Children In State Custody Research Articles

Pediatric Decision-Making for Children in State Custody.

In summer 2022, six points of consensus emerged from a symposium addressing the question, "In the context of U.S. pediatric care, what moral precepts ought to guide parents and clinicians in medical decision making for children?" (Salter et al. 2023). The authors of this statement wrote, however, that the points of consensus may require modification or may not apply in their entirety to children in state custody. This article addresses the consensus recommendations in the context of the thousands of children removed annually from the custody of their parents. While the consensus statements developed at the symposium provide a good starting point for decision-making in the context of these children, some alterations and nuance must be applied to attend to the specific needs of this population. The article works through what special considerations and changes ought to be made to expand the reach of the original points of consensus without neglecting the particular conditions of children in state custody, as well as their parents and caregivers.

Georgia's new mental health parity law took effect July 1

Under the state's new mental health parity law, Georgia health insurers must cover mental health treatment at the same level as physical ailments, the Cherokee Tribune & Ledger‐News reported on July 2 (see MHW, May 30). “Parity kicks in immediately,” Rep. Todd Jones, R‐South Forsyth, said about the new law's July 1 start date. “Georgia families hopefully have a greater opportunity to receive treatment they're entitled to,” Rep. Mary Margaret Oliver, D‐Decatur, bill co‐sponsor, said of the change introduced by the new parity rule. “Folks that have not been getting adequate treatment: new funding is coming, new attention is coming,” Oliver said. The mental health law also sets up a new Multi‐Agency Treatment for Children (MATCH) team. The team will start meeting soon and look carefully at the problem of Georgia children in state custody who lack stable placements, Oliver said. The new mental health law also helps set up mental health co‐responder programs, Oliver said, with funds provided in the fiscal year 2023 budget. Later this year, the state will solicit proposals from communities that want to set up assisted outpatient treatment programs. The new mental health law provides for five such programs on a pilot basis.

Māori Health Review: Oranga Tamariki and the Well Child Tamariki Ora review

It is well established that Aotearoa, New Zealand has high rates of child abuse compared to other OECD (The Organisation for Economic Co-Operation and Development) countries. From 2007 to 2017, 12% of homicides were of tamariki (children) under 12 years of age. On average, a child dies every five weeks from family violence, ranking Aotearoa 7th highest for child homicide and 35th out of 41 OECD countries for child wellbeing outcomes. Inequities in health outcomes exist outside of child abuse as well — Māori tamariki with meningococcal disease are hospitalised at 3.5 times the rate of non-Māori, non-Pasifika children. Māori tamariki with skin infections are also hospitalised at 2–2.5 times the rate of non-Māori, non-Pasifika children. These examples serve to highlight the inequitable outcomes Māori tamariki experience in both disease and abuse. With the prevalence of child abuse, there is a corresponding amount of activity in the child protection sector. Oranga Tamariki is the branch of government that oversees care for children of the state, youth offenders, and children at risk of harm from violence. In the 12 months prior to September 2021, 5100 children were entered into the care and custody of Oranga Tamariki. Out of these children in state custody, 57% identified as Māori and a further 11% identified as both Māori and Pasifika.5 These statistics serve to demonstrate the inequitable picture that makes up child protection interventions and outcomes in Aotearoa. The conclusive evidence that we have a child abuse epidemic in our country needs to be framed in the context of its inequitable representation. It is Oranga Tamariki and its subsidiaries that are responsible for upholding the legislative duty of the New Zealand Government as the Crown partner in Te Tiriti o Waitangi (the Treaty of Waitangi) to provide equitable outcomes for Māori children and their whānau (families).

Service System Barriers to Reunification

Programs to reunice children in state custody with their families and communities have not proliferated to the same extent as have programs designed to prevent placement. Although reunification is ...

