Purpose: This study examines foster children's transition into intensive mental health and residential care settings, defined as treatment foster care, group homes, residential care and inpatient psychiatric care (subsequently called ‘restrictive care settings'). Entry into such settings is theoretically intended as an intervention of last resort and as a response to psychosocial problems that cannot be addressed in less restrictive family-based out-of-home care settings. The study examines timing and duration of episodes in restrictive care settings and models risk and demographic, clinical, and service use determinants of first entry into such settings.

Methods: This research uses data from The National Survey of Child and Adolescent Well-being (NSCAW), the first prospective study using a nationally representative sample of children involved with child welfare. Data are based on interviews with foster caregivers and child welfare workers utilizing multiple standardized measures in domains including clinical need, family functioning, service history, etc. The current analysis is based on 1,557 children who experienced any stays in out-of-home care during the 36-month study period (Wave 4). Event history analysis methods with time-varying variables are used to model risk and determinants of entry into restrictive care. Covariates in the model include demographic variables, clinical need (developmental, health, and mental health status), maltreatment type, service use variables (mental health services, number of out-of-home placements, prior episodes in out-of-home care) and contextual variables (poverty, rural/urban). All analyses were conducted using STATA 7.0. This statistical software can account for sample weights and the study's two-stage cluster sample design as well as conduct event history analysis with multiple time-varying covariates.

Results: Findings show that 22% of the children experienced 479 episodes in restrictive care over the 36-month study period. Almost 80% of episodes were in group homes and residential care. Two-thirds of the children entered restrictive care following placements in lower level settings, such as nonrelative and relative foster care. For one-third, a restrictive care setting was the first primary placement following entry into out-of-home care. Cumulative hazard curves indicate that the risk of entry into restrictive care is highest during the first 200 days following entry into out-of-home care. Cox regression results with time-varying variables show older age, externalizing behavior problems, physical abuse and chronic health problems to increase risk of entry into restrictive care, with the effect of health status on risk varying over time. Preliminary results did not find developmental problems, number of prior placements or outpatient mental health services to affect risk of entry into restrictive care.

Conclusions: Study findings will be discussed within the context of the conceptual and empirical literature on intensive mental health and residential care services for foster children. Findings from this study raise important questions about the role of different restrictive care settings within the continuum of services for maltreated children.