write a paper

For this assignment, read chapter 5, and please choose one of the two case examples in your text (pages 272-277).  

Choose either the Willie M. Program or the Ventura County System of Care.  Both of these programs were created as a response to policy changes that were attempting to bring more comprehensive and systemic care to children with mental health diagnoses.

1. Briefly describe the program you chose. 

2. Then discuss at least 
three
 methods that program developers used to address treating children with SEDs in order to be compliant with the state guidelines.

3. In what ways would this program enhance protective factors OR alleviate risk factors for children with SEDs and their families?

Social Policy for Children and Families
Third Edition
2

3

Social Policy for Children and
Families
A Risk and Resilience Perspective
Third Edition
Edited by
Jeffrey M. Jenson
University of Denver
Mark W. Fraser
University of North Carolina at Chapel
Hill
4

FOR INFORMATION:
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5

photocopying, recording, or by any information storage and retrieval
system, without permission in writing from the publisher.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Social policy for children and families: a risk and resilience perspective / edited by
Jeffrey M. Jenson, Mark W. Fraser. — Third edition.
pages cm
Includes bibliographical references and index.
ISBN 978–1–4833–4455–3 (pbk.: alk. paper)
1. Children—Government policy—United States. 2. Child welfare—United States.
3. Youth—Government policy—United States. 4. Family policy—United States.
5. Developmental psychology. 6. Child development. I. Jenson, Jeffrey M. II.
Fraser, Mark W., 1946–
HV741.S623 2016
362.82’5610973—dc23      2014048506
This book is printed on acid-free paper.
15 16 17 18 19 10 9 8 7 6 5 4 3 2 1
Publisher: Kassie Graves
Editorial Assistant: Carrie Montoya
Production Editor: Jane Haenel
Copy Editor: Allan Harper
Typesetter: C&M Digitals (P) Ltd.
Proofreader: Jeff Bryant
Indexer: Jean Casalegno
Cover Designer: Gail Buschman
Marketing Manager: Shari Countryman
6

Contents
Acknowledgments
Introduction
1. A Risk and Resilience Framework for Child, Youth, and Family
Policy
2. Antipoverty Policies and Programs for Children and Families
3. Child Welfare Policies and Programs
4. Education Policy for Children, Youth, and Families
5. Child Mental Health Policy: Promise Without Fulfillment?
6. Health Policy for Children and Youth
7. Policies and Programs for Children and Youth With Disabilities
8. Policies and Programs for Adolescent Substance Abuse
9. Juvenile Justice Policies and Programs
10. Toward the Integration of Child, Youth, and Family Policy:
Applying Principles of Risk, Resilience, and Ecological Theory
Index
About the Editors
About the Contributors
7

Acknowledgments
The ideas expressed in the third edition of this volume address many of the
most pressing problems confronting children, youth, and families in
American society. We thank each of the chapter authors for providing
important new information about innovative approaches to public policy in
their respective service delivery sectors. Each author’s commitment to
expanding the application of principles of risk, protection, and resilience to
the design, implementation, and evaluation of social policies for young
people and their families is exemplary. A book such as this one owes a
great debt to many people behind the scenes. Thanks to Diane Wyant of
the University of North Carolina at Chapel Hill and Jenifer Rinner of the
University of Denver for administrative and technical support in
manuscript preparation. Finally, special thanks to Mary, Nils, and Anna
Jenson and to Mary, Alex, and Katy Fraser for the daily reminders of what
it means to be a family.
—Jeffrey M. Jenson
—Mark W. Fraser
SAGE Publications acknowledges the contributions of the following
reviewers:
Lisa R. Caya, University of Wisconsin–La Crosse
Michael Cheang, University of Hawaii at Manoa
Jennifer Cornish Genovese, Syracuse University
Angela Fontes, NORC at the University of Chicago
Clinton G. Gudmunson, Iowa State University
Ivan L. Page, Albany State University
Carlos Perez, Lubbock Christian University
Wendy Thompson, Andrews University
8

Introduction
Much has been written about risk and protective factors associated with
social and health problems. Begun some 35 years ago, research to trace the
causes of behavior problems in young people has led to a new
understanding of the individual, interpersonal, and environmental factors
that affect developmental and, indeed, life course outcomes. In recent
years, attention has been directed to increasing our understanding of the
concept of resilience, which is commonly thought of as a child’s capacity
to overcome adverse life circumstances (Fraser, Kirby, & Smokowski,
2004). Knowledge of risk and resilience has been widely used to improve
the efficacy of prevention and treatment programs for vulnerable children
and families (Catalano et al., 2012; Jenson & Bender, 2014).
In the first and second editions of this book, we argued that the principles
of risk, protection, and resilience held great promise for the design of
social policies and the delivery of social programs for children and
families. We also noted that knowledge gained from longitudinal
investigations of risk, protection, and resilience in children and youth was
rarely applied to social policy. Our view has not changed. We still have
much to learn about the etiological processes of risk and resilience and
about the application of these principles to social interventions and
programs. However, considerable progress in understanding principles of
risk, protection, and resilience has been made since the publication of the
first two editions of this book. Equally important, advances in fields such
as public health and prevention science—in which research-based
knowledge is used to design prevention interventions—are now having a
practical and significant effect on social policies. innovative policies and
programs based on risk and resilience are all the more evident in each of
the chapters in the third edition. Clearly, one dramatic example of change
and innovation lies in health-care reform, exemplified by the
implementation of the Patient Protection and Affordable Care Act (PL 11–
148). This legislation and other new policies affecting the nation’s children
and families are reviewed in this edition. We hope that this book will help
students, practitioners, policymakers, and researchers apply principles of
risk and resilience to the design of social and health policies.
9

Organization of the Book
The core section of the book is formed by eight chapters devoted to
poverty, child welfare, education, mental health, health, developmental
disabilities, substance abuse, and juvenile justice policies. Chapter authors
identify key policies in their respective areas and evaluate the extent to
which the principles of risk, protection, and resilience can be used to
improve existing programs and services. Recommended readings,
questions for discussion, and Web-based resources are provided for each
of the core chapters. In this regard, authors follow a similar outline in
which they
trace the purpose of social policy in a substantive area;
describe the incidence and prevalence of problems;
articulate common risk and protective factors associated with the
onset or persistence of the relevant problem behavior;
identify historical and current policies that have been developed to
address these problems;
evaluate the extent to which policies have been based on the
principles of risk, protection, and resilience;
identify strategies for incorporating elements of risk, protection, and
resilience in new policy directives; and
discuss ways of integrating social policy for children, youth, and
families across policy and service domains.
Trina Williams Shanks and Sandra Danziger identify critical approaches to
combating poverty in Chapter 2. Past and current income-maintenance
policies are reviewed in the context of risk, protection, and resilience.
Williams Shanks and Danziger describe several innovative programs to
illustrate the promise of recent policy approaches to reducing poverty and
social disadvantage.
Peter Pecora and Markell Harrison-Jackson examine child welfare policies
and programs aimed at children, youth, and families in Chapter 3. In
describing a key service domain for children, youth, and families, Pecora
and Harrison-Jackson trace the history and evolution of American child
welfare policy and offer suggestions about ways to incorporate principles
of risk, protection, and resilience in a key service domain.
10

Public schools touch the lives of a majority of American children and
families. Changes in educational policy and practice that have been made
since the publication of the first edition of this book are having a profound
effect on teachers, parents, and children and youth in elementary, middle,
and high schools. In Chapter 4, Andy Frey, Myrna Mandlawitz, Armon
Perry, and Hill Walker update their discussion of the landmark No Child
Left Behind Act and its sweeping implications for the character of public
education across the country. They note that educational reform is closely
linked to political ideology and societal values pertaining to educational
access and opportunity. Frey and colleagues conclude by offering an
agenda for reform.
In Chapter 5, Mary Fraser and Paul Lanier review the effectiveness of
mental health policies for children, youth, and families. Key among the
promising policy and program directives that they identify is the system of
care approach. Fraser and Lanier note the frequency of co-occurring
problems among youth and suggest making the integration of mental
health, juvenile justice, and substance abuse policies a public policy
priority.
Kathleen Rounds, William Hall, and Guadalupe Huitron trace the
development of key U.S. public health policies in Chapter 6. The authors
highlight important changes reflected in the implementation of the Patient
Protection and Affordable Care Act (PL 11–148) and assess the impact of
those changes on young people and their families. Recommendations for
integrated health policy based on risk, protection, and resilience are
offered.
In recent years, recognizing and understanding developmental disabilities
that are commonly found among children and youth has become a focus of
policy debate. In Chapter 7, Susan Parish, Alison Saville, Jamie Swaine,
and Leah Igdalsky discuss changes in policy for children with
developmental disabilities in the past several decades. Using a risk and
protective factor perspective, they offer recommendations for improving
service delivery to children and youth with developmental disabilities.
In Chapter 8, Elizabeth Anthony, Jeffrey Jenson, and Matthew Howard
review current trends in the prevalence, etiology, prevention, and treatment
of adolescent substance abuse. The authors trace the origins of policies
aimed at young substance abusers and comment on the relative
effectiveness of alternate policy approaches. Implications of the Patient
11

Protection and Affordable Care Act on funding streams for substance
abuse prevention and treatment are noted. Anthony and colleagues
conclude that principles of risk, protection, and resilience have been
influential in improving the efficacy of prevention and treatment programs
for young people and reflect on the implications of these findings for
substance abuse policy.
In Chapter 9, William Barton traces major changes in juvenile justice
policy since the creation of the juvenile court. He identifies the tension
found in public policy between the competing program goals of
rehabilitation and punishment. Barton concludes with cautious optimism
about the application of public health principles to juvenile justice policies
and programs.
In the final chapter of the book, we expand on our framework for using
principles of risk, protection, and resilience to develop more fully
integrated policies for children, youth, and families. We argue that
integration of policy and programs across service domains should be a
goal of future policy directives targeting children, youth, and families.
Considerations are given to the developmental processes of children and
youth in the design of this framework. Recommendations for ways to
advance a public health framework based on risk, protection, and
resilience in policy design, implementation, and evaluation are offered.
12

Summary
We hope that the interdisciplinary framework described in this book
stimulates innovative ideas about the design of policies for vulnerable
children and families. Principles of risk, protection, and resilience—too
often ignored in policy discussions—hold great promise for improving the
efficacy of social policies. We believe that an increased focus on risk and
protection will lead to policies that are more likely to produce services and
programs that effectively help children and families to prevail over
adversities.
13

References
Catalano, R. F., Fagan, A. A., Gavin, L. E., Greenberg, M. T., Irwin, Jr., C.
E., Ross, D. A., & Shek, D. T. (2012). Lancet, 379, 1653–1664.
doi:10.1016/S0140-6736(12)60238-4.
Fraser, M. W., Kirby, L. D., & Smokowski, P. R. (2004). Risk and
resilience in childhood. In M. W. Fraser (Ed.), Risk and resilience in
childhood: An ecological perspective (2nd ed., pp. 13–66). Washington,
DC: NASW Press.
Jenson, J. M., & Bender, K. A. (2014). Preventing child and adolescent
behavior. Evidence-based strategies in schools, families, and
communities. New York: Oxford University Press.
14

Chapter 1 A Risk and Resilience
Framework for Child, Youth, and
Family Policy
Jeffrey M. Jenson
Mark W. Fraser
Over the past 100 years or more, social policies and programs for
American children, youth, and families have undergone frequent shifts in
philosophy and direction. Many policy frameworks, such as universal
prevention, selective eligibility, rehabilitation, and punishment, have
contributed to the conceptual bases for services, programs, and
interventions designed for young people. However, the most consistent
characteristic of American social policy for children and families may be
the sheer inconsistency of efforts aimed at helping the nation’s most
vulnerable populations.
Recent advances in understanding the developmental processes associated
with the onset and persistence of child and adolescent problems warrant
new thinking about policies and programs. Since the second edition of this
book was published in 2011, we have learned more about why some
children and adolescents develop social and health problems, and—in the
case of such problems as sexually transmitted diseases, drug use, and
delinquency—why some youths make choices that lead to poor outcomes
at home and in school and the community. Unfortunately, this knowledge
is not yet systematically applied to policy or program design, which results
in poorly specified, inadequately integrated, and wastefully duplicated
services for children and families. The motivation for the third edition of
this volume comes from the growing recognition that knowledge gained
from understanding the developmental trajectories of children who
experience social and health problems must be used to craft more effective
policies and programs.
15

Coming of Age in America
Children, youth, and families face enormous challenges in American
society. At no time in the country’s history have young people and their
parents been confronted simultaneously by such a wide array of positive
and negative influences and opportunities. Most children and youth
become healthy adults who participate in positive—or prosocial—
activities guided by interests that lead to meaningful and fulfilling lives.
However, for some American children and youth, the path to adulthood is
a journey filled with risk and uncertainty. Because of the adversities these
young people face, the prospect of a successful future is often bleak.
If we were to draw a picture depicting the current health of America’s
children and youth, it would be a portrait of contrasts. On a positive note,
young people between 16 and 24 years old are volunteering and becoming
more involved in social causes than in the past (Center for Information and
Research on Civic Learning and Engagement, 2014). In addition, the
prevalence of some problem behavior—most notably, violent offending—
has decreased considerably in recent years. For example, following a
period of rapid increase between the late 1980s and 1995, violent juvenile
crime rates reached historically low levels in 2011 (Puzzanchera, 2013).
Juxtaposed against this promising news are the disturbing accounts of
school shootings, persistently high rates of school dropout and drug use,
and increases in childhood poverty (for reviews of school shootings, see
Bockler, Seeger, Sitzer, & Heitmeyer, 2013; Vossekuil, Fein, Reddy,
Borum, & Modzeleski, 2002; Wike & Fraser, 2009). Nearly 40% of public
schools in the United States reported at least one violent incident to police
in the 2009–2010 school year (U.S. Department of Education, 2014).
Sporadic acts of school violence have occurred in virtually every region of
the country in the years following the horrific 1999 shootings at
Columbine High School in Colorado (Centers for Disease Control and
Prevention, 2008a). The deaths of 20 young children and six adults at
Sandy Hook Elementary School in Newtown, Connecticut, was a jolting
reminder that students and teachers are not always safe in their own
schools and communities (Swanson, 2013).
Academic failure and school dropout have become profound social
16

problems. About 4% of all youth between the ages of 16 and 19 years old
dropped out of school in 2012. Particularly troubling is evidence indicating
that youth of color drop out of school at much higher rates than Caucasian
students. In 2012, 7% of Latino, 10% of American Indian, and 6% of
African American students dropped out of school as compared with only
3% of Caucasian youth (Annie E. Casey Foundation, 2014). As the world
moves to greater globalization of markets and demands a more educated
workforce, these young people face lives of limited opportunities and high
unemployment, bringing consequential high societal costs.
Drug use among American youth also imposes considerable individual and
societal costs on the nation. In 2013, nearly 50% of the nation’s senior
high school students reported lifetime use of any illicit drug, and 25%
indicated they had used an illicit drug other than marijuana (Johnston,
O’Malley, & Bachman, 2013). Despite a recent leveling in drug use trends,
more than 20% of eighth-grade students reported lifetime use of any illicit
drug in 2013. Particularly worrisome is evidence indicating that 7% of the
nation’s high school seniors have tried dangerous drugs such as ecstasy
(Johnston et al., 2013). These unacceptably high rates of drug use among
children and youth are the focus of multifaceted policy and practice efforts
at the federal, state, and local levels.
Poverty is related to many social and health problems. Nearly 23% of U.S.
children younger than 18 years old live in poverty, which significantly
affects individuals, families, and communities (Annie E. Casey
Foundation, 2014). In the United States, children are more likely than all
other age groups to be poor (Cauce, Stewart, Rodriguez, Cochran, &
Ginzler, 2003), and children of color are disproportionately represented in
poverty. Among all U.S. children younger than 18 years, 40% of African
Americans, 37% of American Indians, and 34% of Latino children were
poor in 2012. Those rates are more than double the rates for Asian and
Pacific Islanders (15%) and non-Latino Caucasians (14%) living in
poverty (Annie E. Casey Foundation, 2014).
These statistics are important because living in poverty has both short- and
long-term effects. Poverty has negative effects on several key outcomes
during childhood and adolescence, including school achievement and
delinquency (Brooks-Gunn & Duncan, 1997; Hannon, 2003; Yoshikawa,
Aber, & Beardslee, 2012). Poverty is also associated with adverse
consequences during adulthood and later stages of life (Duncan, Ziol-
17