Who gets a CASA? Selective characteristics of children appointed a CASA advocate

Prior research examining the effectiveness of Court-Appointed Special Advocates (CASA) as an intervention for improving the outcomes of children in state custody has been hindered by selection bias, because children may be selected to receive CASA representation based on non-random characteristics. Selection bias poses a strong threat to internal validity, and researchers have struggled to isolate the effects of CASA services on child and case outcomes. The present study examines the extent of selection bias in the CASA assignment process over a 2-year period for a full population of foster children in regions served by CASA programs in Texas (N = 32,349), thereby increasing the capacity to control for selection characteristics and supporting causal inference in ongoing studies. This analysis of CASA and state child welfare administrative data examines differences in the baseline child-, family-, and case-level characteristics of children who were appointed CASA representation compared to children who received child welfare services without CASA representation. Mixed-effect logistic regression modeling identifies independent predictors of CASA appointment while controlling for a range of factors and accounting for data clustering in the selection process. Findings indicate that CASA cases in this population have indicators of greater complexity and severity compared to their non-CASA counterparts. By empirically identifying the factors that predict assignment to CASA at the population level, this study lays the foundation for an advanced quasi-experimental outcome evaluation to examine CASA's effectiveness at improving child and case outcomes while minimizing the influence of selection bias.

Paradigm Shifts Don’t Come Easy: Confrontations between the Trauma Perspective and the DSM in Mental Health Treatment for Abused and Neglected Children

Abused and neglected children are in need of trauma-informed behavioral health care. This research explores whether the trauma perspective has infiltrated the system of care for these children. A case study was conducted of a behavioral health program that serves children in State custody in a large urban area in the US. Results reveal that trauma is not incorporated into behavioral health services in any formal or substantive way. In addition, data suggest that the Diagnostic and Statistical Manual of Mental Disorders (DSM) represents a significant barrier to the creation of trauma-informed systems. Data reveal how the DSM ignores, defeats, or co-opts the trauma perspective. These findings suggest that trauma-informed care is not easily added to the existing behavioral health system. Research and dialogue are needed about how to achieve system change so that maltreated children’s trauma histories inform and influence the services they receive.

Father involvement in child welfare: Associations with changes in externalizing behavior

Nonresident fathers can have a significant impact on children's behavioral outcomes. Unfortunately, the impact of nonresident father involvement on the behavioral outcomes of children with child welfare involvement has received scant attention in the literature, a limitation the current study sought to address. A sample of 333 children in state custody in Illinois between the ages of six and 13 participated and were assessed using the externalizing behavior scale of the Child and Adolescent Needs and Strengths (CANS) at regular intervals throughout their time in care. Father involvement was measured through a review of case files and interviews with child welfare workers. Growth trajectories were fit to children's externalizing behavior across time and were predicted using Time 1 characteristics. Father involvement, total non-father relative involvement, and gender (girls) was associated with lower baseline externalizing behavior and the African American children in the sample experienced higher baseline externalizing behavior. However, only Time 1 father involvement predicted slope trajectories after controlling for Time 1 externalizing behavior; more father involvement was associated with lower externalizing behavior trajectories. These results suggest that even in the unique and stressful context of child welfare, father involvement can be protective regarding children's externalizing behaviors.

Post-Permanency Continuity: What Happens After Adoption and Guardianship From Foster Care?

A new dynamic faces the U.S. child welfare system. Since 1998 there has been a simultaneous decrease in children in state custody and increase in children in subsidized adoptive and guardianship homes. In 2013 there were 2.8 children in federally assisted adoptive or guardianship homes for every child in a federally assisted foster home. While generally lauded as positive, little empirical research chronicles the post-adoption or post-guardianship outcomes of these children, and there is no agreed-upon terminology for children who leave their legally permanent homes prior to becoming adults. This study examined outcomes for 21,629 children adopted or taken into guardianship, and tracked for at least 10 years, or until age 18. Most (87%) did not reenter foster care or experienced another type of temporary or long-term interruption in care. Based on the experiences of the 13%, this study suggests new terminology, post-permanency discontinuity, to describe these experiences.

A Systems-Building Model for Children and Youth in State Custody

Objective: Children and youth in the child welfare and juvenile justice systems or at risk of entering them are known to have high rates of mental health problems and psychiatric disorders. Many states are struggling with the provision of mental health services for these important populations, both providing timely and adequate access to services as well as providing evidence-based interventions to address their complex needs. The state of Tennessee developed a program of regional Centers of Excellence (COEs) based within pediatric tertiary centers that provide clinical and consultative services, and technical assistance to behavioral health providers and regional branches of the state child welfare agency. These are oriented to improve access, quality, and effectiveness of care. Methods: This manuscript briefly reviews the history and process of development for the Tennessee COEs for Children in State Custody. It also outlines their evolving clinical and consultative activities, and activities to develop services infrastructure on behalf of children in custody with complex behavioral health needs. Results: The COEs have provided a significant number of direct consultative and clinical services that have been formally evaluated as highly valuable by stakeholder agencies. They have also developed an infrastructure for training and dissemination of best practices and evidence-based interventions oriented to the special needs of children in state custody. Conclusions: The Tennessee COEs serve as a national model for the building and development of regional systems, both for children in state custody and for other children and youth with complex mental health needs. Keywords: Child and adolescent mental health, child welfare, state custody, systems of care.

