Psychiatric Residential Treatment Among Children in the Child Welfare System

Background and Purpose:

Children and adolescents suffering from severe mental health disorders are often placed for long-term treatment in psychiatric residential treatment facilities (PRTFs), a highly restrictive and expensive treatment setting. In many states, PRTF admissions have increased despite evidence that home and community-based mental health services can provide an effective treatment alternative and produce savings to Medicaid. There is also growing evidence that children often exit and re-enter PRTFs multiple times. One particularly vulnerable population, children served by the child welfare system, are at higher risk for PRTF entry and recidivism. This increased PRTF utilization may be due to higher rates of mental health disorders related to trauma in early childhood, a lack of stable and permanent placements in the foster care system, and a fragmented system of care. However, no longitudinal research has explored which children are at highest risk for PRTF entry and re-entry. To address this gap, this study used longitudinal, multi-sector, secondary data to answer the following questions: 1) Among children with child welfare contact during early/middle childhood (ages 0-12), what factors predict later PRTF entry (ages 12-17)? 2) Among adolescents with prior child welfare contact who enter a PRTF, what factors predict re-entry?

Methods:

This study used secondary administrative data from the state of North Carolina from 2006 to 2012. To focus on children receiving services from the child welfare system, the sample consisted of all children with a child welfare record prior to age 12 (n = 237,258). The sample was linked to Medicaid claims to examine behavioral health service use, diagnosis, and drug prescriptions. For the second question, the sampling frame included adolescents who exited a PRTF before age 18 (n = 889). Logistic regression and Cox proportional hazards regression, a class of survival analysis, were used.

Results:

Among children with a first report of maltreatment prior to age 12, children with a substantiated report were about 6 times more likely to enter a PRTF than children with no substantiated reports. The number of foster care placements also predicted PRTF entry. About 12% of children who entered a PRTF and were discharged prior to age 18 were re-admitted. Risk for PRTF re-entry was highest for children who received prescriptions for three or more antipsychotic drugs (HR= 4.3). However, risk for re-entry was reduced for children who received medication management services after PRTF discharge, (HR = 0.71).

Conclusions and Implications: 

These results have important implications for mental health and child welfare policy and practice. The findings suggest that maltreated children are more likely to suffer behavioral health symptoms requiring care in PRTFs. This lends support for primary maltreatment prevention and also screening and early intervention for maltreatment victims. Further, caregivers of children who are removed to foster care require support to address complex behavioral concerns in the home. Multiple, unstable foster care placements often result in PRTF placement. The findings regarding PRTF re-entry underscore the need to better understand the use of psychotropic drugs to treat behavioral health problems of maltreated children.