Guest, & Kalil, 2010; McCord, 1997; Nikulina, Widom, & Czaja, 2011).
The social and environmental conditions created by poverty give rise to a
variety of public health problems that require well-reasoned evidence-
based policy and program responses.
18

Policy and Program Responses to
Childhood and Adolescent Problems
Experts from the fields of criminology, education, medicine, nursing,
psychology, public health, social work, and sociology agree that no single
pathway leads to school failure, drug use, delinquency, and other social
and health problems. Rather, it is the accumulation of risk—the sheer
number of adversities and traumas confronted by children and families—
that seems to disrupt normal developmental trajectories (Rutter, 2001). In
the mid-1970s, Jessor and Jessor (1977) asserted that a small group of
youth simultaneously engaged in a variety of dangerous and costly
problem behaviors; that assertion has been well supported by the research
evidence over the past three decades. Indeed, the same academically
marginalized youths who are involved in drug use may also be the youths
who are at risk of sexually transmitted diseases and violent victimization
by family members or partners. Despite the fact that we know far more
about these high-risk youths, their friends, and their families (e.g.,
Catalano et al., 2012; Elliott et al., 2006; Fraser, 2004; Jenson & Bender,
2014), we have seen few innovative policy strategies being introduced to
reduce the number of children and adolescents who experience these
problems. A looming challenge for both advocates and experts is to find
ways to incorporate and translate new knowledge (i.e., the product of
research) into public policies and programs.
One barrier to the uptake of research knowledge is that current social
policies and programs intended to meet the needs of U.S. children, youth,
and families are highly fragmented. Many policies aimed at improving
conditions for vulnerable and high-risk populations have failed to consider
the number, nature, or severity of problems experienced by American
families. Other policies and resultant programs are duplicated among
agencies, leading to a host of eligibility and implementation conflicts in
child welfare, developmental disability, mental health, substance abuse,
education, and juvenile justice services.
Moreover, the application of theoretical and empirical evidence to the
design of social policies and programs aimed at improving the lives of
children, youth, and families is limited. Social policy is often hurriedly
created in the context of galvanizing community events—such as the rush
19

to implement safety policies in the aftermath of the shootings at Sandy
Hook Elementary School in 2012—or trends that have attracted public
attention and compelled legislation. In some cases, policies developed in
reaction to specific events lead to decisions that fail to account adequately
for unforeseen or unintended long-term consequences. A case in point is
that of the extensive juvenile justice reforms implemented across the
country in the early to mid-1990s. Faced with increased rates of gang
activity and violent youth crime, nearly all states enacted reforms
emphasizing strict sanctions and punishments for young offenders. Many
of these reforms—most notably, boot camp programs and the extensive
use of judicial waivers for serious offenders (with some juvenile offenders
being prosecuted in criminal courts and exposed to adult rather than
juvenile sanctions)—subsequently produced mixed or ineffective results
(Bernard & Kurlychek, 2010; Jenson, Potter, & Howard, 2001).
Over the past several decades, we have learned much about the causes and
progression of child and adolescent problems. However, advances in
understanding the life-course development of problem behaviors among
children and youth primarily have been used to enhance prevention and
treatment strategies rather than to inform theory development (Biglan,
Brennan, Foster, & Holder, 2004; Farrington, 2011). Aside from
Bronfenbrenner’s (1979, 1986) ecological perspective, the field lacks
conceptual models that inform social and health policies for children,
youth, and families. In this book, we argue that a public health framework
—rooted in ecological theory and based on principles of risk and resilience
—is defining a new and useful conceptual model for the design of public
policy across the substantive areas of child welfare, education, income
assistance, mental health, health, developmental disabilities, substance use,
and juvenile justice.
20

Public Health Frameworks for Social
Policy
In the field of prevention science, public health frameworks for
understanding and preventing child and adolescent problems have become
widely used to promote positive youth outcomes (Biglan et al., 2004;
Catalano et al., 2012; Hawkins, 2006; Jenson & Bender, 2014). When
designing or selecting interventions to ameliorate youth problems, social
scientists give first consideration to the presence or absence of risk and
protective factors affecting youth outcomes. Another concept closely
related to those of risk and protection is the concept of resilience, which is
the ability to overcome adverse conditions and to function normatively in
the face of risk. A public health perspective guiding policy development
aimed at children, youth, and families must incorporate these key concepts
of risk, protection, and resilience.
21

Risk and Protection
Risk factors are individual, school, peer, family, and community
influences that increase the likelihood that a child will experience a social
or health problem. Although the idea of identifying risk factors to better
understand childhood and adolescent problems has gained widespread
acceptance in the prevention field (Catalano, 2007; Jenson, 2006;
O’Connell, Boat, & Warner, 2009; Romer, 2003; Woolf, 2008), its origins
are relatively recent. The early work on identifying risk factors dates only
to the 1970s, when researchers began placing greater importance on
understanding the individual, family, and community correlates of mental
illness (Rutter, 1979, 1987). Stimulated in part by advances in research
design and statistical analysis (e.g., the development of path analysis and
structural equation modeling), a new emphasis on modeling underlying
causes led investigators to identify specific factors that were associated
with the occurrence of delinquency, drug use, suicide, school dropout, and
other problems. This approach, adapted from public health efforts to
identify risk factors associated with problems such as smoking and heart
disease, led to the use of “risk-based” strategies to prevent social problems
in childhood and adolescence (Hawkins, Catalano, & Miller, 1992).
Risk Factors
The earliest risk factor models were simple lists of the correlates of
adolescent problems (e.g., Garmezy, 1971). These models were drawn
from previous research that identified risk factors for adolescent problem
behaviors such as substance abuse and delinquency (e.g., Hawkins, Jenson,
Catalano, & Lishner, 1988). Early models often failed to consider the
temporal relationship of risk factors to the occurrence of specific behaviors
or to examine the additive and interactive effects of risk factors. However,
recent reviews of risk factors for adolescent problem behaviors have
improved on earlier efforts by limiting their selection of studies to those in
which the risk factor clearly preceded a problem behavior (e.g., Fraser,
Kirby, & Smokowski, 2004; Fraser & Terzian, 2005; Herrenkohl,
Aisenberg, Williams, & Jenson, 2011; Herrenkohl, Chung, & Catalano,
2004). In addition, longitudinal studies have been conducted to better
understand the processes by which risk factors influence behavior over the
course of childhood and adolescence (e.g., Hawkins, Kosterman, Catalano,
22

Hill, & Abbott, 2005; Loeber, Farrington, Stouthamer-Loeber, & Van
Kammen, 1998; Spoth, Redmond, & Shin, 1998). In this book, we adopt
Fraser and Terzian’s (2005) definition of a risk factor: “Broadly defined,
the term risk factor relates to any event, condition, or experience that
increases the probability that a problem will be formed, maintained, or
exacerbated” (p. 5).
This definition recognizes that the presence of one or more risk factors in a
person’s life has the potential to increase the likelihood that a problem
behavior will occur at a later point in time. However, the presence of a risk
factor does not ensure or guarantee that a specific outcome, such as school
failure, will inevitably occur. Rather, the presence of a risk factor suggests
an increased chance or probability that such a problem might develop.
Table 1.1 presents common risk factors for childhood and adolescent
problems arranged by level of influence. These and other factors are
discussed in relation to specific topics presented in Chapter 2 through
Chapter 9. In addition, the discussions address protective factors, which
are closely related to risk factors. Protective factors are those influences,
characteristics, and conditions that buffer or mitigate a person’s exposure
to risk.
23

Source: Adapted from Fraser et al. (2004); Jenson and Bender (2014); and
O’Connell et al. (2009).
Protective Factors
Researchers began to notice that some apparently high-risk youths did not
engage in problem behaviors. Studies showed that these youths were
protected from risk. That is, they seemed to have personal resources that
helped them prevail over adversities. These resources came to be called
protective factors. Still today, there is ongoing debate about the exact
definition of protection as well as how to put knowledge about protective
factors into practice (Fletcher & Sarkar, 2013; Fraser et al., 2004; Rossa,
2002). Most investigators agree that protective factors are attributes or
characteristics that lower the probability of an undesirable outcome
(Benard, 2004; Rutter, 1987; Werner & Smith, 1992). However, whether
protective factors are independent of risk factors remains in contention.
The knowledge base associated with the concept of protection emerged in
24

the 1980s, when investigators such as Rutter (1979) and Werner and Smith
(1982) observed that certain positive attributes appeared to operate in the
presence of risk or adversity. However, the exact definition of a protective
factor quickly became a topic of debate. Most of this debate has centered
on the confusion created when risk and protective factors are thought of as
opposite ends of a single continuum (Pollard, Hawkins, & Arthur, 1999).
For example, researchers have often identified consistent family
management practices as important in producing positive outcomes in
children, whereas a style of inconsistent family management is construed
as a factor leading to poor outcomes. In some studies, consistent family
management is identified as a protective factor and inconsistent family
management is seen as a risk factor. Using risk and protection in this
manner establishes the two concepts as polar opposites, with one pole
representing positive outcomes and the other pole representing negative
outcomes. Therein lies the ongoing debate among social scientists, which
can be briefly summarized as two questions:
1. Do risk factors and protective factors represent measurable levels of
an attribute or characteristic that has two poles along a single
continuum?
2. Are risk factors and protective factors separate and independent
constructs?
Our concept of protection holds that protective factors operate as a
buffering agent to moderate exposure to risk. We offer the following
definition from Fraser and Terzian (2005): “protective factors [are]
resources—individual or environmental—that minimize the impact of
risk” (p. 12).
This definition is important because it views protective factors as
individual characteristics and environmental conditions, and it emphasizes
that those conditions or characteristics interact with specific risk factors
present in either the child or the child’s environment. We argue that
protective factors operate in three ways, by serving to
reduce or buffer the impact of risk in a child’s life,
interrupt a chain of risk factors that may be present in a young
person’s life (e.g., disrupt a potential chain of risk that begins with
peer rejection and leads to involvement with antisocial peers and then
to delinquency), and
prevent or block the onset of a risk factor (Fraser & Terzian, 2005).
25

Table 1.2 shows common protective factors discussed by authors in
subsequent chapters.
26

Resilience: When a Child Prevails Over Adversity
Resilience is characterized by successful adaptation in the presence of risk
or adversity (Garmezy, 1986; Luthar, 2003; Olsson, Bond, Burns, Vella-
Brodrick, & Sawyer, 2003; Ungar, 2011). Fortunately, we have numerous
examples of young people and adults who have “overcome the odds” of
the negative effects of risks identified in areas of child welfare (Festinger,
1984), juvenile justice (Grunwald, Lockwood, Harris, & Mennis, 2010;
Vigil, 1990), and substance abuse (Werner & Smith, 2001). Rather than a
single influence or factor, we conceptualize resilience as the outcome of a
process that takes into account both the level of risk exposure and the
presence of protective factors. When exposure to risk is high, evidence
suggests that most children and adolescents experience some type of
problem or developmental difficulty (Cicchetti & Rogosch, 1997; Pollard
et al., 1999). In circumstances in which the risk level is high, protective
factors exert their influence on developmental outcomes; however, in
circumstances in which the risk level is low, protective factors are more
likely to have a neutral or relatively benign effect (Fraser, Richman, &
Galinsky, 1999).
27

Source: Adapted from Fraser et al. (2004); Jenson and Bender (2014); and
O’Connell et al. (2009).
Sameroff and colleagues (Sameroff, 1999; Sameroff & Fiese, 2000;
Sameroff & Gutman, 2004) have used the phrase promotive factor to refer
to attributes or characteristics that have direct protective effects on
people’s lives, irrespective of the level of risk exposure (for a discussion of
direct versus interactive protective effects, see Lösel & Farrington, 2012).
Researchers have observed that some factors (e.g., high intelligence, low
delinquency among peers) have positive effects on child and adolescent
outcomes independent of risk. Whether protection operates principally as a
buffer that interacts with risk exposure or whether protection has both
interactive and direct promotive effects on life course outcomes is the
focus of ongoing discussion and research. To date, tests of the impact of
direct protective effects have been relatively limited (see, e.g., Gutman,
Sameroff, & Eccles, 2002; Lösel & Farrington, 2012; Pardini, Loeber,
28

Farrington, & Stouthamer-Loeber, 2012; Sameroff, Bartko, Baldwin,
Baldwin, & Siefer, 1999; Youngblade, Theokas, Schulenberg, Curry,
Huang, & Novak, 2007).
On balance, experts are viewing resilience as the outcome of an interactive
process involving risk and protection. Thus, adaptation, which is
expressed through individual behavior, is interpreted as an interactive
product involving the presence or absence of a specific risk; the level of
exposure to risk; and the strength of the specific risk and protective factors
present in a child’s life.
29

Applying Principles of Risk and Resilience
to Social Policy
Applications of public health principles primarily have been used to
develop preventive interventions in school and community settings
(Catalano et al., 2012; Durlak, Weissberg, Dymnicki, Taylor, &
Schellinger, 2011; Jenson & Bender, 2014; Luthar & Cicchetti, 2000). The
results have been impressive. Recent research has identified a number of
efficacious risk-oriented programs aimed at preventing child and
adolescent problems such as substance abuse (Botvin & Griffin, 2004;
Foxcroft, Ireland, Lister-Sharp, Lowe, & Breen, 2003; Gottfredson &
Wilson, 2003) and delinquency (Catalano, Loeber, & McKinney, 1999;
Limbos et al., 2007; Wilson & Lipsey, 2007). Research and governmental
entities, which are concerned with improving the dissemination of
effective programs, have made lists of effective interventions available to
practitioners, educators, and the general public (Campbell Collaboration
Library, 2014; Center for the Study and Prevention of Violence, 2014;
Substance Abuse and Mental Health Administration, 2014). Prevention
and treatment strategies using a risk and protective perspective are now
widely recognized by public and private entities (at both the state and
federal levels) as the dominant approach to preventing and treating
childhood and adolescent problems (Center for the Study and Prevention
of Violence, 2014; Centers for Disease Control and Prevention, 2008b;
National Institute on Drug Abuse, 1997; O’Connell et al., 2009; Schinke,
Brounstein, & Gardner, 2002).
A logical next step in the application of the risk and resilience model
requires extending the framework to the development of a broader cross-
section of programs and public policies (Fraser & Galinsky, 2004). To
date, only a few examples of this process exist. Investigators in the public
health field have applied principles of risk, protection, and resilience to
their design of prevention strategies targeting risk factors for AIDS.
Evidence suggests that the implementation of this approach has led to
reductions in the spread of AIDS in many parts of the world (Sorenson,
Masson, & Perlman, 2002).
A second example of using a public health framework to effect program
and policy change comes from innovations in substance abuse prevention.
30