Addressing Injuries in Vulnerable Populations: Research Collaborations and Partnerships

Injury-related morbidity and mortality disproportionately impact vulnerable groups, including children under the age of 5, older adults, racial and ethnic minority populations, and people of low socioeconomic status.1–4 The Emory Center for Injury Control (ECIC) is a Centers for Disease Control and Prevention (CDC) Injury Control Research Center5 charged with reducing the health and economic impact of injuries in Atlanta, Georgia and worldwide. The ECIC seeks to achieve its mission by focusing specifically on translation research and vulnerable populations. Moreover, the ECIC is committed to encouraging innovative, interdisciplinary collaborations in the realms of research, training, and outreach. Examples of successful interdisciplinary activities include outreach to local emergency departments (ED) to screen patients for mental health symptoms and exposure to intimate partner violence and collaboration with the Georgia Child Fatality Review Panel to evaluate its processes and identify risk factors for death among children in state custody. At the grassroots level, the ECIC serves as the research/scientific arm of the Metropolitan Atlanta Violence Prevention Partnership, providing scientific support and technical assistance to this community-level organization of partners working in inner city, disadvantaged settings. In order to disseminate the research findings generated by faculty and researchers associated with the ECIC, a partnership with the Western Journal of Emergency Medicine editorial team was formed to dedicate special thematic journal issues featuring research underway by the ECIC. We are delighted to report that this is the third special issue from this partnership, and we are very excited to present the injury prevention community with new research findings to inform programs, policy, and future research. The current special issue presents findings on a range of topics that highlight injury-related health disparities and vulnerable populations. More specifically, there is a commentary regarding the healthcare disparities in trauma care as well as a manuscript addressing the benefit of a tiered trauma activation system.6,7 Another manuscript examines the predictors of post-traumatic stress disorder among trauma victims and yet another manuscript assesses ED visits for traumatic brain injuries among older adults.8,9 Two other manuscripts examine poisonings.10,11 In addition, there are several manuscripts on intimate partner violence and unwanted sexual intercourse. For example, 1 study examines the latent trajectories of intimate partner violence and seeks to determine if childhood experiences impact these trajectories.12 Three other studies examine intimate partner violence victimization and health behaviors among women, the racial and ethnic differences in unwanted sexual intercourse among girls, and the feasibility of using social media to study intimate partner violence among gay men. 13–15 Another manuscript related to youth examines bystander motivation in bullying incidents.16 Moreover, one manuscript examines the associations between temperature and violent crime.17 International research included in this special issue examines intimate partner violence and social pressure among gay men across 6 countries and violence victimization and perpetration among youth in the slums of Kampala, Uganda. 18,19 The range of manuscripts and professional affiliations reflected among the authors of the manuscripts included in this special issue underscore the strength and breadth of the ECIC – a ‘center without walls or silos.' The ECIC links numerous professionals and disciplines at Emory University with counterparts at Atlanta-area public universities, private colleges, government agencies, and community-based organizations. In addition to its academic partners, the ECIC is closely aligned with local hospitals (particularly Grady Memorial Hospital, Atlanta's largest Level I trauma and burn center), and stakeholder groups directly affected by violence and unintentional injuries. Our consortium includes individuals with national and international reputations in the fields of neuroscience, injury epidemiology, criminology, poison control, health policy, rehabilitation, prevention science, acute care, disaster preparedness, public health training, and translation research. It is through these partnerships we can build the momentum to truly reduce injuries in vulnerable populations and to strengthen our capacity to reach underserved populations.

Missouri's Developing Public–Private Partnership for Child Welfare: Using Performance-Based Contracting to Achieve System-Wide Results

The state of Missouri developed a model of privatization of child welfare services with a specific focus on partnership between the public and private sectors and improved outcomes for children. With initial development of a prototype in 1998, the state gained some experience with performance-based contracting, utilizing a true “case rate” model. This model eventually became the foundation for a much broader involvement of private agencies, which evolved to private case management of approximately 30% of the children in state custody, utilizing seven primary contractors with 15 of the state's major private agencies providing direct services.

