Congregate Care and Risk of Delinquency: A Reexamination Accounting for Preexisting Youth Behavioral Risk

Background and Purpose

The use of congregate care (CC) in the United States has declined substantially in the last 25 years, from 110,000 in 2000 to approximately 44,000 in 2018. Following the passage of the Family First Prevention Services Act in 2018, which limits federal funding for CC placements longer than two weeks for most children, the numbers have fallen further to 34,000 in 2022. However, states have faced challenges in reducing CC, and the number of children without placements – sleeping in agency offices, hotels, emergency rooms, and shelters has increased.

Efforts to reduce the use of congregate care (CC) as an out-of-home placement (OHP) are in part motivated by studies linking CC to delinquency and other adverse outcomes. Yet, because CC is an OHP of last resort, associations may reflect pre-existing behavioral health differences between adolescents in CC versus other OHPs. Prior research has not adequately controlled for the potential confounding effect of pre-existing behavioral health risk. Thus, this study examines three questions: (1) Is CC associated with delinquency, net of pre-existing behavioral health? (2) Does the association between CC and delinquency vary as a function of children’s preexisting behavioral health? (3) Do these associations differ during or after placement?

Methods

This study examines all youth (N=12,126) entering OHP in Pennsylvania in 2015-2018. Youth behavioral health risk is measured using pre-OHP indicators from child welfare, juvenile justice, and Medicaid records. The two most common types of CC, group homes and institutions, are measured separately. (1) We estimate the probability of a new delinquency referral within 12 months of OHP including pre-existing behavioral health measures as controls. (2) We add interaction terms between pre-existing behavioral health measures and OHP types. (3) We estimate the hazard of first delinquency referral during and after placements separately.

Results

(1) Accounting for pre-existing behavioral risk modestly attenuates the association between CC and delinquency (group home odds ratio (OR)=1.61, p<0.05, institution OR=1.55, p<0.05). (2) Moderation analyses reveal that the association is strongest for low-risk youth and disappears for youth with a history of delinquency prior to placement. (3) The hazard ratios (HRs) for group homes during placement (HR=1.43, p<0.05) vs after placement (HR=1.46, p<0.05) are similar. For institutions, the HR for institutions during placement is not significant (HR=1.08). However, it is significant after placement (HR=1.58, p<0.05).

Conclusions and Implications

CC reforms should focus on avoidance of CC for youth without severe behavioral health concerns. Yet, given the limited alternatives for placement, high-acuity youth may benefit more from efforts to increase the quality of CC. With the exception of during placement, group homes and institutions were similar in terms of their associations with delinquency.