Hawkins, Catalano, and colleagues at the Social Development Research
Group (Hawkins, Catalano, & Associates, 1992) created the Communities
That Care (CTC) program, which is a theoretically based prevention
system designed to help community leaders develop and implement
effective substance abuse prevention programs. The CTC program is based
on the social development model (SDM), which is a general theory of
human behavior that integrates perspectives from social control theory
(Hirschi, 1969), social learning theory (Bandura, 1989), and differential
association theory (Matsueda, 1982; Sutherland, 1973). SDM specifies the
mechanisms and causal pathways by which risk and protective factors
interact in the etiology of various behaviors, including adolescent drug use
(Catalano & Hawkins, 1996). The SDM proposes that four protective
factors inhibit the development of antisocial behaviors in children: (1)
bonding, defined as attachment and commitment to family, school, and
positive peers (Garmezy, 1986); (2) belief in the shared values or norms of
these social units; (3) external constraints such as clear, consistent
standards against drug use (Hansen, Malotte, & Fielding, 1988; Scheier &
Botvin, 1998); and (4) social, cognitive, and emotional skills that provide
protective tools allowing children to solve problems (Rutter, 1987), to
perform in social situations (Werner & Smith, 1982), and to resist
influences and impulses to violate their norms for behavior (Hansen,
Graham, Sobel, Shelton, Flay, & Johnson, 1987).
In the CTC model, communities form coalitions to engage in systematic
prevention planning, which requires them to identify risk and protective
factors for adolescent problems that are prevalent in their localities.
Following the assessment of such factors, communities are encouraged to
select prevention strategies based on available empirical evidence (Brown,
Hawkins, Arthur, Briney, & Fagan, 2011). Recent findings from the
Community Youth Development Study, which is a longitudinal,
randomized trial that uses principles of the CTC model, have revealed
significantly lower rates of delinquency and drug use among students in
experimental communities as compared with control communities
(Hawkins et al., 2008; Hawkins et al., 2012). These groundbreaking
findings suggest that well-organized and well-implemented community
planning efforts that focus on risk and protection can lead to positive
outcomes for young people. Although the CTC model falls short of
satisfying the criteria for a formal policy, it successfully initiates a process
whereby knowledge of risk and protective factors becomes an integral part
of program design. As implied in the preceding examples, applying
31

principles of risk and resilience to policy design requires an understanding
of the developmental trajectories associated with the onset or persistence
of child and adolescent problems. Figure 1.1 illustrates the process
involved in applying a public health perspective to policy and program
design for children, youth, and families.
Two additional elements in the risk and resilience model, ecological theory
and life-course development, are outlined briefly in the next section.
Figure 1.1 A Risk and Resilience Framework for Child, Youth, and
Family Policy
32

Ecological Theory and Life-Course
Development
As we mentioned earlier, we use an ecological perspective to provide a
context for thinking about principles of risk, protection, and resilience over
the course of child development. The ecological perspective is well known
and widely applied in education, practice, and research across many
disciplines and professions (Bronfenbrenner, 1979, 1986; Fraser, 2004;
Germain, 1991). Ecological theory posits that development is deeply
affected by interactions between the biological and psychological
characteristics of the individual child and conditions in his or her
environment. Environmental conditions are usually described as the
developmental context, as layers of family, peer, school, and community
influences (Bronfenbrenner, 1979, 1986). An ecological perspective holds
that child development is a product of transactions between an organism
and these layers of contextual influence. In the vernacular of practice,
child development is influenced by events that occur in the lives of young
people within their family, peer, school, and community settings.
We believe social policies for children, youth, and families must be framed
in an ecological perspective that considers the influence of context. For
example, a child who is referred to the juvenile justice system is also a
child who lives within some type of family unit, attends a local school, and
has a network of peers. Evidence indicates that both unique and
interrelated risk and protective factors increase or decrease the likelihood
of problem behavior within each of these domains (Fraser, 2004;
Herrenkohl et al., 2011; Jenson & Howard, 1999). Therefore, social
policies are most likely to be effective when they address the myriad
influences that lead to and may sustain problem behavior for young
people. In earlier work, we discussed risk and protective factors in the
context of the ecological perspective as a way to explain the onset and
prevention of childhood and adolescent problems (Fraser, 2004; Jenson,
2004). However, the knowledge of such factors has seldom been used as a
lens through which to examine social policy for children, youth, and
families. Our intention is to show how principles contained in the
ecological perspective can be used to create integrated policies that may
cut across traditional policy boundaries found within care systems for
33

American children, youth, and families.
34

Summary
Knowledge gained from studies of risk, protection, and resilience has
significantly affected our understanding of the onset and persistence of
childhood and adolescent problems. Principles of risk, protection, and
resilience also have been helpful in improving the conceptual and
methodological rigor of prevention and treatment programs for children
and youth (Jenson & Bender, 2014; Kaftarian, Robinson, Compton, Davis,
& Volkow, 2004; Limbos et al., 2007; Wilson & Lipsey, 2007). However,
to date, these principles have not been systematically applied to social
policies for children and families. This chapter has outlined a public health
framework for child and family policy based on risk, protection, and
resilience. Principles of ecological theory and life-course development
were introduced as essential parts of the framework. In subsequent
chapters, we more fully examine the utility of a public health framework
for child and family policy.
35

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48

Chapter 2 Antipoverty Policies and
Programs for Children and Families
Trina R. Williams Shanks
Sandra K. Danziger
Poverty is acknowledged as a risk factor for many problems experienced
by children and youth. Evidence from various disciplines indicates that
children growing up in low-income households experience social and
health conditions that place them at risk for later academic, employment,
and behavioral problems (Conley, 1999; Davis-Kean, 2005; Duncan &
Brooks-Gunn, 1997; Guo & Harris, 2000; McLoyd, 1998; Sampson,
Morenoff, & Gannon-Rowley, 2002; Williams Shanks & Robinson, 2013).
Indeed, the detrimental influence of poverty is apparent in all of the
substantive policy areas discussed in this book.
Children are poor because they reside in households and/or communities
that are poor. Thus, a principal goal of antipoverty policies is to break the
link between poor resources of parents or caregivers and adverse child
outcomes. To achieve this goal, some antipoverty policies and programs
provide material support to parents. Other antipoverty initiatives offer
resources and opportunities directly to children. Evidence suggests that the
specific targets of social policy should not be an “either-or” proposition or
strategy. That is, studies show that it is important both to support low-
income parents and to promote child well-being (Waldfogel, 2006; Waters
Boots, Macomber, & Danziger, 2008; Haskins, Garfinkel, & McLanahan,
2014).
In this chapter, we examine risk and protective factors associated with
childhood and adolescent poverty. Major income-assistance and income-
maintenance policies for children and families are reviewed. Trends in
antipoverty policy are noted; particular emphasis is paid to the Great
Recession of 2007 to 2009 and its impact on children and families. We
conclude with a brief discussion of how American social policies aimed at
ameliorating childhood poverty compare with approaches in other
industrialized countries. Finally, policy and program directives that may
help improve the comprehensiveness and integration of services and
49

promote positive outcomes for children and families are identified.
50

Prevalence and Trends in Poverty
The debate about the best way to measure poverty is long and ongoing
(Blank, 2008; Couch & Pirog, 2010). To bring some unity to the study of
poverty, the U.S. Census Bureau in the 1960s established income
thresholds based on before-tax cash sources to determine whether a
household is officially poor. These thresholds are updated annually. As
shown in Figure 2.1, child poverty rates reached a low during the late
1960s to early 1970s. Since then, child poverty rates have fluctuated with
periodic increases and decreases. Nearly 23% of all children under the age
of 18 lived in poverty in 1993; child poverty declined between 1993 and
2002 but increased in the last decade. By 2012, 22.3% of children lived in
poverty. Since 2011, the Census Bureau also has reported an alternate
measure, the Supplemental Poverty Measure, which includes the value of
noncash benefits for basic needs and subtracts taxes and other expenses.
By this measure, 18% of children were poor in 2012 (Short, 2013).
Figure 2.1 Child Poverty Rates in the United States by Race and Ethnicity,
1960–2012
Source: U.S Census Bureau (2012).
http://www.census.gov/hhes/www/poverty/data/historical/hstpov3.xls
51

However, the average poverty rate hides considerable variation by race
and ethnicity, as shown in Figure 2.1. Black and Hispanic children
continue to be twice as likely to be poor compared with Asian and non-
Hispanic White children. As shown in Figure 2.2, children residing in
female-headed households experience poverty at four times the rate of all
other households. These poverty disparities remain high in the post–Great
Recession period.
Figure 2.2 Child Poverty Rates by Household Type, 1960–2012
Source: U.S Census Bureau (2012).
http://www.census.gov/hhes/www/poverty/data/historical/hstpov10.xls
In spite of the widespread use of the Census Bureau definition and its use
of the new measure, the measurement of poverty continues to be debated.
Critics charge that the majority of surveys that measure income flows into
a household miss an important aspect of a household’s financial situation
because they fail to consider family assets. For example, a family with
housing equity, savings, and investments is in a better situation and has
more favorable long-term prospects than a family of equal income but no
assets. Although there is no official approach to measuring assets,
researchers typically calculate assets by using household net worth
(Brandolini, Magri, & Smeeding, 2010; Haveman & Wolff, 2004; Shapiro,
Oliver, & Meschede, 2009).
52

Data reflecting household net worth reveal that racial and ethnic disparities
in assets are even greater than disparities in income (Lui, Robles, Leondar-
Wright, Brewer, & Adamson, 2006; Oliver & Shapiro, 1995; Shapiro,
2004). As shown in Figure 2.3, Black and Hispanic households at times
own about a tenth, respectively, of the median net worth of non-Hispanic
White households. Although most households faced declines in net worth
after the recession of 2007 to 2009, households of color fared worse and
now have less than five cents for every dollar of wealth owned by non-
Hispanic White households. Furthermore, as depicted in Figure 2.4,
households with children have the lowest levels of net worth. Couples with
no children have the most wealth, followed by couples with children,
followed by single-parent households with children at a distant third. The
situation is even worse when considering financial net worth, which
excludes home equity and the value of vehicles. Over half of families with
children are asset-poor according to this measure, meaning that they lack
sufficient financial assets to sustain the household at the poverty line for
three months. In fact, female-headed households with children had asset
poverty rates as high as 77% in 2007 (Aratani & Chau, 2010).
Figure 2.3 Median Household Net Worth by Race and Ethnicity, 1983–
2010 (in Thousands, 2010 dollars)
Source: Wolff, E. N. (2012). The asset price meltdown and the wealth
of the middle class (Working Paper No. 18559). Cambridge, MA:
National Bureau of Economics Research.
53

Another way to think about poverty is at the neighborhood or community
level. Neighborhood poverty refers to the spatial concentration of poor
households in neighborhoods, which are measured by census tracts.
Generally, a poor neighborhood is one in which 20% to 40% of residents
live below the poverty line. The concentration of the poor in high-poverty
census tracts in the United States increased dramatically between 1970 and
1990. Since that time, as shown in Figure 2.5, the number of people living
in poor neighborhoods and the number of poor neighborhoods fell in the
first decade and rose again in the 2000s (Jargowsky, 2013).
Figure 2.4 Median Net Worth by Household Types, 1989–2010 (in
Thousands, 2010 dollars)
Source: 2010 Survey of Consumer Finances Chart Book.
http://www.federalreserve.gov/econresdata/scf/files/2010_SCF_Chartbook
In the early period, the growing concentration of poverty resulted from two
main macroeconomic changes. First, a decline in manufacturing markets
negatively impacted inner cities and resulted in an increase in urban
poverty rates. Second, factors such as discrimination in the housing and
lending markets and rapid suburban development increased racial and
socioeconomic segregation such that inner-city neighborhoods became
predominantly Black and poor (Jargowsky, 1997; Massey & Denton,
1993). The 1990s were also characterized by an increase in the
suburbanization of neighborhood poverty. That is, although poverty
54

declined in all other areas, rates of suburban poverty experienced almost
no change (Jargowsky, 2003; Kingsley & Pettit, 2007).
The decline in neighborhood poverty between 1990 and 2000 may be
explained by neighborhood fluctuations in moderate, high, and extreme
poverty rates (Kingsley & Pettit, 2007) and by decreases in overall poverty
caused by the improving economy of the late 1990s (Jargowsky, 2003).
Recent evidence suggests that the economic decline since 2000 and
especially during the Great Recession has led to a new increase in poverty
—both nationally and in isolated neighborhood settings. Suburban poverty
has continued to grow, especially in western and Sun Belt states
(Kneebone, 2009), and neighborhood poverty has also increased in
midwestern cities and suburbs in recent years (Kneebone & Garr, 2010).
Figure 2.5 Number of High-Poverty Census Tracts and Percentage of
Population Living in High-Poverty Tracts
Source: Jargowsky, P. A. (2013). Concentration of poverty in the new
millennium. Changes in prevalence, composition, and location of
high poverty neighborhoods. A Report by the Century Foundation
55

and the Rutgers Center for Urban Research and Education. Retrieved
from: http://tcf.org/bookstore/detail/concentration-of-poverty-in-the-
new-millennium
People of color experience poverty at much higher rates than Whites; this
disparity is most evident among children (Jargowsky, 2003; Sharkey,
2009). Only 1% of White children born between 1955 and 1970 lived in
poor neighborhoods, whereas 29% of Black children born during this time
lived in poor neighborhoods at some point in their childhood. About 31%
of Black children born between 1985 and 2000 experienced neighborhood
poverty (Sharkey, 2009). Inequality and poverty in neighborhood contexts
for children expose them to serious risks that often compromise normal
and healthy development.
56

Poverty, Risk, and Protection
Poverty stems from interpersonal, social, and environmental factors that
occur at all levels of a child’s life (Bronfenbrenner, 1979). Figure 2.6
depicts the increasingly wide spheres of influence related to the onset,
persistence, and consequences of poverty. Poverty and low income are due
in part to economic conditions and policies regarding jobs, housing, and
stocks, all of which fell to crisis levels and created economic loss and
instability for families and children during the Great Recession (see text
box). Clearly, efforts to prevent or reduce poverty should include state and
federal policies and programs that target the multiple levels of influence,
from socioeconomic conditions to community and family resources. We
discuss interpersonal, social, and environmental risk and protective factors
associated with poverty in the following section.
57