Investigating geographic variation in use of psychotropic medications among youth in child welfare

Objectives Public Law (P.L.) 110-351, the “Fostering Connections to Success Act,” calls for state child welfare agencies to partner with Medicaid and pediatric experts to provide planning and oversight regarding the provision of health and mental health services, including medication, to children in state custody. Recent reports, media cases, and class action lawsuits suggest over-use of psychotropic medications to address the behavioral needs of children in the child welfare system. We examined geographic variability in psychotropic medication use across US child welfare agency catchment areas to determine how rates of psychotropic medication use vary in relation to child, community, child welfare, and health system-level factors. Methods Cross-sectional analysis of Wave 1 data for the 92 child welfare catchment areas participating in the National Survey of Child and Adolescent Well-being, a random probability sample of 2,504 children ages 2–15 years undergoing investigation for abuse and neglect. We employed multilevel regression modeling to examine the impact of catchment-level variables on medication use, controlling for child-level variables. Results Fifteen percent of children reported taking psychotropic medications. Rates of medication use across catchment areas ranged widely from 0 to 40%, a 40-fold difference. On multi-level logistic regression modeling, older age ( p < .001), male gender ( p < .001), emotional and behavioral problems ( p < .001), and insurance ( p = .05) were associated with psychotropic medication use at the child-level. At the catchment-level, stressful environment within the child welfare system was negatively associated with medication use. No other catchment-level variables examined were found to explain use. Conclusions Striking disparities in medication use exist across catchment areas in this national sample. Of the catchment variables examined, only stressful environment was related to medication use. Practice implications These findings highlight significant geographic variation in medication use that most likely reflect both under-use and over-reliance on psychotropic medication. The link between child welfare environment and medication use suggests the influence of systemic, as opposed to clinical, causes of variation in medication use. This requires greater implementation of organizational processes governing quality of care for this highly vulnerable population.

Child Protection Mediation: An Evaluation of Services Provided by Cook County Juvenile Court

Mediation in the Cook County Circuit Court Child Protection Mediation Program provides the family of children in state custody with the first opportunity to voice their concerns, feel heard and discuss their children’s future. This was one of the major findings of an evaluation of the program conducted by Resolution Systems Institute. The study looked at three areas: program performance, program process and stakeholder understanding and assessment of mediation and its role and function within the child protection system. The study included data from 164 cases referred to mediation, as well as interviews of mediation participants, judges, attorneys and program staff. Participants, particularly family members, had very positive reactions to the program. However, very few were given the opportunity to experience it. Judges and hearing officers saw the value in the program, but did not often make referrals to it. The majority of judges and attorneys interviewed believed mediation could occur early on, but almost always referred cases to the program after the disposition hearing (generally two years after the children were brought into the system). This is the paradox of the program. It works well, is well-regarded by almost everyone, and the participant families find it to be a rewarding experience, but it is underutilized.

Pediatric Bipolar Disorder: An issue for Child Welfare

A new diagnosis for children has emerged in the last decade: Pediatric Bipolar Disorder. Children who would have in the past been given other diagnoses are now being relabeled as Pediatric Bipolar. Drugs prescribed for adult Bipolar Disorder are being prescribed for children. The case for delaying pharmacological intervention for treatment of Bipolar Disorder, particularly among young children, is considered. Evidence against the kindling hypothesis, the basis of the case for early pharmacological treatment of Bipolar Disorder, is reviewed. The implications of the controversy over Pediatric Bipolar and medications for small children are discussed with particular consideration given to children in state custody.

Kinship foster parenting; gender, class and labour-force participation

Objective: Knowledge about gender, class and labour-force participation of kinship foster parents in European countries is scarce. This study examines the gendered structure and generational pattern of kinship foster parenting in Norway and compares class components and labour-force participation of kinship foster mothers to the larger female population and to non-kinship foster mothers. Method: The analysis is based on survey data on relationships between foster parents and child, social demographics and placement characteristics from 123 kinship and 88 non-kinship foster mothers of children in state custody. Labour Force Survey and Education Statistics from Statistics Norway were used to compare the kinship sample to the average female population. Findings: Kinship foster care in Norway is gendered, in that it is women who assume the responsibility for relatives' children. Kinship foster care reflects class differences in that the educational level of kinship foster mothers and their household income are lower than the average female population and of non-kinship foster mothers in Norway. The labour-force participation of kinship foster mothers in Norway is comparable to that of the country's female population in general, except for women aged 35–55 with children under seven, among whom labour-force participation is lower than for the female population.

