The Intersection of Child Welfare and Behavioral Health: Are Maltreated Children More Likely to Receive Care in Psychiatric Residential Treatment?
Children served by child welfare systems have higher rates of behavioral health concerns than other children. This is likely due to exposure to traumatic experiences including abuse, neglect, and family instability, but can also be due to a fragmented and unresponsive public mental health service system. Although many service needs go unmet, children in child welfare too often receive care in highly restrictive settings. Despite a preference for home and community-based services, children in many states are increasingly placed in psychiatric residential treatment facilities (PRTFs). Although a small portion of children receive behavioral health services in PRTF settings, they are extremely costly. In North Carolina, Medicaid expenditures on PRTFs increased from $50 million in 2009 to $97 million in 2011. We do not know whether maltreated children are more likely to be placed in PRTFs. To address this gap, this study used longitudinal, multi-sector, secondary data from linked state systems. This study sought to answer the following questions: 1) Is child maltreatment associated with higher risk for PRTF entry, and 2) Among those who enter PRTFs, do maltreated children differ from other children by demographic characteristics and prior placement?
Methods
This study used secondary administrative data from the state of North Carolina from 2006 to 2012. To focus on services provided to low-income children, the sampling frame was limited to children with caregivers with a record of Temporary Assistance to Needy Families (TANF) benefits (n= 460,716). The sample was linked to other state data systems to examine child welfare system involvement and behavioral health services including PRTF entry. The association between child maltreatment and PRTF entry was assessed using chi-square analysis.
Results
Among the sample of low-income children, 21.1% had a child welfare report during the study time frame. The unadjusted odds of experiencing a PRTF entry was 19.7 (95% CI 16.5 to 23.5) times higher for maltreated compared to non-maltreated children. Maltreated children were older on average at their first PRTF entry and were more likely to be female. Maltreated and nonmaltreated children were equally likely to enter a PRTF following residential treatment.
Conclusions and Implications
These results have two important implications for policy and practice. The findings can be interpreted to mean that maltreated children are more likely to suffer behavioral health symptoms requiring care in PRTFs. This lends support for primary maltreatment prevention and also early screening and intervention for maltreatment victims. However, it may also be that PRTF settings are being used more often for children receiving child welfare services not because of need but due to a lack of other less-restrictive care settings appropriate for children with a history of maltreatment. The apparent overuse of PRTFs for child welfare populations may represent an enduring illustration of disconnected child welfare and behavioral health systems. Community-based alternatives are needed that can address the needs of this vulnerable child population.