Interpersonal and Social Risk Factors
Material hardships such as food insufficiency, unstable housing, and lack
of basic health care are consistently associated with poverty. Material
hardship is particularly important because it adversely affects many
aspects of child development. In 1999, findings from a national sample of
children revealed that 23% of families below the federal poverty level had
experienced food insecurity (they were unable to afford balanced meals,
had to cut the size of meals, or had too little money for food) in the past
year (Gershoff, 2003). A 2006 survey revealed that 25% of children in
families with income below the poverty level had experienced food
insecurity in the past year (Nord, 2009). Since the Great Recession, food
insecurity has risen, such that, in 2012, 20% of households with children
across the income spectrum were food insecure at some point in the year
(Coleman-Jenson, Nord, & Singh, 2013).
Qualitative researchers have detailed the many stressors and negative
outcomes experienced by children residing in low-income families that are
trying to meet basic needs (Edin & Lein, 1998; Newman, 1999). Parenting
practices and behaviors that are created as a result of economic strain and
material hardship also indirectly affect children. Conger and colleagues
(1991) proposed a family process model that considers the influence of a
family’s economic problems and parental depression on child and youth
development. In this model, a low-income mother’s and father’s
depression is hypothesized to increase marriage hostility and decrease
nurturing and involved parenting (Conger et al., 1991; Conger et al.,
2002). Studies have also found that material hardship and financial stress
are related to low self-esteem, a decreased sense of control over one’s life,
and feelings of helplessness among parents, which in turn adversely affects
their ability to use effective parenting skills (Bradley & Corwyn, 2002;
Conger & Donnellan, 2007; Gershoff, Aber, Raver, & Lennon, 2007;
McLoyd, 1990, 1998).
Parent and family investment in children’s education and development—
including educational materials in the home, engagement with school, and
facilitation of extracurricular activities—is another way in which poverty
influences child development. Mayer found that parental education,
attitudes, and behaviors were more important than income in explaining
58

child outcomes, once basic material needs are met (Mayer, 1997).
Cognitive stimulation in the home both in terms of the availability of
learning materials and parental teaching and conversations is correlated
with household income and is predictive of positive educational outcomes
and fewer behavior problems (Bradley & Corwyn, 2002, 2003; Guo &
Harris, 2000; Shonkoff & Phillips, 2000). A positive home environment is
especially important for children’s academic growth during the summer,
when school resources are not available (Downey, von Hippel, & Broh,
2004; Entwisle & Alexander, 1992). Clearly, poor parents often lack the
resources, skills, and opportunities to help their children succeed in school.
Recent findings from investigators interested in promoting asset-based
policies suggest that a family’s assets offer protection for children,
particularly those residing in low-income households (Grinstein-Weiss,
Williams Shanks, & Beverly, 2014; Huang, Sherraden, Kim, & Clancy,
2014; Williams Shanks, Kim, Loke, & Destin, 2010). Assets appear to
operate as an important protective factor in relation to standardized test
scores, school performance, and certain types of antisocial conduct and
behaviorial problems (Conley, 1999; Orr, 2003; Williams Shanks, 2007).
Equally important, studies have found positive relationships between
household assets and children’s academic outcomes across racial groups
(Williams Shanks & Destin, 2009) and among female-headed households
(Zhan, 2006; Zhan & Sherraden, 2003).
Figure 2.6 Circles of Influence on Childhood Family Poverty
59

Source: Adapted from Bronfenbrenner (1979).
60

Environmental Risks
Wilson (1987, 2009) suggested that concentrated neighborhood poverty
isolates poor residents and limits their exposure to positive role models,
employment networks, and community resources. A large body of research
has examined the direct and indirect effects of neighborhood poverty on
child and adolescent outcomes (Harding, 2003; Hart, Atkins, & Matsuba,
2008; Kling, Ludwig, & Katz, 2005; Leventhal & Brooks-Gunn, 2000;
Pachter, Auinger, Palmer, & Weitzman, 2006). Many investigators have
emphasized the significant and adverse effects of limited local resources
and opportunities on children’s development. Poor neighborhoods tend to
lack quality institutions and social services (Leventhal & Brooks-Gunn,
2000; Sampson et al., 2002). Children growing up in poor neighborhoods
witness frequent acts of violence and experience considerable chaos,
disorder, and isolation. In such communities, parental stress and a lack of
support services negatively affect developmental outcomes in children and
youth (Klebenov, Brooks-Gunn, & Duncan, 1994; Kohen, Leventhal,
Dahinten, & McIntosh, 2008; McLoyd, 1998; Patton, Woolley & Hong,
2012; Williams Shanks & Robinson, 2013).
Much research has documented the escalating trend in mass incarceration
and its unequal impacts on poor and especially urban communities of
color. Loury (2010), for example, noted the “ubiquity” of this experience,
reporting that in some neighborhoods, one in five adult men may be
behind bars on any given day. According to Clear, having so many young
men go in and out of jails and prisons is “a central factor determining the
social ecology of poor neighborhoods” (Clear, 2009, p.10). Research has
attempted to disentangle the effects of parental incarceration from the
effects of other family and community risk factors in terms of the impact
on children (e.g., Wildeman and Western, 2010; Wildeman and Turney,
2014). In addition to the impacts of parental incarceration on parent
involvement, family resources, and family structure, many poor outcomes
for children have been linked to this experience, including future
criminality and incarceration, child health, child behaviorial problems
associated with mental health and cognitive risks, homelessness, and foster
care placement (Wildeman and Western, 2010). The impacts of
disproportionate incarceration are also likely felt at the neighborhood,
school, and community levels and should be considered when mapping
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strategies for service intervention to increase support for affected families
and to prevent the more deleterious effects on children.
Children and families living in poor neighborhoods are doubly
disadvantaged by frequent exposure to numerous interpersonal, social, and
environmental risk factors. These factors interact in complex ways and
lead to a number of adverse outcomes for children. Youth exposed to
neighborhood and household poverty encounter negative influences and
antisocial environments that place them at risk for a number of adverse
individual and social outcomes. These risks are particularly influential
during early childhood (Shonkoff & Phillips, 2000). Policies and programs
such as asset building and income support, which target the upstream
economic strain of poverty, along with initiatives to enhance parenting
skills and home environments, which target the downstream processes of
social disadvantage, are necessary to set a course for children to escape
poverty. While it is important that interventions take place during early
childhood, it is also crucial to develop and sustain policies and programs
aimed at reducing risk and fostering resilience across the life course.
62

Antipoverty Policies and Programs
The United States has never instituted a comprehensive federal response to
child poverty. In fact, no federal role in cash aid to poor children and
families existed prior to 1935; only assistance from state, local, and private
charities was available. Even today, with an array of federal antipoverty
programs, no policy or program reaches everyone who is eligible, and
typically no priority is given to social development or economic mobility
(Williams Shanks, 2014). Although critically important to child well-
being, we exclude health insurance, medical care, and educational
programs because these topics are covered in other chapters. Table 2.1
provides an overview of some of the major federal programs that offer
support for the basic needs of low-income children; funding levels for
major antipoverty programs between 1960 and 2012 are shown in Figure
2.7.
The first federal welfare program, Aid to Dependent Children, was part of
the 1935 Social Security Act. The name of the program changed at
midcentury to Aid to Families with Dependent Children (AFDC). The
Personal Responsibility and Work Opportunity Reconciliation Act
(PRWORA, Public Law No. 104–93), signed by President Bill Clinton in
August 1996, ended AFDC’s 60-year history and resulted in major
changes in the structure of the program and its diminished role as a
resource for the poor. Compared with AFDC, the new Temporary
Assistance for Needy Families (TANF) plays a smaller role as a resource
for families.
Several rules restrict participation in TANF, including lifetime time limits
for receipt of benefits and a mandatory work requirement. States are
required to impose sanctions in the form of benefit reduction or case
closure to families who do not comply with requirements. States can
implement diversion programs to deter or deflect applicants from entering
the program (e.g., providing a one-time lump-sum payment to families
who agree not to seek cash benefits for a set period of time). TANF
disallows parents with a drug felony conviction from receiving benefits
and requires teenage parents under the age of 18 to live with an adult and
attend school as a condition of receiving benefits. New legal immigrants
are not allowed to receive means-tested public benefits, including TANF,
63