Using Decision Support to Address Racial Disparities in Mental Health Service Utilization

SUMMARY Unfortunately, racial disparities are well documented in the delivery of behavioral health services. This study examines the effects of implementing a decision support process, integrating clinical information into the administration of mental health services, on racial disparities in psychiatric hospital admissions for children in state custody. Differences in a hospitalization prediction model and the proportion of low-risk admissions in Caucasian, African American, and Hispanic youth from 1998 to 2002 were assessed in a statewide sample of 7,653 screenings. Differences in low-risk admissions were assessed after the 1999 initiation of the decision support process. Following the initiation of feedback to clinicians and the use of the Childhood Severity of Psychiatric Illness (CSPI), a decision support tool, the hospitalization prediction model improved significantly. The proportions of low-risk Caucasian and Hispanic youth hospitalized decreased from 1998 to 1999; the proportions of low-risk African American youth hospitalized during this period significantly decreased. In addition to traditional methods of addressing racial disparities in behavioral health care, such as increasing cultural competence in service delivery, providing feedback to service providers to improve the consistency of decision-making may have significant secondary impacts on other system problems— in this case, racial disparity.

Role of Independent Advocates for Research Subjects Who Are Child Wards of the State

Specific advocate guidelines are needed for the protection of children in state custody who are potential research subjects in trials that would expose them to greater-than-minimal risk but also hold the prospect of direct benefit. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Research on Foster Children: A Role for Social Work

In Spring 2005, media outlets began reporting on the use of foster children in drug experiments (AIDS Drugs Tested, 2005). Although this may have been new information to major U.S. outlets, the BBC began reporting on the testing of AIDS drugs on foster children during fall 2004 (Doran, 2004). Vulnerable children in state custody have been subject to experiments in the past--for example, the 1950s radioactive milk testing on developmentally disabled children at Fernald and the 1960s hepatitis testing on developmentally disabled children at Willowbrook--experiments that were so egregious that procedures to ensure the protection of human subjects became a requirement for anyone receiving federal research support (Resnick, 2005). One such protection is the appointment of independent advocates to ensure that safeguards are in place and that children are not exposed to unjustified risk of harm. It is urgent that professional organizations such as the National Association of Social Workers (NASW), the Child Welfare League of America, the Children's Defense Fund, and other groups expand their efforts on behalf of children used as research subjects. On June 29, 2005, the U.S. Senate passed two amendments to limit the testing of pesticides on humans (Critics Claim, 2005). These amendments were in response to a plan by the Environmental Protection Agency (EPA) and the chemical industry to pay parents to apply pesticides and chemicals in rooms primarily occupied by infants. After much discussion, the EPA announced new rules on dosing children with pesticides on January 26, 2006. The rules indicated that human subject protections would be advanced to pregnant women and children. There are, however, exceptions to these protections. Only studies that fail to substantially comply with the new rules will be rejected. If there are significant public health benefits, the EPA may choose to accept ethically flawed studies (Stokstad, 2005). These exceptions indicate that children may still be subject to pesticide testing. THE NATURE OF THE RESEARCH ON FOSTER CHILDREN The facts so far appear to be that dozens of federally approved clinical trials testing AIDS drugs used foster children in at least seven states (Colorado, Illinois, Louisiana, Maryland, New York, North Carolina, and Texas). The adequacy of the protection of these foster children is in question (Solomon, 2005). There is much speculation about the AIDS drug testing and how much injury may have been sustained by the children (Saying 'No,' 2005). As more details of the drug testing have become known, there appear to have been violations of the mandated human subject protections required of researchers by the federal government. On May 18, 2006, the House's Subcommittee on Human Resources began an investigation into these and other possible violations of federal protections for human subjects. Investigations are continuing, and more details will be revealed in the coming months (Special Protections, 2005). For two decades, the National Institutes of Health (NIH) has conducted medical research on AIDS drugs using children as test subjects. During this same time period (the 1980s and 1990s), children with HIV were entering the foster care system in significant numbers (Scott & Kaufman, 2005). The long-term prognosis of these children was poor given that the battle against AIDS was in its early stages and medications were limited and often toxic even to the adults using them. Effective drugs were unavailable for the pediatric population because they had not been tested on infants and children. Drug trials with children were the only way to establish the drugs' effectiveness and safety. Not to do the research would have delayed treatment and might have resulted in more illness and death among the child population. Clinical drug trials would provide more information. Clinical drug trials are classified by stage. Early trials--stages I and II--test the drug's safety, look for toxic side effects, and try to determine the amount and frequency of dosage by weight. …

