent Society. New York, NY: Guilford Press;1997 :124 –149
  11. Cicchetti D, Lynch M. Failures in the expectable environment and their impact on individual development: the case of child maltreatment. In: Cicchetti D, Cohen DJ, eds. Developmental Psychopathology: Risk, Disorder, and Adaptation. NY: Wiley;1995 :32 –71 Vol2 . New York
  12. Cicchetti D, Toth SL. Developmental processes in maltreated children. In: Hansen D, ed. Nebraska Symposium on Motivation: Child Maltreatment. NE: University of Nebraska Press;2000 :85 –160 Vol46 . Lincoln
  13. Egeland B, Sroufe LA. Developmental sequelae of maltreatment in infancy. In: Cicchetti D, Rizley R, eds. New Directions in Child Development: Developmental Approaches to Child Maltreatment. San Francisco, CA: Jossey Bass;1981 :77 –92
  14. Egeland B, Sroufe LA, Erickson M. The developmental consequences of different patterns of maltreatment. Child Abuse Negl.1983; 7 (4):459 –469[CrossRef][Medline]
  15. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics.1998; 102 (2 pt 1):300 –307[Abstract/Free Full Text]
  16. Famularo R, Fenton T, Kinscherff R. Medical and developmental histories of maltreated children. Clin Pediatr (Phila).1992; 31 (9):536 –541[Abstract/Free Full Text]
  17. Makaroff KL, Putnam FW. Outcomes of infants and children with inflicted traumatic brain injury. Dev Med Child Neurol.2003; 45 (7):497 –502[CrossRef][ISI][Medline]
  18. Eigsti I-M, Cicchetti DV. The impact of child maltreatment on expressive syntax at 60 months. Dev Sci.2004; 7 (1):88 –102[CrossRef][ISI][Medline]
  19. Cicchetti DV. An odyssey of discovery: lessons learned through three decades of research on child maltreatment. Am Psychol.2004; 59 (8):731 –741[CrossRef][Medline]
  20. Flaherty EG, Thompson R, Litrownik AJ, et al. Effect of early childhood adversity on child health Arch Pediatr Adolesc Med.2006; 160 (12):1232 –1238[Abstract/Free Full Text]
  21. Takayama JI, Wolfe E, Coulter KP. Relationship between reason for placement and medical findings among children in foster care. Pediatrics.1998; 101 (2):201 –207[Abstract/Free Full Text]
  22. Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youth involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry.2004; 43 (8):960 –970[CrossRef][ISI][Medline]
  23. Stahmer AC, Leslie LK, Hurlburt M, et al. Developmental and behavioral needs and service use for young children in child welfare. Pediatrics.2005; 116 (4):891 –900[Abstract/Free Full Text]
  24. National Survey of Child and Adolescent Well-being Research Group. Methodological lessons from the National Survey of Child and Adolescent Well-being: the first three years of the USA's first national probability study of children and families investigated for abuse and neglect. Child Youth Serv Rev.2002; 24 (6/7):513 –541[CrossRef][ISI]
  25. Dalaker J. Poverty in the United States: 2000. Available at: www.census.gov/prod/2003pubs/p60-222.pdf. Accessed May 16,2008
  26. Newborg J, Stock JR, Wnek L, Guildubaldi J, Svinicki J. Batelle Developmental Inventory: With Recalibrated Technical Data and Norms: Examiner's Manual. Itasca, IL: Riverside Publishing;1984
  27. Kaufman A, Kaufman N. Kaufman Brief Intelligence Test. Circle Pines, MN: American Guidance Service;1990
  28. Zimmerman IL, Steiner VG, Pond RE. Preschool Language Scale: 3. San Antonio, TX: Psychological Corporation;1992
  29. Sparrow SS, Balla DA, Cicchetti DV. Vineland Adaptive Behavior Scales. Circle Pines, MN: American Guidance Service;1984
  30. Achenbach TM. Manual for the Child Behavior Check List/4-18 and 1991 Profile. Burlington, VT: University of Vermont, Department of Psychiatry;1991
  31. Achenbach TM. Manual for the Child Behavior Check List/2-3 and 1992 Profile. Burlington, VT: University of Vermont, Department of Psychiatry;1992
  32. Gresham FM, Elliot SN. Social Skills Rating Scale. Circle Pines, MN: American Guidance Service;1990
  33. Woodcock RW, McGrew KS, Werder JK. Woodcock-McGrew-Werder Mini-Battery of Achievement. Itasca, IL: Riverside Publishing;1994
  34. RTI International. SUDAAN User's Manual, Release 9.0. Research Triangle Park, NC: RTI International;2005
  35. US Department of Education. 25th Annual (2003) Report to Congress on the Implementation of the Individuals With Disabilities Act. Vol1 . Washington, DC: US Department of Education;2005
  36. Costello JE, Messer SC, Bird HR, Cohen P, Reinherz HZ. The prevalence of serious emotional disturbance: a re-analysis of community studies. J Child Fam Stud.1998; 7 (4):411 –432[CrossRef]
  37. American Speech-Language-Hearing Association. Speech-language disorders and the speech-language pathologist. Available at: www.asha.org/students/professions/overview/sld.htm. Accessed March 15,2007
  38. Bloom B, Cohen RA. Summary health statistics for US children: National Health Interview Survey, 2006. Vital Health Stat 10.2007; (234):1 –79
  39. Hussey JM, Marshall JM, English DJ, et al. Defining maltreatment according to substantiation: distinction without a difference? Child Abuse Negl.2005; 29 (5):479 –492[CrossRef][ISI][Medline]
  40. Leiter J, Myers K, Zingraff M. Substantiated and unsubstantiated cases of child maltreatment: do their consequences differ? Soc Work Res.1994; 18 (2):67 –78[ISI]
  41. Casanueva C, Cross T, Ringeisen H. Developmental needs and individualized family service plans among infants and toddlers in the child welfare system. Child Maltreat.2008; In press
  42. Newacheck PW, Rising JP, Kim SE. Children at risk for special health care needs. Pediatrics.2006; 118 (1):334 –342[Abstract/Free Full Text]
  43. van der Lee JH, Mokkink LB, Grootenhuis MA, Heymans HS, Offringa M. Definitions and measurement of chronic health conditions in childhood. JAMA.2007; 297 (24):2741 –2751[Abstract/Free Full Text]
  44. Family Life Development Center, Cornell University. National Survey of Child and Adolescent Well-being restricted release, waves 1–4 and wave 5 follow-up. Available at: http://ndacan.cornell.edu/NDACAN/Datasets/Abstracts/DatasetAbstract_127.html. Accessed December 10,2007
  45. Stein REK, Bauman LJ, Silver EJ. Questionnaire for identifying children with chronic conditions: revised. Available at: www.neserve.org/neserve/pdf/NES%20Publications/QUiCCC_R.PDF. Accessed November 15,2007
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