for the first 5 years after entry (Fix, 2006).
Neither the critics’ dire predictions of increased child poverty nor the
proponents’ rosy forecasts that children would directly benefit from seeing
their mothers take jobs came true in the first decade after welfare reform
(Danziger, 2010). Studies did not find that welfare leavers had
improvements in terms of stress levels and mental health status as they
exited the rolls, nor did the lives of children improve as a result of welfare
reform and increases in the employment of mothers (Danziger, 2010; Edin
& Kissane, 2010).
Welfare reform has dramatically reduced nationwide reliance on cash
assistance, even while participation in other antipoverty programs has
grown, as shown in Figure 2.7 (Danziger, 2010). Welfare caseloads have
fallen precipitously since the mid-1990s and did not increase during the
Great Recession (see text box). The failure of the welfare system to
respond to increased poverty during the recession raises concern for how
single mothers and their children will fare in the coming years.
The food stamp program became the Supplemental Nutrition Assistance
Program (SNAP) in 2008 (H.R. 2419, the Food, Conservation, and Energy
Act of 2008). SNAP provides food assistance in the form of electronic
benefit transfer (EBT) cards, which function like debit cards at retail
grocery stores. SNAP program participation increased to an estimated 11%
of U.S. households in 2009 (U.S. Department of Agriculture, 2010a). The
rise in program participation is associated with the deep recession and the
rise in unemployment and poverty. A federal entitlement program, SNAP
is open to anyone who is income-eligible and helps to ease the family
budget by covering food costs. The average monthly per person benefit in
2009 was $125.31(Food and Nutrition Service, 2009). The maximum
monthly benefit for a family of four in 2014 is $632. As shown in Figure
2.7, the rate of participation in SNAP is quite high. However, only 37.9%
of low-income (<185% poverty level) children experiencing food insecurity receive SNAP. Similarly, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal food- support program for low-income pregnant and postpartum women and their young children (U.S. Department of Agriculture, 2010b). However, states administer WIC and set the eligibility requirements, and the program is funded through the mechanism of a limited block grant to states rather than as an open-ended entitlement. 64 An increasingly important addition to antipoverty efforts is the Earned Income Tax Credit (EITC), a refundable tax credit to low-income workers and their families. In 2010, more than 27 million families received income support through the federal EITC. It is estimated that the program lifts 2.5 million children with working parents out of poverty each year (U.S. Department of the Treasury, 2010). For most individuals filing without children, the maximum annual benefit in 2013 was $487, but for a single person with two dependent children, the maximum benefit was $5,372. The maximum allowable income to receive any benefit is just above $51,500 (married filing jointly with three children or more), which is more than 200% of the federal poverty line. Some states and localities also have tax credits for working low-income families that supplement this program (Purmort, 2010). As Figure 2.7 shows, the number of households receiving the EITC began to exceed Temporary Assistance for Needy Families (TANF) participation in the early 1990s, when EITC federal policy expanded. EITC has now outstripped TANF as a source of income support, but it only is available for children with employed parents. The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) expanded and consolidated federal funding for child care for employed parents into the Child Care and Development Block Grant (CCDBG). Under this act, states are provided flexibility in determining income and work eligibility, structuring the voucher program, and determining which types and standards of care will be reimbursed at what rates. There is consistent evidence that subsidies facilitate employment of low-income and welfare recipient families (Blau & Tekin, 2007; Danziger, Ananat, & Browning, 2004; Bainbridge, Meyers, & Waldfogel, 2003; Meyers, Heintze, & Wolf, 2002; Press, Fagan, & Laughlin, 2006). Between 1997 and 2006, public funding more than doubled from $3.7 billion to $9 billion (U.S. House of Representatives, 2008). During the recession of 2007 to 2009, The American Recovery and Reinvestment Act expanded funds for child-care subsidies and for quality improvements in child-care services. Although the majority of low-income families rely on child care that is developmentally inadequate or minimally adequate (Levine Coley, Li-Grining, & Chase-Lansdale, 2006), it is unclear whether subsidy receipt leads to higher quality care (Antle et al., 2008). Subsidies could be structured to promote use of higher quality care, but the issue of greatest priority is access as only 20% of those who are eligible receive assistance with child care. 65 Supplemental Security Income (SSI) is a program of the Social Security Administration. Unlike retirement income from social security, which is funded by social security taxes, SSI is funded by general federal tax revenues. Families with children who have a disability are eligible to receive SSI support; in 2010, 15.7% of recipients were under 18 (Social Security Administration, 2010). Eligibility requirements were made more stringent with the passing of PRWORA in 1996. The average monthly benefit for a child recipient (under the age of 18) was $597 in 2010 (Social Security Administration, 2010). Although a relatively high rate of those who qualify are served, many people who are unemployed for long periods because of illness or disability experience long delays in the application and review process (U.S. General Accounting Office, 2009). The federal government also supports the employment of youth and adults through training and education programs designed to ensure that participants are job-ready. Although job-training programs were originally designed to assist dislocated workers, they became a part of federal antipoverty strategies by the 1960s (LaLonde, 1995). Just as PRWORA shifted the focus of welfare toward “work first,” the approach of job- training programs has also shifted toward employment. The Workforce Investment Act of 1998 (WIA) was enacted to replace the Job Training Partnership Act (JTPA), with an emphasis on job placement before training or education (Holzer, 2008). With the changes from JTPA to WIA, substantially fewer low-income youth and adults received training. About 95% of program leavers reported receiving training in JTPA, compared with 68.4% of exiters from WIA in 2003 (Frank & Minoff, 2005). Federal housing assistance is funded through the U.S. Department of Housing and Urban Development (HUD) and is administered by local housing authorities. It takes two main forms: (1) Section 8 housing vouchers for private units and (2) subsidized public housing units. Both programs serve a small fraction of low-income renters and have long waiting lists of families who have applied for assistance. About half of those served in these programs are families with children. Moreover, 5.6 million eligible households with children experience serious housing needs (Turner & Kingsley, 2008). The character of public housing in the United States has been changing in the last 20 years as a result of efforts such as Moving to Opportunity (MTO) and Hope VI. These initiatives attempt to disperse concentrated neighborhood poverty. Although the goal of the 66 program was to improve outcomes for individuals, the development of new mixed-income housing units decreased the amount of housing generally available to poor residents (Sharkey, 2009). Once again, access has been a key concern, with few eligible households receiving needed assistance. Finally, a federal program that is not shown in Table 2.1 provides another source of assistance to low-income families and their children. In 1998, the Assets for Independence Act (AFIA) was enacted and funded with $125 million over 5 years. Annual appropriations for the program from1999 through 2009 have ranged between $10 million and $25 million. The AFI program provides federal funding to support Individual Development Account (IDA) programs at the community level. Paired with local match funding, the program offers incentives for those earning below 200% of the Federal Poverty line to save for a home, pursue higher education, or capitalize a small business. The program is still very small and, over the first decade of its existence, has supported the opening of fewer than 100,000 accounts. However, AFI provides an example of a policy that intentionally seeks to improve the long-term economic condition of low- to moderate-income households (U.S. Department of Health and Human Services, 2010; Williams Shanks, 2014). 67 U.S. Department of Housing and Urban Development (2012) http://www.huduser.org/portal/datasets/picture/yearlydata.html#data- display-tab Turner & Kingsley (2008). U.S. Department of Agriculture (2012). 68 http://www.huduser.org/portal/datasets/picture/yearlydata.html#data-display-tab http://www.fns.usda.gov/pd/SNAPsummary.htm U.S. Department of Agriculture (2011). http://www.fns.usda.gov/sites/default/files/Reaching2011_Summary U.S. Department of Agriculture (2012). http://www.fns.usda.gov/pd/wisummary.htm U.S. Department of Agriculture (2009). http://www.fns.usda.gov/sites/default/files/WICEligibles2000- 2009Summary_0 Social Security Administration (2012). http://www.ssa.gov/policy/docs/statcomps/ssi_asr/2012/ssi_asr12 Waters Boots (2010). Internal Revenue Service (2012). http://www.eitc.irs.gov/EITC- Central/eitcstats Internal Revenue Service (2010). http://www.eitc.irs.gov/EITC- Central/Participation-Rate U.S Department of Health and Human Services (2012). http://www.acf.hhs.gov/programs/occ/resource/fy-2012-ccdf-data- tables-preliminary-table-1 U.S. House of Representatives (2008). U.S. Department of Health and Human Services (2012). https://www.acf.hhs.gov/sites/default/files/ofa/2012trec_tan ? nocache=1358959977 Social Policy Research Associates (2010). Another way to think about the degree to which social policy assists children and families is to compare child poverty in the United States with that in other industrialized countries. The U.S. child poverty rate is more than four times higher than rates in such European countries as Sweden, Norway, Finland, and Denmark (Lindsey, 2004; Rainwater & Smeeding, 2003a, 2003b). The low child-poverty rates in these nations are realized not because earnings are higher but because a large proportion of children 69 http://www.fns.usda.gov/pd/SNAPsummary.htm http://www.fns.usda.gov/sites/default/files/Reaching2011_Summary http://www.fns.usda.gov/pd/wisummary.htm http://www.fns.usda.gov/sites/default/files/WICEligibles2000-2009Summary_0 http://www.ssa.gov/policy/docs/statcomps/ssi_asr/2012/ssi_asr12 http://www.eitc.irs.gov/EITC-Central/eitcstats http://www.eitc.irs.gov/EITC-Central/Participation-Rate http://www.acf.hhs.gov/programs/occ/resource/fy-2012-ccdf-data-tables-preliminary-table-1 https://www.acf.hhs.gov/sites/default/files/ofa/2012trec_tan ?nocache=1358959977 are being lifted from poverty through government intervention (Rainwater & Smeeding, 2003a). The reduction in child poverty resulting from governmental programs and income transfers in the United States is less than 25%, compared with more than 75% in Sweden and Norway (Lindsey, 2004; Rainwater & Smeeding, 2003a, 2003b). In sum, a variety of antipoverty programs provide assistance through cash, food support, tax credits, childcare, workforce development, and housing. However, despite all of these programs, many eligible low-income at-risk families are not served. In some cases, mothers with work requirements may be able to increase earnings through employment but subsequently risk losing eligibility for other forms of assistance, resulting in little aggregate benefit in terms of poverty status (Currie, 2006). Moreover, when parents are required to work outside the home, parental well-being may not improve and children actually may receive less attention. Indeed, there could be an increase in the number of poorly supervised or unsupervised, latchkey children and little reduction in family poverty. There are many gaps in the existing safety net, particularly when viewed from the broader goal of improving outcomes for children and youth. Figure 2.7 Federal Antipoverty Program Participation, 1965 to 2012 Source: U.S Department of Agriculture (2012). http://www.fns.usda.gov/pd/SNAPsummary.htm; U.S Department of Agriculture (2012). http://www.fns.usda.gov/pd/wisummary.htm; Tax Policy Center (2012). 70 http://www.taxpolicycenter.org/taxfacts/displayafact.cfm? DocID=37&Topic2id=40&Topic3id=42; Social Security Administration (2012). http://www.ssa.gov/policy/docs/statcomps/supplement/2013/7a.html#table7.a9; Social Security Administration (2005–2013). http://www.ssa.gov/policy/docs/statcomps/supplement/ 71 Impacts of the Great Recession of 2007 to 2009 on Children and Youth The Great Recession of 2007 to 2009 was the most severe economic crisis in the U.S. since the 1930s. During these 18 to 24 months, incomes declined by an average of 8%, the number of jobs declined by 6%, and unemployment peaked at 10% (Danziger, 2013). Housing and stock prices collapsed, creating widespread residential instability, declining wealth, and wider racial and ethnic disparities in income (Danziger, 2013). According to the Bureau of Labor Statistics, the percentage of parents with children age 18 years of age or under who were employed (the employment:population ratio) fell from 79% in 2001 to 74% in 2010; it recovered to only 75% by 2013. Estimates of extreme poverty among households with children have been even more alarming. Shaefer and Edin (2013) found a significant increase in families with children living on $2 a day per person or less. The authors reported that by “mid-2011, 1.65 million households with 3.55 million children were living in extreme poverty in a given month . . . constituting 4.3 percent of all nonelderly households with children” (p. 265). This reflects a 159% increase since 1996, but, when taking into consideration the receipt of public food assistance, housing subsidies, and tax credit, the growth in extreme poverty since 2007 has been 50%. Shaefer and Edin (2013) argued that the disappearance of the cash safety net, slow economic growth during the 2000s, and major job losses of the Great Recession are contributing to the growing population of children who experience spells of little to no family income. Many studies have examined the direct and indirect effects of the Great Recession on family economic loss, material hardship and stress, and parent and child well-being (e.g., Ananat, Gassman-Pines, Francis, & Gibson- Davis, 2013; Leininger & Kalil, 2014). Sudden and large drops in income, home foreclosures, and general housing instability have increased debt and spending cutbacks since the recession. Many indicators of child well-being, from health to child behavior to cognitive skills, may be adversely affected by these economic shocks. Furthermore, parents with severe economic loss and instability tend to live in poor and jobless communities characterized by low-quality early childhood education and inadequate public schools. The combination of low income, difficult living conditions, and poor-quality education significantly increases risk for adverse outcomes during childhood and adolescence. Economic factors are especially harmful during infancy. Johnson and Schoeni (2007) used data from the Panel Study of Income Dynamics to 72 analyze the impact of early life experiences on later behavior. They found that poor health at birth and limited parental resources (including low income, lack of health insurance, and unwanted pregnancy) interfered with cognitive development and health outcomes in childhood, led to reduced educational attainment during adolescence, and led to worse labor-market and health outcomes in adulthood. These effects suggest that socioeconomic factors have both immediate and long-term negative effects on the lives of young people. Studies of the recession are raising long-term danger signs. Ananat and colleagues (2013) found that variation in a state’s job losses among adults were related to the state’s average math scores. This relationship was strong even when the findings for students whose parents lost jobs were compared with those for students whose parents remained employed. The authors showed that the recent economic recession affected all students, not just those whose parents had lost jobs. Children were also affected by job losses among family friends and neighbors and by resulting changes to their communities and classrooms. Leininger and Kalil (2014) used data from the Michigan Recession and Recovery Study, a random survey of households in the three-county Metropolitan Detroit Area in 2009 to 2011, to examine the effect of parental economic strain and perceived financial worries on childhood behaviorial problems. The authors found that financial strain was significantly related to internalizing behavior problems among White children. In contrast, the relationship between financial strain and internalizing behaviors among Black children was of small magnitude and was not significant once objective measures of economic hardship were considered. Research also illustrates the positive impacts of having an economic safety net before and/or during the recent recession. For example, Short (2013) found that 18% of children who were 18 years of age or younger were poor in 2010. She estimated that this rate would have increased by four percentage points had the Earned Income Tax Credit (EITC) not been in place at the time. Short also suggested that food assistance through SNAP and housing subsidies and school-lunch participation reduced poverty by several percentage points. She concluded by noting that poverty would decline if more people had access to antipoverty programs. Analysts from the Center on Budget and Policy Priorities examined the effects of the expansion of safety net programs (e.g., child tax credit, EITC, food stamps, and unemployment) that were included in the American Recovery and Reinvestment Act of 2009 (ARRA) (Sherman, 2011). They found that, in 2011, 9 million poor children were lifted out of poverty when these benefits were considered. However, while the official child poverty rate increased from 18% to 22% during the Great Recession, evidence suggests that income from these programs helped keep this increase from being even higher (Sherman, 2011). This finding suggests that the increase 73 in child poverty was partially offset by supports found in the ARRA. Unfortunately, these supports expired at the end of the recent recession. Many analysts question the decision not to expand effective safety net programs during difficult economic conditions. They argue against policies that promote budget cuts to programs for families hit hardest by the recession. Furthermore, beyond poverty reduction and lessening the exposure to poverty, new studies point to beneficial outcomes for high-risk children who live in communities with available safety net services. In a recent paper, Almond and colleagues (Almond, Hoynes, & Schanzenbach, 2011) found positive long-term impacts on adult health and economic well- being for high-risk infants born in counties where the early Food Stamp program had begun compared with those born in areas where the federal program had not yet started. Using data from the Panel Study of Income Dynamics and administrative data, the authors found that exposure to the program before the age of 5 years led to greater long-term economic self- sufficiency and lower risk for diabetes and heart disease. Findings such as these suggest that cutbacks in safety net programs could have long-term adverse consequences for children. 