"I'll Try Anything Once": Using the Conceptual Framework of Children's Human Rights Norms in the United States

International human rights law provides norms, concepts, and standards of immediate and practical value to attorneys for court-involved children in the United States. The conceptual framework of the comprehensive rights of the child is broadly congruent with, or closely related to, the strongest aspects of US. constitutional law and practice. The expansive language of children's human rights offers an historic opportunity: new tools and a more comprehensive context in which to change how we think about young people in conflict with the law, children in state custody, and children in related legal settings. The challenge is to use these fresh substantive concepts as terms of reference in our work and our thinking, as a prelude and incentive to integrating the "instructive" nature of children's international law with the interpretation of our own laws and constitutional traditions. The adoption of the discourse itself can encourage and influence future implementation of enforceable domestic and international law that expands the rights and well-being of children.

Monitoring and Managing Outcomes in Residential Treatment: Practice-Based Evidence in Search of Evidence-Based Practice

In 1995, the Illinois Department of Children and Family Services (IDCFS) spent about $350 million on longterm residential treatment and psychiatric hospitalization, accounting for more than three fourths of the total funds spent on mental health services for the more than 50,000 children in state custody. At that time, no community-based treatment options existed for these children other than outpatient clinic visits (Lyons et al., 1998). The problem was especially acute in poor urban neighborhoods, where even outpatient clinic services were less available and used (Lyons et al., 1998). A more balanced system of care was lacking, leading to disproportionate use of residential treatment, a level of care both costly and incongruent with the leastrestrictive treatment approach (Stroul, 1993). In response to the perceived problems with residential care, the IDCFS established a project to determine whether a subset of children in residential care could be effectively served in the community. Lyons and colleagues (1998) conducted a clinical needs assessment of 333 youths, all in state custody, randomly selected from 17 randomly selected residential treatment settings of various sizes and types (i.e., residential placement programs, group homes, supervised independent living facilities, and residential treatment programs for sexual offenders). The Childhood Severity of Psychiatric Illness (CSPI; Lyons, 1998), a standardized assessment tool comprising 27 items, each with four anchored levels, was used to assess children’s mental health needs across several domains, including psychiatric symptoms, risk behaviors, and functioning. Results indicated that although the majority of children in the sample had levels of mental health need consistent with residential services, 41.4% of the girls and 29.7% of the boys were judged, based on their level of risk, to be eligible for community-based treatment (Lyons et al., 1998). The proportion of children receiving residential treatment yet not appearing to require it varied according to the size and type of residential facility. In both large and small residential facilities, the proportion of low-risk children (i.e., no current suicidal ideation or history of suicide attempt, danger to others, runaway risk, delinquent behavior, or sexual aggression) was higher than in mid-sized residential facilities; in independent living facilities, the majority of children were at low risk, and in both sexual offender programs and mid-sized facilities, far more children were at high risk (Lyons et al., 1998). On the basis of these data, the IDCFS implemented a process of residential placement review and a system of residential facility gatekeepers to ensure more appropriate placement and to monitor progress in care (Illinois Department of Children and Family Services, 2000). This is an example of evidence-based practice: the finding that a proportion of children in residential treatment were at sufficiently low risk that they likely could be served in the community incited systematic changes regarding residential treatment. Between 1995 and 2003, the number of children in residential care in Illinois decreased by almost 60% from 4,015 children in 1995 to 1,683 in 2003 (Budde et al., 2004). As a result, far more Accepted September 1, 2005. The preparation of this article was funded in part by the Illinois Department of Children and Family Services through a contract with Northwestern University. The authors thank Julie Eisengart and Catherine Francis for their assistance with this project. Correspondence to Dr. John S. Lyons, Mental Health Services and Policy Program, Northwestern University, Feinberg School of Medicine, Abbott Hall, Suite 1205, 710 North Lake Shore Drive, Chicago, IL 60611; e-mail: jsl329@northwestern.edu. The authors are with the Mental Health Services and Policy Program, Northwestern University, Feinberg School of Medicine, Chicago. 0890-8567/06/4502–0247 2006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000190468.78200.4e