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Children who experience maltreatment are particularly vulnerable to behavioral and emotional problems, yet they often do not receive necessary assessments or services. High-risk subgroups—such as those contacted by child protective services (CPS) or involved in foster care—are frequently underrepresented in national health surveillance systems. This study draws on two administrative datasets to examine the prevalence of behavioral and emotional problems among CPS-involved and foster care children. It explores demographic disparities and compares findings to national survey data, aiming to address gaps in understanding the scale of these issues among system-involved children.
Methods
This study analyzed behavioral and emotional problems using NCANDS and AFCARS data from 2015–2021 to ensure comparability with national surveys (NSCH, NSDUH). Twenty-eight states met inclusion criteria based on complete county-level reporting and the availability of at least two relevant indicators. The number of children involved in CPS varied widely across states, ranging from 4,000 (SD) to 147,000 (IN), while foster care populations ranged from 300 (DE) to 11,700 (OH). Six outcomes were examined: behavioral problems, emotional disturbance, drug use, alcohol use, learning disability, and intellectual disability. Hierarchical logistic regression models estimated predicted probabilities and assessed demographic and geographic disparities, with state-level random intercepts included to account for system-level variation and improve model convergence and interpretability.
Results
Across all systems, children in foster care consistently exhibited the highest rates of behavioral and emotional problems, followed by children in the general population, with the lowest rates observed among children with CPS contact. Behavioral problems declined significantly from 2015 to 2021 in both CPS and foster care datasets, while rates remained stable in national survey data. Emotional disturbance, particularly anxiety, increased in the general population, remained flat in foster care, and declined slightly in CPS. Both CPS-involved adolescents and those in foster care showed nearly double the rates of drug abuse compared to children in the general population. Alcohol abuse declined in both CPS and foster care samples, while trends remained stable in the general population.
Demographic models showed that older children and boys were consistently more likely to be identified with behavioral health concerns. Racial disparities varied: Black and Hispanic children in CPS were less likely to be identified, except for higher behavioral problem rates among Black children. Multiracial children showed elevated risks across several outcomes. Rural residence was linked to higher identification of most behavioral health outcomes in CPS, but not in foster care.
Conclusions and Implications
This study highlights underreporting of behavioral and emotional problems in CPS administrative data, raising concerns about missed opportunities for early intervention. Boys, rural youth, and multiracial children showed elevated risks, while Black and Hispanic children were less likely to be identified across outcomes. Strengthening behavioral health screening, improving data quality, and expanding integrated services especially in rural areas are important. Tailored services will ensure all children receive appropriate assessment and support for behavioral issues within the child welfare system.