74 Using Knowledge of Risk, Protection, and Resilience to Achieve Service Integration In recent years, investigators and policy officials have begun to promote positive social development as a means to ameliorate childhood poverty. Such a focus represents an alternative to emphasizing the relationship between poverty and adverse child outcomes in policies and programs. Sen (1993, 1999) suggested that a person’s functional capabilities and the freedom to attain what is valued for one’s own welfare should form the basis of antipoverty policies and programs. Similarly, Sherraden (1991) argued that income-support policies provide an important safety net but are insufficient for long-term growth and development. He suggested that helping low-income households build tangible financial assets can lead to positive changes in self-efficacy and civic participation and to improvements in child well-being (Sherraden, 2005). Sherraden’s work suggests that the accumulation of resources in the form of savings and assets promotes investment for long-term security either by increasing human capital or by anticipating future circumstances (e.g., expanding a business or planning for retirement). Although there has been experimentation at the local and state levels to incorporate these social- development and asset-building ideas, they currently receive very little federal expenditure. Yet, demonstration projects and local initiatives that promote social mobility and increase economic security for vulnerable children and households are receiving greater attention and are contributing to policy conversations (Cramer & Williams Shanks, 2014). Integrated and systems-level interventions represent one important approach to preventing and ameliorating childhood poverty. Systems-level approaches focus on better coordination across service sectors. Thus, rather than creating public policies composed of separate streams of money to address particular needs or problems, a systems approach argues for a comprehensive community-change strategy that addresses the full array of problems facing families. One cross-system policy and program example that has received considerable attention recently is the Harlem Children’s Zone (HCZ) in New York City (Tough, 2008). In the HCZ, Geoffrey Canada and colleagues have developed an array of community programs and educational innovations (including two charter schools) in a 75 97-block area of Harlem. Services are designed to support children and families in a metaphorical “conveyor belt” from birth to college (Tough, 2008). Specific interventions include parenting classes in The Baby College, pre-kindergarten instruction in Harlem Gems, and an array of afterschool, health, college-preparatory, employment-training, and substance-abuse programs and services. Initial evidence shows that children who are enrolled in the HCZ schools have better attendance, more time in classroom instruction, and better achievement scores in math and English than those who are not enrolled (Dobbie & Fryer, 2009; Tough, 2008). Although it is hard to disentangle school and community effects, HCZ intentionally bundled a high-quality school experience with complementary wrap-around services to improve achievement and reduce gaps that have traditionally existed between low-income minority children and their better-off peers (Dobbie & Fryer, 2009). In 2010, the federal government launched a Promise Neighborhood initiative based on the HCZ model. As of 2012, Promise Neighborhood planning and implementation grants have been given to communities in 20 states and the District of Columbia (U.S. Department of Education, 2014). Others have created and supported similar comprehensive community- building strategies. For example, the Annie E. Casey Foundation has funded a series of neighborhood-change initiatives aimed at childhood poverty, including the Rebuilding Communities and Making Connections programs (Annie E. Casey Foundation, 2010). The Skillman Foundation has launched comprehensive community-building initiatives in six local neighborhoods in Detroit through its Good Neighborhoods Initiative (Skillman Foundation, 2010). Efforts to assess and evaluate these long- term comprehensive change projects face major research challenges (Kubisch et al., 2002; Stone, 1996). Although much has been learned, no clear blueprint for how to successfully make low-income communities safe and healthy places for children has emerged. In a similar vein, some also argue for greater expansion of programs with a two-generation approach that offer comprehensive services simultaneously for adults and their young children. Such programs seek to encourage human capital in the same family across generations by combining education or job training for low-income parents and early childhood education for their young children (Chase-Lansdale & Brooks-Gunn, 2014). One strategy is to offer high-quality early-childhood education based on proven models. A second approach is to provide comprehensive 76 education and employment services that eventually lead to family- supporting wages for parents along with appropriate guidance and support. The idea is to increase the likelihood of a quality learning-focused environment for children both at school and at home as well as to provide parental resources so that participating families avoid many of the stressors typically encountered by children living in poverty (Chase-Lansdale & Brooks-Gunn, 2014). Another promising approach to promoting positive development among low-income youth incorporates an asset-building strategy to establish a child development account (CDA) system (Elliott, 2012; Goldberg, 2005; Williams Shanks et al., 2010). The vision is that every child from birth gets a subsidized account in her or his own name with an initial deposit that also matches additional savings. The deposit is intended to provide a foundation for family financial capability and tangible resources that can be invested in a child’s future. A primary use of the account is initially to save for college or postsecondary education. However, money also could be used for other purposes in early adulthood. The intent of this strategy is to provide young people with resources to support whatever choices might help them build personal capabilities and get started in life, regardless of their parents’ financial situation. An example of this approach, the Saving for Education, Entrepreneurship, and Downpayment (SEED) initiative, has been tested in the United States (Center for Social Development, 2010), and similar programs are beginning to emerge at the state and municipal levels (Cramer, Black, and King, 2014). The concept of child development accounts has already been established as policy internationally. In the United Kingdom, the Child Trust Fund (CTF) has provided a certificate for at least £250 to the parents of every baby born in the country, with additional funds offered to the parents of low- income children (Child Trust Fund, 2010). Parents use these certificates to open an account on their child’s behalf, which can grow tax-exempt until the child reaches age 18. The U.K. government imposes no restrictions on use once a child reaches 18 but plans to offer financial information and counseling within schools as part of its national education curriculum. When the program launched in 2005, it opened 3 million CTFs. In 2007, about one quarter of these accounts received additional contributions beyond the initial government deposit (Bennett, Chávez Quezada, Lawton, & Perun, 2008). With a change in government in 2010, the U.K. no longer guarantees an initial deposit for these CTFs, but children with existing 77 accounts are allowed to keep them. Singapore has introduced child development accounts that can be used for preschool and other education- or health-related expenses from birth to age 6 (Loke & Sherraden, 2007). The government has also created the Post- Secondary Education Account (PSEA) to cover approved education- related expenses between the ages of 7 and 20. Unused balances from the child accounts can roll over to a child’s PSEA, and unused balances from PSEAs can be rolled over to the adult child’s Central Provident Fund. Thus, Singapore essentially has a lifelong system of accounts to help its citizens build assets and meet personal and financial goals (Loke & Cramer, 2009). These examples may provide important lessons to policymakers in the United States. 78 Summary This chapter has provided evidence that income poverty, asset poverty, and neighborhood poverty, alone and in combination, are associated with profound disadvantages for children and families, particularly since the Great Recession of 2007 to 2009. From our review, it is also apparent that existing antipoverty policies and programs in the United States, although providing crucial supports to many, are not sufficient to lift large numbers of children out of poverty or to greatly shift developmental outcomes for poor children. However, if the will and resources to make systemic change could be found, a variety of programs, including comprehensive community-change and asset-building strategies, are showing promise. To realize long-term success in breaking the link between household poverty and child well-being, a few observations can be made. A “family security approach”—like that called for by Waters Boots et al. (2008)—is crucial in that multiple generations within a family and multiple levels of influence must be targeted concomitantly. No single program is likely to be enough. Although the most concrete issue for a family may be insufficient income, “fixing” income-support policies alone might not take us far enough along in a risk and protection framework. We have seen the failure of the current array of antipoverty programs to reach and respond to those experiencing poverty and economic shocks. Families with children, especially those headed by young single women, undoubtedly could use better-designed cash assistance and financial help with housing, child care, food, and job training to make ends meet. However, to prevent a lifetime of poverty and dead-end jobs, a host of other resources—education, parenting support, services to provide children with a nurturing home environment, and high-quality early child care—are needed. Given that families may experience spells in and out of poverty throughout the life course, it would be strategic to assist parents of young children, both women and men, to increase their educational attainment and plan a better life for themselves and for their children. Work-related support services and training might be part of a broader goal to improve long-term outcomes for entire families. Finally, American antipoverty policies and programs have failed to reduce racial and ethnic inequities in income, wealth, and neighborhood poverty. 79 Income and, indeed, health disparities by race and ethnicity have not narrowed over time (see Chapter 6). This situation warrants targeted supports and interventions for diverse communities at highest risk, particularly Hispanic-origin and Black families. Benchmarks for a successful policy approach would be both improved outcomes for poor children and decline in racial and ethnic disparities. 80 Questions for Discussion 1. What risk and protective factors are associated with poverty? 2. Some experts point to income inequality itself as a cause of poor child- development outcomes. What are the relative advantages and potential disadvantages of focusing policy attention on reducing poverty (i.e., income inequality) versus assisting children and families in need? 3. How do current public-assistance programs target supports for low-income families with children? What are their limitations from a risk and resilience framework? 4. What new social-development and system-level approaches have been developed to prevent or reduce poverty? How do these approaches aim to break the link between poverty and child well-being? 5. How has the Great Recession of 2007 to 2009 affected the number of poor children and families in the United States? 6. What impacts did safety net programs have on children and families affected by poverty during the years of the recession? 7. 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JAMA Pediatrics, 168(3), 265–271. doi:10.1001/jamapediatrics.2013.4643. Jargowsky, P. A. (1997). Poverty and place: Ghettos, barrios, and the American city. New York: Russell Sage Foundation. Jargowsky, P. A. (2003). Stunning progress, hidden problems: The dramatic decline in concentrated poverty in the 1990s. Washington, DC: The Brookings Institution. Jargowsky, P. A. (2013). Concentration of poverty in the new millennium. Changes in prevalence, composition, and location of high poverty neighborhoods. A Report by the Century Foundation and the Rutgers Center for Urban Research and Education. Retrieved from: http://tcf.org/bookstore/detail/concentration-of-poverty-in-the-new- millennium Johnson, R.C., & Schoeni, R. F. (2007). The influence of early-life events on human capital, health status, and labor market outcomes over the life course. PSC Research Report No. 07-616. Kingsley, G. T., & Pettit, K. L. S. (2007). 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E., Leventhal, T., Dahinten, V. S., & McIntosh, C. N. (2008). Neighborhood disadvantage: Pathways of effects for young children. Child Development, 79(1), 156–169. doi:10.1111/j.1467– 8624.2007.01117.x Kubisch, A. C., Auspos, P., Brown, P., Chaskin, R., Fulbright-Anderson, K., & Hamilton, R. (2002). Voices from the field II: Reflections on comprehensive community change. Washington, DC: Aspen Institute. LaLonde, R. J. (1995). The promise of public sector–sponsored training programs. The Journal of Economic Perspectives, 9(2), 149–168. Leininger, L., & Kalil, A. (2014). Parents’ financial strain and children’s behavior problems in the aftermath of the Great Recession. Journal of Marriage and the Family, 76 (October), 998–1010. doi:10.1111/jomf.12140. Leventhal, T., & Brooks-Gunn, J. (2000). The neighborhoods they live in: The effects of neighborhood residence on child and adolescent outcomes. 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Sen (Eds.), The quality of life (pp. 30–53). Oxford, UK: Clarendon Press. doi:10.1093/0198287976.003.0003 Sen, A. (1999). Development as freedom. New York: Knopf. Shaefer, H.L. & Edin, K. (2013). Rising extreme poverty in the United States and the response of federal means-tested transfer programs. Social Service Review, 87(2), 250–268. Shapiro, T. M. (2004). The hidden cost of being African American: How wealth perpetuates inequality. New York: Oxford University Press. 92 http://colorado.edu/journals/cye Shapiro, T. M., Oliver, M. L., & Meschede, T. (2009). The Asset Security and Opportunity Index. Waltham, MA: Brandeis University. Sharkey, P. (2009). Neighborhoods and the black–white mobility gap. Washington, DC: Pew Charitable Trusts. Sherman, A. (2011). Poverty and financial stress would have been substantially worse in 2010 without government action. Washington, D.C. Center on Budget and Policy Priorities Sherraden, M. (2005). Assets and public policy. In M. Sherraden (Ed.), Inclusion in the American dream: Assets, poverty, and public policy (pp. 3–19). Oxford, UK: Oxford University Press. Sherraden, M. W. (1991). Assets and the poor: A new American welfare policy. Armonk, NY: M. E. Sharpe. Shonkoff, J. P., & Phillips, D. A. (2000). From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academies Press. Short, K. (2013). The Research Supplemental Poverty Measure 2012. U.S. Census Bureau Current Population Reports P-60 247 Skillman Foundation (2010). About the Skillman Foundation. Retrieved from www.skillman.org Social Policy Research Associates. (2010). PY 2008 WIASRD data book (Project No. 1382). Washington, DC: U.S. Department of Labor, Office of Performance Technology, Employment and Training Administration. Social Security Administration. (2010). Monthly statistical snapshot, May 2010. Retrieved from 93 http://www.skillman.org http://www.socialsecurity.gov/policy/docs/quickfacts/stat_ snapshot/#table3 Stone, R. (1996). Core issues in comprehensive community-building initiatives. Chicago: Chapin Hall. Tough, P. (2008). Whatever it takes: Geoffrey Canada’s quest to change Harlem and America. New York: Houghton Mifflin. Turner, M. A., & Kingsley, G. T. (2008). Federal programs for addressing low-income housing needs: A policy primer. Washington, DC: The Urban Institute. U.S. Department of Agriculture. (2010a). Supplemental nutrition assistance program. Retrieved from http://www.fns.usda.gov/snap U.S. Department of Agriculture. (2010b). Women, infants and children program. Retrieved from http://www.fns.usda.gov/wic/ U.S. Department of Education (2014). Promise Neighborhoods. Retrieved from http://www2.ed.gov/programs/promiseneighborhoods U.S. Department of Health and Human Services. Administration for Children and Families. Office of Community Services. 2010. Assets for Independence Program: Status at the conclusion of the tenth year. Report to Congress. U.S. Department of the Treasury. (2010). The earned income tax credit. Retrieved from http://www.eitc.irs.gov U.S. General Accounting Office. (2009). Social Security Administration: Further actions needed to address disability claims and service delivery challenges (GAO 09–511T). Washington, DC: U.S. Government 94 http://www.socialsecurity.gov/policy/docs/quickfacts/stat_ snapshot/#table3 http://www.fns.usda.gov/snap http://www.fns.usda.gov/wic/ http://www2.ed.gov/programs/promiseneighborhoods http://www.eitc.irs.gov Printing Office. U.S. House of Representatives. (2008). Background material and data on the programs within the jurisdiction of the Committee on Ways and Means. 2008 Green Book. Washington, DC: Government Printing Office. Retrieved from http://waysandmeans.house.gov/singlepages.aspx?NewsID=10490 Waldfogel, J. (2006). What children need. Cambridge MA: Harvard University Press. Waters Boots, S. (2010). Improving access to public benefits: Helping eligible individuals and families get the income supports they need. Baltimore: The Ford Foundation, Open Society Institute, and Annie E. Casey Foundation. Waters Boots, S., Macomber, J., & Danziger, A. (2008). Family security: Supporting parents’ employment and children’s development (New Safety Net Paper No. 3). Washington, DC: Urban Institute. Wildeman, C., & Western, B. (2010). Incarceration in fragile families. The Future of Children 20 (2), 187–177. Wildeman, C., & Turney, K. (2014). Positive, negative, or null? The effects of maternal incarceration on children’s behavioral problems. Demography doi:10.1007/s13524-014-0291-z Williams Shanks, T. R. (2007). The impact of household wealth on child development. Journal of Poverty, 11(2), 93–116. doi:10.1300/J134v11n02_05 Williams Shanks, T. R. (2014). The evolution of anti-poverty policies and programs. In R. Cramer & T. R. Williams Shanks (Eds). The Assets Perspective: The Rise of Asset Building and its Impact on Social Policy 95 http://waysandmeans.house.gov/singlepages.aspx?NewsID=10490 (p. 13–31). New York, NY: Palgrave Macmillan. Williams Shanks, T. R., & Destin, M. (2009). Parental expectations and educational outcomes for young African American adults: Do household assets matter? Journal of Race and Social Problems, 1(1), 27–35. doi:10.1007/s12552–009–9001–7 Williams Shanks, T. R., Kim, Y., Loke, V., & Destin, M. (2010). Assets and child well-being in developed countries. Children and Youth Services Review. doi:10.1016/j.childyouth.2010.03.011 Williams Shanks, T. R. & Robinson, C. (2013). Assets, economic opportunity and toxic stress: A framework for understanding child and educational outcomes. Economics of Education Review,33,154–170. http://dx.doi.org/ 10.1016/j.econedurev.2012.11.002. Wilson, W. J. (1987). The truly disadvantaged: The inner city, the underclass, and public policy. Chicago: University of Chicago Press. Wilson, W. J. (2009). More than just race: Being Black and poor in the inner city. New York: W. W. Norton. Wolff, E. N. (2012). The asset price meltdown and the wealth of the middle class (Working Paper No. 18559). Cambridge, MA: National Bureau of Economics Research. Zhan, M. (2006). Assets, parental expectations and involvement, and children’s educational performance. Children and Youth Services Review, 28(8), 961–975. doi:10.1016/j.childyouth.2005.10.008 Zhan, M., & Sherraden, M. (2003). Assets, expectations, and children’s educational achievement in female-headed households. Social Service Review, 77(2), 191–211. doi:10.1086/373905 96 http://dx.doi.org/ 10.1016/j.econedurev.2012.11.002 Additional Reading Bane, M. J., & Zenteno, R. (Eds.). (2009). Poverty and poverty alleviation strategies in North America. Cambridge, MA: Harvard University Press. Cancian, M., & Danziger, S. (Eds.). (2009). Changing poverty. New York: Russell Sage Foundation. Cramer, R. & Williams Shanks, T.R. (2014). The assets perspective: The rise of asset building and its impact on social policy. New York, NY: Palgrave Macmillan. Currie, J. M. (2006). The invisible safety net: Protecting the nation’s poor children and families. Princeton, NJ: Princeton University Press. Lindsey, D. (2004). The welfare of children. New York: Oxford University Press. Sherraden, M. (Ed.). (2005). Inclusion in the American dream: Assets, poverty, and public policy. Oxford, UK: Oxford University Press. Tough, P. (2008). Whatever it takes: Geoffrey Canada’s quest to change Harlem and America. New York: Houghton Mifflin. Waldfogel, J. (2006). What children need. Cambridge MA: Harvard University Press. 97 Web-Based Resources Center for Social Development, George Warren Brown School of Social Work, Washington University in St. Louis, http://csd.wustl.edu Institute for Research on Poverty, University of Wisconsin–Madison, http://www.irp.wisc.edu/ National Center for Children in Poverty, http://www.nccp.org/ National Poverty Center, Gerald R. Ford School of Public Policy, University of Michigan, http://www.npc.umich.edu/ AUTHORS’ NOTE: The authors would like to thank Megan Gilster and Pinghui Wu for their diligent research assistance in preparing this chapter. 