With Simple Tool, Primary Care Providers May be Able to Identify, Refer Foster Care Youth with Social and Emotional Problems

Study by RWJF Physician Faculty Scholar alumna shows that a short survey of youth and foster parents can help identify mental health problems, as well as strengths.

    • May 20, 2011

At the Monroe County Health Department in Rochester, New York, Starlight Pediatrics serves as a medical home for children in foster care. These children—who often have a different set of mental and physical health needs than children not in foster care—see a physician on a regular basis, which allows for easier identification of problems and more timely referrals to other professionals when appropriate.

Primary care professionals are the “gatekeepers” to subspecialty care for foster care youth, says Sandra H. Jee, M.D., M.P.H., an alumna of the Robert Wood Johnson Foundation (RWJF) Physician Faculty Scholar program (2007-2010) and an associate professor of pediatrics at the University of Rochester School of Medicine and Dentistry. Children in foster care are particularly vulnerable to mental health problems as a result of adverse childhood experiences, Jee says. Because their mental health problems often pre-date entry into the foster care system, early identification and intervention is essential to getting them the treatment they need.

Typically, children in foster care are evaluated for social and emotional problems through an extensive home-based structured clinical interview. But a simple behavioral screening survey, done systematically in the primary care office, may be as effective, Jee and her colleagues found in a study published in the May 2011 issue of Pediatrics. In addition to Jee, it was authored by Moira Szilagyi, M.D., Ph.D., Anne-Marie Conn, M.A., Wendy Nilsen, Ph.D., Sheree Toth, Ph.D., Constance D. Baldwin, Ph.D., and Peter G. Szilagyi, M.D., M.P.H.

“We wanted to come up with a standardized way to do mental health screenings” for foster care youth, Jee said. “There are general guidelines about systematic screenings but no empirical research about what tools should be used.”

“Teens in foster care have already been questioned many times,” she said. “They’ve seen so many people by the time they enter our door. We wanted to do something accurate but not too long.”

In 2007, Starlight Pediatrics began asking youth, ages 11 to 17, to complete the Strengths and Difficulties Questionnaire (SDQ) at the beginning of routine clinical visits. This 25-question behavioral assessment tool asks youth to rank their emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and pro-social behavior on a scale of one to five. This screening is unique in that parents are also given the survey to fill out about their child, and it assesses strengths as well as difficulties, Jee explained.

The team recruited a random sample of youth who had completed the SDQ to also complete the Children’s Interview for Psychiatric Syndromes (ChIPS) – the widely-used longer, more structured interview process. Researchers then and compared the results of the two testing methods.

“We found that the Strengths and Difficulties Questionnaire had good agreement with the Children’s Interview,” Jee said, particularly when parent and youth responses were evaluated together. Current foster parents were more likely to report problems than youths, regardless of how long the child or children had lived with them.

Combining data from youth and parents, 93 percent of youth who were identified with any type of mental disorder through ChIPS also had an SDQ-identified problem. The SDQ also identified 11 of 22 youth as having a significant problem that the ChIPS did not identify, the study says.

Jee and her research team concluded that the simpler youth/parent SDQ survey did better at identifying single problems in foster youth, and the more comprehensive ChIPS did a better job of identifying multiple or more complex problems.

So the information provided by an office-based screening like the SDQ may help primary care professionals provide guidance or resources before, or in lieu of, a formal mental health evaluation. It provides an effective first screening.

“I hope this encourages other primary care sites to take the initiative to do systematic mental health screenings for children in foster care,” Jee said.

Although one of the goals of the study was to identify mental health problems, Jee notes that the research team also identified the strengths of these youth in the SDQ. “There’s a lot of negative press about teens in foster care, but we found a high percentage of them had strengths. They’re very resilient.”

Standardizing Care for Children in Foster Care

This study is not Jee’s first to look at health care for children in foster care. She has authored studies examining the population’s developmental delays, emergency department utilization and chronic conditions, among others.

She is also working with foster care health sites around the country in a learning collaborative to determine standards and best practices for children in foster care. Although the American Academy of Pediatrics provides guidelines on foster care health, there is a lot of variability in the interpretations of those guidelines, Jee explains.

“These are not necessarily researchers [in the collaborative]; these are people on the ground level,” she said. “We want to put our heads together to improve care for foster children.”