98 http://csd.wustl.edu http://www.irp.wisc.edu/ http://www.nccp.org/ http://www.npc.umich.edu/ Chapter 3 Child Welfare Policies and Programs Peter J. Pecora Markell Harrison-Jackson 99 Purpose and Overview of Child Welfare Policy The child welfare system provides a variety of child and family social services. About 3.4 million referrals for alleged maltreatment were reported to U.S. child protection services in 2012 (U.S. Department of Health and Human Services [DHHS], 2013a). Compared with 1990, this is a profound increase in the number of children being referred as victims of maltreatment.1 Notwithstanding these long-term increases, there is some evidence that both reporting and incidence rates of child maltreatment have decreased significantly over the past ten years (Finkelhor & Jones, 2006; Sedlak et al., 2010; U.S. DHHSa). For the analyses included in a recent report from the National Center on Child Abuse and Neglect Data System, a perpetrator is the person who is responsible for the abuse or neglect of a child. In 2012, 80.3% of perpetrators of child maltreatment were parents, and another 6.1% were other relatives of the victim. Of the perpetrators who were parents, 88.5% were the biological parent of the victim. Women are slightly more likely than men to be perpetrators, accounting for 53.5% of perpetrators. And approximately four out of five perpetrators (82.2%) were between the ages of 18 and 44 years (U.S. DHHS, 2013a). In the United States during 2012, about 399,546 children were in out-of- home protective placements in foster care and nonfamily settings, and 748,000 children were served by child welfare agencies2 (see Table 3.1). Overall, the number of children in placement rose steadily between 1980 and 2000. However, as a result of changes in public policies and programs, the number of children in out-of-home care has slowly decreased since 2000 (U.S. DHHS, 2013b, 2013c). This decline in out-of-home care is likely due also to decreases in the incidence rates of child maltreatment in some communities (Sedlak et al., 2010). Child maltreatment is clearly a major social and health problem. The purpose of this chapter is to describe public policies in the field of child welfare. In this field, public policymakers, practitioners, and scholars are working to devise new ways to deal with maltreatment. Indeed, new 100 resources and ideas are reshaping child welfare practices across the country. Notably, agencies in Florida, Illinois, and New York City are making successful efforts to reduce children’s lengths of stay in out-of- home care, to reduce the level of restrictiveness of child placements, and to increase the proportion of children placed with kin who are not blood relatives. In addition, the number of children being adopted or securing a permanent placement through guardianship has increased over the last two decades because some states have substantially decreased the time to adoption (Avery, 1998; U.S. DHHS, 2003a, 2013c). These innovations may expand further with new initiatives designed to reduce time in care and increase permanency. These initiatives include child welfare demonstration waivers,3 “permanency roundtables,”4 expedited adoptive parent assessments, expedited approvals of subsidy applications, increased judicial personnel, and heightened attention by the agencies and courts to the need for more timely permanency planning. Although the child welfare system is burdened, professionals, families, and advocates across the country are experimenting with new policies and procedures designed to find safe and enduring living arrangements for children. In this chapter, we review risk and protective factors related to the reasons that children and their families become involved in the child welfare system, as well as the major social policies that are directed toward these families. In addition, we examine the ways in which the concepts of risk and protection are implemented in those policies. Drawing from innovative projects and programs across the country, we conclude with a discussion of current policy issues and recommendations for improving child welfare services. 101 Mission and Goals of Child Welfare Services Early childhood development, neuroscience, and epigenetic research are underscoring the importance of communities paying careful attention to nurturing children via supporting the adults raising them (Biglan, Flay, Embry, & Sandler, 2012). Developmentally, maltreatment often results in delayed physical growth, neurological damage, and mental and emotional/psychological problems, such as violent behavior, depression, and posttraumatic stress disorder. Research has shown that maltreatment is positively associated with a variety of social and health problems, including substance abuse, eating disorders, obesity, depression, suicide, and sexual promiscuity in transition to adulthood (e.g., Kendall-Tackett, 2013). Thus, child maltreatment is a costly problem, with detrimental consequences that follow the initial trauma of neglect or abuse and continue throughout development to adult emotional and physical adaptation. According to some research, foster care expenditures in the past decade for child maltreatment alone totaled $14.4 billion (Wang & Holton, 2008). 102 103 Vespa, J., Lewis, J. M., & Kreider, R.M. (2013). America’s families and living arrangements: 2012 population characteristics. (Current Population Reports, P20-570). Washington, D.C.: U.S. Department of Commerce Economics and Statistics Administration, U.S. Census Bureau. Retrieved July 1, 2014 from http://www.census.gov/prod/2013pubs/p20-570 . The terms used to describe racial/ethnic groups are those used by the U.S. Census Bureau. See Federal Interagency Forum on Child and Family Statistics (2014). America’s children: Key national indicators of well-being, 2013 (Pop 3 Excel table). Washington, D.C.: Retrieved 104 http://www.census.gov/prod/2013pubs/p20-570 September 30 , 2014 from: http://www.childstats.gov/americaschildren/glance.asp. Vespa et al. (2013), p. 28. U.S. Census Bureau. (2013). Father’s Day: June 16, 2013. Part of the Profile America, Facts for Features series. Retrieved July 1, 2014 from http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb13- ff13.html. Also see: Livingtson, G. (2013). Growing number of dads home with the kids. Washington, D.C.: Pew Research Center. Retrieved July 3, 2014. http://www.pewsocialtrends.org/2014/06/05/growing-number-of- dads-home-with-the-kids/. The Pew Foundation survey is based on fathers who are 18 to 69 years of age and have their own (biological, adopted, or step) children less than 18 years of age in the household. Fathers who are living apart from all of their children are not included. “Stay-at-home fathers” were not employed at all in the year prior to the survey, while “working fathers” were considered to be those who worked for pay in the prior year. Vespa et al. (2013). See more at: http://www.childtrends.org/? indicators=family-structure#sthash.m6vTpoKS.dpuf. Grandparents are a major caregiver group. See Vespa et al. (2013), p.8. Source: America’s Families and Living Arrangements (2012), Table C4. Retrieved July 7, 2014 from https://www.census.gov/hhes/families/data/cps2012C.html. For a concise factsheet on grandparents as child caregivers, see http://kidshaverightsblog.org/2013/07/31/us-census-bureau-facts- figures-grandparents-as-caregivers-links/. U.S. Census Bureau. (2013). About three in four parents living with children are married, Census Bureau reports. http://www.census.gov/newsroom/releases/archives/families_households/cb13- 199.html. Note that children in nonparental care were 2.7 times as likely as children living with two biological parents to have had at least one of the adverse childhood experiences assessed in National Survey of Child Health. See Bramlett, M. D., & Radel, L F. (2014). 105 http://www.childstats.gov/americaschildren/glance.as http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb13-ff13.html http://www.pewsocialtrends.org/2014/06/05/growing-number-of-dads-home-with-the-kids/ http://www.childtrends.org/?indicators=family-structure#sthash.m6vTpoKS.dpuf https://www.census.gov/hhes/families/data/cps2012C.html http://kidshaverightsblog.org/2013/07/31/us-census-bureau-facts-figures-grandparents-as-caregivers-links/ http://www.census.gov/newsroom/releases/archives/families_households/cb13-199.html Adverse family experiences among children in nonparental care, 2011–2012. National Health Statistics Report, 74 (May), p. 4. Retrieved July 7, 2014, from http://www.cdc.gov/nchs/data/nhsr/nhsr074 . U.S. Census Bureau. (2013). Poverty. Retrieved July 7, 2014, from http://www.census.gov/hhes/www/poverty/about/overview/. The data presented here are from the Current Population Survey (CPS), 2013 Annual Social and Economic Supplement (ASEC), the source of official poverty estimates. The CPS ASEC is a sample survey of approximately 100,000 household nationwide. These data reflect conditions in calendar year 2012. DeNavas-Walt, C., Proctor, B.D., & Smith, J.C. (2013). Income, poverty, and health insurance coverage in the United States: 2012. Washington, D.C.: U.S. Census Bureau, (P60-245), p. 7. Retrieved July 7, 2014, from http://www.census.gov/prod/2013pubs/p60- 245 . Recently, Diana Pearce has been working to replace the current poverty line measure with an “Index of Economic Self- Sufficiency Standard” that has been used to justify raising the minimum wage and as an outcome indicator for various income assistance programs. See http://www.selfsufficiencystandard.org/standard.html. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2013a). Child maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/research-data- technology/statistics-research/childmaltreatment. U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau (2013b). The AFCARS report–preliminary FY 2012 estimates as of July 2013 (No.20). Washington, D.C.: U.S. Department of Health and Human Services. Retrieved May 27, 2014, from http://www.acf.hhs.gov/programs/cb/resource/afcars-report-20. U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. (2013c). Trends in foster care and adoption—FY 2002-FY 2012. Washington DC: Author, p. 1. Retrieved May 27, 2014, from 106 http://www.cdc.gov/nchs/data/nhsr/nhsr074 http://www.census.gov/hhes/www/poverty/about/overview/ http://www.census.gov/prod/2013pubs/p60-245 http://www.selfsufficiencystandard.org/standard.html http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/childmaltreatment http://www.acf.hhs.gov/programs/cb/resource/afcars-report-20 http://www.acf.hhs.gov/programs/cb/resource/trends-in-foster-care- and-adoption. Recently, a somewhat broader framework for child welfare has emerged, and, in the interest of protecting and nurturing of children, greater emphasis is being placed on communities as a whole. Consistent with this expanded frame of reference, child welfare agencies have increased their efforts to form a broader “child welfare system” in which employers as well as mental-health, education, health-care, and other entities form collaborative community strategies aimed at preventing and responding to child abuse and neglect. Child welfare agencies have begun to look beyond the parent–child dyad, considering what is known about the interplay of risk and protective factors at the levels of the child, parent, family, neighborhood, and community. Although children have highly individual needs and characteristics, they are viewed as living in the context of a family structure. In turn, families are viewed as embedded in the context of a culture and a neighborhood. Finally, neighborhoods are seen as clustered in the context of social, economic, cultural, and political environments. Thus, as a field, child welfare has come to embrace a multisystem and ecological perspective. A child welfare system that fails to incorporate and draw on the richness and strength embodied in this contextual view of what produces family well-being cannot effectively respond to the needs of vulnerable children and troubled families. Although agency mission statements provide the guiding structure for service, it is essential that key goals and outcomes are specified to embrace such functions as establishing strategic plans, using evidence-based programs, securing adequate funding, and implementing practice guidelines within a context that promotes child safety and supports families (American Humane Association, 1998). A key issue affecting the field is the lack of common procedures for describing and classifying child maltreatment. The definitions of abuse and neglect vary across states. Researchers have tried to address the problem, using data to define maltreatment in terms of severity, incidence, chronicity, extent, type, age of onset, and perpetrator (Barnett, Manly, & Cicchetti, 1993; Hanson, Smith, Saunders, Swenson, & Conrad, 1995; Pecora et al., 2010). Notwithstanding, the field lacks a common definition of child maltreatment. To be sure, there are similarities in state definitions, so that policymakers and others who collect data across states can develop 107 http://www.acf.hhs.gov/programs/cb/resource/trends-in-foster-care-and-adoption commonalties among the different types of maltreatment (Pecora et al., 2009; U.S. DHHS, 2013a). However, no single, comprehensive, definitive breakdown of maltreatment types and combinations of abuse unifies either research or public policy. In short, the field of child welfare lacks a common nomenclature for describing and classifying a child’s maltreatment experience. A substantial number of children and adolescents entering and exiting foster care placement are known to have emotional, psychological, and cognitive developmental delays as compared with their peers who are in non-foster care placements (Griffin et al., 2012; Haskins, Wulczyn, & Webb, 2007; Stahmer et al., 2005; Webb, Dowd, Jones-Harden, Landsverk, & Testa, 2010). Recently, there has been a growing consensus across states about the fundamental experiences that place children at risk and the procedures that should be used to assess incidents of maltreatment (Chahine, Pecora, & Sanders, 2013). 108 Key Goals and Outcomes for Child Welfare Services In spite of foundational disagreements on the definition of maltreatment, the field of child welfare services is gaining clarity and consensus about its primary mission. A primary goal and two secondary goals for child welfare services have emerged with widespread support. First and foremost, the primary goal is to protect children from harm. The second goal, which is focused on child permanency, is to preserve existing family units, including birth, relative, and adoptive families, as appropriate. The third goal is to promote children’s development as adults who can live independently and contribute to their communities. This last goal may require a variety of permanency planning alternatives such as family reunification, placement with relatives, different forms of guardianship (depending on local law), adoption, and intentionally planned kinship care with legal safeguards such as guardianship (Pecora et al., 2009; U.S. DHHS, 2003a). Currently, a challenging and controversial issue facing the child welfare system is the disproportionate number of children of color in foster care placements. Of the 101,719 U.S. children awaiting adoption in 2012, nearly 26% (26,117) were Black and 23% (23,243) were Hispanic (U.S. DHHS, 2013b). In fact, 50% of the foster care population (220,331 children) comprises children of color (i.e., African American/Black, Latino/Hispanic, Asian, and Native American/Indigenous), and some of these children will remain in foster care placements until they are emancipated at age 18 (U.S. DHHS, 2013b; Wulczyn, Hislop, & Chen, 2007). Furthermore, African American children currently represent 26% of the children placed in out-of-home care nationwide (U.S. DHHS, 2013b), which is significantly higher than the percentage of African American children in the general population (14%) (O’Hare, 2011, p. 7). There is some debate in the field about making child safety a goal superior to family support. Indeed, many family advocates and some researchers have argued that without a simultaneous emphasis on child safety and family support, neither goal will be achieved in an equitable manner. Similarly, the capacity of the system to support families and promote positive developmental outcomes for children in custody has been the subject of much criticism and debate (Berrick, Needell, Barth, & Johnson- Reid, 1998; Wulczyn, Barth, Yuan, Jones-Harden, & Landsverk, 2005). 109 The key components of each of these major goals (also called outcome domains) are summarized next. Safety of Children Maltreatment has a detrimental impact on the cognitive, emotional, and physical development of children. Thus, a core goal for child welfare services is keeping children safe from child abuse and neglect. This goal includes children living with their birth families, children reunited with their families after a maltreatment event, and children placed in out-of- home care when parental custody has been terminated because of maltreatment. In terms of concrete outcomes, the public policies that support child welfare services are intended (a) to prevent children from being maltreated and (b) to keep families safely together, including families that may be functioning at a minimum standard of parenting. Child welfare workers operate on the philosophical basis that all children have a right to live in a safe environment that is free from abuse and neglect. For example, the focus of child protective services should be to deliver services that are preventive, nonpunitive, and geared toward parental rehabilitation through identification and treatment of the factors that underlie maltreatment. At the most general level, there is consensus regarding the mission of child protection: Services should be designed to protect children from maltreatment committed by their parents or other caretakers. However, in translating this broad mandate into policy and practice, the consensus breaks down in a variety of areas, such as defining what constitutes child abuse or neglect, establishing standards for agency intervention, and specifying what constitutes a minimum standard of parenting (popularized by the question, “What is a good enough parent?”). In the face of this widespread disagreement, child welfare is a policy and practice area that is benefitting from recent research on risk and protective factors in child development. Permanency: Preserving Families and Creating Permanent Homes for Children When the state steps in to protect an abused or neglected child, it is not enough to keep the child safe; the state must also consider the child’s 110 needs for permanent and stable family ties. In addition to protecting a child, the state should ensure that the child has the opportunity to be brought up by stable and legally secure permanent families, rather than in temporary foster care under the supervision of the state. This principle has been well established in federal law: first by the Adoption Assistance and Child Welfare Act of 1980, and then by the Adoption and Safe Families Act of 1997. Child and Family Well-Being: Meeting Developmental Needs Achieving child well-being means not only that a child is safe from child abuse or neglect but also that a child’s basic needs are being met and that the child is provided with the opportunity to grow and develop in an environment with consistent nurture, support, and stimulation. In this goal area, we include the need for children to develop a healthy sense of identity; an understanding of their ethnic heritage; and skills for coping with racism, sexism, homophobia, and other forms of discrimination that remain prevalent in our society. Although there are limits to what child welfare services can provide, the system should promote standards of parenting that, at a minimum, will provide a child with the developmental opportunities and emotional nurturance needed to grow into an adult who can live as independently as possible. Child well-being is related ipso facto to family well-being. Achieving child well-being means that families must have the capacity to care for children and to fulfill children’s basic developmental, health, educational, social, cultural, spiritual, and housing needs. Ensuring family well-being also implies that child welfare staff members have responsibility for locating these essential services and supports and for helping to sustain or promote parents in their child-rearing roles. System Goals Define Outcome Domains Each of these goals is related to outcome domains, albeit imperfectly, by federal outcome standards as shown in Table 3.2. A report from the U.S. General Accounting Office (2004) proposed the first set of federal outcomes set as benchmarks for the performance of state-level child welfare systems: 111 In addition to the on-site review of individual cases, it is against these benchmarks for statewide data indicators that a state is measured. Any state whose performance is found to fall short of substantial conformity (based upon data analysis and an on-site review of individual cases) is given an opportunity to develop and implement a plan to improve performance and avoid the withholding of federal funds. Finally, AFSA [The Adoption and Safe Families Act] also required HHS to prepare and submit to Congress an annual report on the performance of each state on each outcome measure. (McDonald, Salyers, & Shaver, 2004, p. 5) Using these indicators during a child and family services review, a review team assesses a state’s performance by collecting data on (a) seven outcomes in the domains of safety, permanency, and child and family well-being; and (b) seven systemic factors that affect outcomes for children and families. To measure a state’s achievement of the outcomes, the review team assesses items (via onsite review) or items and data indicators (via onsite review plus statewide assessment). To measure achievement of the systemic factors, the review team assesses items to determine whether the systemic factors are in place and functioning satisfactorily. The items or data indicators associated with the outcomes and systemic factors are listed in Table 3.2. The numerical performance standards can be found in Appendix H of the federal Child and Family Services Review manual: http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/. Across states, these review benchmarks and performance measurement methods have stimulated helpful introspection and discussion. However, many experts have continued to advocate for additional refinement (e.g., National Coalition for Child Protection Reform, 2008; Testa & Poertner, 2010; Wulczyn, Orlebeke, & Haight, 2009). In fact, the U.S. Children’s Bureau has issued new standards and in some cases new ways of calculating performance that should be finalized by 2015. (See CFSR federal register announcement at http://www.acf.hhs.gov/programs/cb/resource/cfsr-federal-register-notice.) 112 http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/ http://www.acf.hhs.gov/programs/cb/resource/cfsr-federal-register-notice 113 Sources: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2006). Child and Family Services Reviews Procedures Manual. (Working Draft.) Retrieved from http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/proce_manual.htm Appendix B: Index of Outcomes and Systemic Factors, and Associated Items and Data Indicators. Retrieved from http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/procedures/appendixb.htm Note that the CFSR assesses: (1) Statewide Information Systems; (2) Case Review Systems; (3) Quality Assurance Systems; (4) Staff and Provider Training; (5) Service Array and Resource Development; (6) Agency Responsiveness to the Community; and (7) Foster and Adoptive Parent Licensing, Recruitment, and Retention. And that the standards will be changing by 2015. See http://www.acf.hhs.gov/programs/cb/resource/cfsr-federal-register-notice. 114 http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/proce_manual.htm http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/procedures/appendixb.htm http://www.acf.hhs.gov/programs/cb/resource/cfsr-federal-register-notice Theoretical Frameworks Underlying Child Welfare Policies and Programs A number of theoretical orientations underpin the design of policies and programs in child welfare, including ecological models, child development theories, social learning and social support theories, and risk and protective factor frameworks. 115 Ecological Developmental Models From an ecological and developmental perspective, the life course outcomes of children involved in the child welfare system are perceived as deriving from the complex interaction of life experiences with biological factors (e.g., genetic vulnerability for certain disorders) and a variety of environmental and psychological factors. The conditions that produce developmental outcomes include genetic and epigenetic factors5 such as experiences of poverty, racism, and dangerous living environments as well as family-of-origin characteristics and functioning. In addition, other factors, such as family characteristics and functioning, child and family supports, and the quality and nature of services provided by various community agencies, interact in various ways with the experiences of child maltreatment to produce outcomes (Cicchetti & Lynch, 1993; Fraser, 2004; O’Connell, Boat, & Warner, 2009). The ecological perspective delineated by Cicchetti and Lynch (1993) suggested that the family is a powerful microsystem. In typical child development, the family confers protection, whereas in atypical child development—in families in which maltreatment occurs—the family confers risk. The ecological model proposed by Bronfenbrenner (1979, 1986, 2004) posits that individual development occurs and can be understood only within the context of the family and the larger social– environmental context in which the family is embedded. In this model, to understand child developmental outcomes, it is necessary to understand the interplay of factors at the individual, family, and environmental levels. The ecological perspective requires identifying and analyzing risk and protective factors at the level of the child, the level of his or her family, and the level of the broader society: Children’s development is conceptualized as arising from the complex interplay of these interwoven circles of influence. 116 Developmental Theories and Perspectives Five approaches related to child development theories are especially relevant to child welfare practice. First, attachment theory addresses relationships and traumas occurring prior to the age of 2 years (e.g., Ainsworth, 1989; Weinfield, Ogawa, & Sroufe, 1997). Second, trauma theory (Briere, 1992), as it relates to the effects of abuse and neglect, offers explanations for variations in the influence of abuse and recovery from abuse. Third, as discussed above, the ecological perspective offers useful concepts addressing the relative importance of individual, familial, and societal contexts (e.g., Bronfenbrenner & Morris, 1998; Garbarino, 1992; Pecora et al., 2009). Fourth, risk and protective factor frameworks have descriptive utility for explaining resilience in children and youth who recover from maltreatment and for identifying predictors of life course outcomes. Protective factors can be personal assets (e.g., social competence) and environmental resources (e.g., supportive parents or other relatives) that buffer or suppress risk (Catalano & Hawkins, 1996; Fraser, 2004; Rutter, 1989). Fifth, Erikson’s (1985) stages or steps in child development are useful in understanding and predicting child adjustment sequelae, including how children might adjust to foster care (Downs & Pecora, 2004). 117 Social Learning and Social Support Theories In addition, social learning theory is widely applied in child welfare practice. This theory emphasizes the reciprocal influences of the environment on the person and the person on the environment. Social learning theory holds that human behavior is learned within an interactive social context and conditioned by relationships with family members, peers, and other close associates. For example, based on social learning theory, Chamberlain (2003) and her colleagues have developed and implemented an evidence-based program called Multidimensional Treatment Foster Care. Introduced nearly 100 years ago, social support theory is one of the earliest frameworks for understanding social relations and human development. This theory integrates three aspects of human connectedness (the community, social networks, and bonding relationships) and articulates conditions under which children grow to be self-reliant adults (Caplan, 1974; Casey Family Programs, 2003; Maluccio, Pine, & Tracy, 2002). The perspective stresses the value of providing consistent supports to children, birth parents, and foster families. In addition, social support theory postulates that lack of supportive social relationships can negatively affect children’s mental health and other developmental outcomes (Caplan, 1974). Social support theory is often applied to placement disruptions and transition from foster care to young adulthood (e.g., Pecora et al., 2010; Ryan & Testa, 2004). On balance, studies suggest that social support reduces stress, buffers risk exposure, and promotes psychological adaptation (DePanfilis, 1996; Mann, 2003; McIntosh, 1991). 118 Risk, Protection, and Resilience in Child Welfare A variety of biological, psychological, and environmental factors converge to create the conditions in which maltreatment occurs, and a somewhat similar set of factors influences a child’s recovery from maltreatment. The application of a risk and resilience perspective to child welfare falls in two areas. The first has to do with factors that elevate the odds for maltreatment, and the second has to do with factors that promote recovery from the experience of maltreatment. As shown in Table 3.3, the factors correlated with maltreatment include poverty, parental substance abuse, parental mental illness, parental history of child maltreatment, social isolation, lack of employment resources in the community, and neighborhood gangs and crime (see Child Welfare Information Gateway, 2010). However, none of these factors alone is sufficient to produce maltreatment. Nevertheless, maltreatment becomes more likely as the number of risk factors increases. At the same time, we now know that a number of factors operate protectively and can reduce the likelihood of maltreatment in the presence of risk. These protective factors are also shown in Table 3.3. The fourth National Incidence Study (NIS-4) updated the set of risk factors for child maltreatment in key areas: 119 120 Source: This table is adapted from Coll and Magnuson (2000); Garbarino and Ganzel (2000); Hodges (1994); Osofsky and Thompson (2000); and U.S. Department of Health and Human Services (2003b). Much of the research on protective factors has focused on individual traits. This category of protective factors refers to factors that are learned (self-care and interpersonal attributes) as well as factors for which the individual has no control (birth order, gender). (Garmezy, 1983, 1985; Rae-Grant, Thomas, Offord, & Boyle, 1989; Rutter, 1979, 1981, 1985, 1987, 1990; Werner, 1989). Family characteristics also act as protective factors (Garmezy, 1983, 1985; Rae-Grant et al., 1989; Rutter, 1979, 1981, 1985, 1987, 1990; Werner, 1989). Community characteristics include individuals and institutions that are external to the family and that provide educational, emotional, and 121 general supportive ties with the family unit as a whole or with individual family members. (Garmezy, 1983, 1985; Rae-Grant et al., 1989; Rutter, 1979, 1981, 1985, 1987, 1990; Werner, 1989). Employment. Compared to children with employed parents, those with no parent in the labor force had two to three times the rate of maltreatment overall. Family structure and living arrangement. Compared to children living with married biological parents, those children whose single parent had a live-in partner had more than 8 times the rate of maltreatment overall, over 10 times the rate of abuse, and nearly 8 times the rate of neglect.6 Grandparents as caregivers. Children cared for by a grandparent had lower rates of physical abuse compared to those with no identified grandparent caregiver.7 Socioeconomic status. Children in low socioeconomic status households had significantly higher rates of maltreatment. They experienced some types of maltreatment at more than five times the rate of other children; they were more than three times as likely to be abused and about seven times as likely to be neglected.8 Family size. The general pattern was nonlinear: The incidence rates were highest for children in the largest families (those with four or more children), intermediate for singleton children (i.e., “only” children) and those in households with three children, and lowest among children in families with two children. (See the NIS-4 report for more details.) Child’s age. In most cases, 0- to 2-year-old children had significantly lower maltreatment rates than older children.9 County metropolitan status. On balance, the incidence of maltreatment was higher in rural counties than in urban counties. Perpetrator’s relationship to the child. Biological parents were the most closely related perpetrators, accounting for 71% of physically abused children and for 73% of emotionally abused children. The pattern was distinctly different for sexual abuse, with 42% of sexually abused children victimized by someone other than a parent (whether biological or nonbiological) or a parent’s partner, whereas just over one third (36%) were sexually abused by a biological parent. In addition, the severity of harm from physical abuse varied by the perpetrator’s relationship to the child. A physically abused child was more likely to sustain a serious injury when the abuser was not a 122 parent. Perpetrator’s alcohol use, drug use, and mental illness. Alcohol use and drug use contributed approximately equally to maltreatment, each applying to 11% of the countable children, whereas mental illness was a factor in the maltreatment of 7% of the children. All three factors were more often involved in maltreatment when the perpetrator was a biological parent (Sedlak et al., 2010, pp. 14–15). In cases involved with child welfare, indeed across all children, the NIS-4 and other research by Putnam-Hornstein (2011), suggest that developmental outcomes are influenced by individual and environmental risk factors as well as by a host of cultural resources and practices that may both buffer against risk and promote recovery from negative life events. One of the most frequently discussed risk factors is poverty. Low-income families are less likely to have adequate food, safe housing, and prenatal or other medical care. Households that are living near or below the poverty line tend to have few social supports and experience more stress in child rearing, all of which can increase the risk of child maltreatment. Generally, poverty has a direct negative influence on maternal behavior and subsequently on the quality of parenting that children receive (Brooks- Gunn, Klebanov, & Liaw, 1995). For children, living in poverty is associated with a host of negative consequences, including poor physical health, diminished cognitive abilities, reduced educational attainment, increased emotional and behavioral problems, and higher risk of maltreatment (Brooks-Gunn & Duncan, 1997; Ridge, 2009; Sedlak et al., 2010). The relationship of poverty to maltreatment and other negative child developmental outcomes appears mediated in part by stress. Using global data, Wilkinson and Pickett (2009) charted the level of health and social problems against the level of income inequality in 20 of the world’s richest nations and in each state of the United States. They found that mental illness, drug and alcohol abuse, obesity, and teenage pregnancy were more common in states and countries with a big gap between the incomes of rich and poor households. Moreover, areas with a large income gap also had higher homicide rates, shorter life expectancies, and lower scores for children’s educational performance and literacy. The Scandinavian countries and Japan consistently scored at the positive end of this spectrum, and these countries have the smallest differences between higher and lower incomes and the best record of psychosocial health. The 123 countries with the widest gulf between rich and poor, and the highest incidence of health and social problems, were Britain, the United States, and Portugal. The Wilkinson and Pickett (2009) data and recent reviews of families living in “deep poverty” (Urban Institute, 2013) suggest that poverty creates not only physical hardship but also a stressful environment that exacerbates social and health problems. Commenting on Wilkinson and Pickett, Carey (2009) argued, It is not only the poor who suffer from the effects of inequality, but the majority of the population. For example, rates of mental illness are five times higher across the whole population in the most unequal than in the least unequal societies in their survey. One explanation . . . is that inequality increases stress right across society, not just among the least advantaged. Much research has been done on the stress hormone cortisol, which can be measured in saliva or blood, and it emerges that chronic stress affects the neural system and in turn the immune system. When stressed, we are more prone to depression and anxiety, and more likely to develop a host of bodily ills including heart disease, obesity, drug addiction, liability to infection and rapid ageing. (p. 1) Although it is far beyond the capacity of service providers to influence national income differentials, these data suggest that health promotion and child safety may be associated with poverty and stress. In seeking to reduce stress, researchers are increasingly looking at protective factors, including cultural rootedness and resources, which buffer against stress related to poverty and other adversities such as racial discrimination. Consistent with this perspective, the American Psychological Association’s Task Force on Resilience and Strength in Black Children and Adolescents (hereafter, APA Task Force) called for reframing research to better conceptualize adaptive and protective processes for African American children. With the intent of providing researchers, policymakers, educators, practitioners, and the public with a useful lens through which to view the design of services for African American youth, the report explored how themes of resilience cut across five widely accepted developmental domains of functioning: 124 Identity development. A positive racial identity is essential to the well-being of African American youth. Children should be encouraged to develop a positive sense of self in a society that often devalues them through negative stereotypes. Emotional development. Coping with emotions effectively is directly related to self-esteem and better mental health. African American youth need to be made aware of how their emotional expressions resonate across all situations and circumstances. Social development. Family and community interaction are crucial to African American youths’ social development. This interaction includes having access to high-quality child care, afterschool programs, and faith-based institutions. Cognitive development. African American youth must believe in their abilities in the classroom. Parents should avoid harsh parenting styles, and schools should continue to look at ways to infuse culturally relevant themes into the classroom as a way to improve academic performance. Physical health and development. Access to health care must be improved. A wide range of health conditions disproportionately affect African American youth, including obesity, poor oral health, asthma, violent injury, sickle-cell anemia, diabetes, and HIV/AIDS (APA Task Force, 2008). In addition to African American youth and their families, immigrant families constitute an increasing part of the population served by child welfare. In designing more effective services for these children, data suggest that it is important to understand how the experiences of immigration, immigration stress, and acculturation affect family dynamics, strengths, and risk and protective factors (e.g., Dalla, Defrain, Johnson, & Abbott, 2009; De Anda, 2003). In child welfare, protection has always been an element of services, but the literature on risk and resilience has given new meaning to protection. For many children, prevailing over the adversity of maltreatment involves strengthening protective processes in the family and community context. These strengthening efforts include building parental competence and teaching positive disciplinary approaches; enhancing the racial and ethnic identities of children; and engaging caregivers, advocates, peer networks, and extended family members in providing culturally anchored social support. Other critical protective characteristics involve inclusion of 125 families in community activities and the availability of medical, educational, and financial resources that allow parents to provide appropriate care for their children. Although the available research on protective factors associated with child maltreatment is limited, this research has been growing (e.g., Development Services Group, Inc., 2013) and has been informed by the larger body of literature on protective factors. Several studies have outlined factors that differentiate resilient children from children who experience serious adjustment problems. Protective factors appear to fall into three general categories: individual characteristics, family characteristics, and the presence of supportive others (Garmezy, 1985; Rutter, 1990; Werner, 1989). Individual characteristics include attributes such as self-sufficiency, high self-esteem, and altruism. Family characteristics include supportive relationships with adult family members, harmonious family relationships, expressions of warmth between family members, and the ability to mobilize supports in times of stress. Finally, community supports refer to supportive relationships with people or organizations that are external to the family. These external supports provide positive and supportive feedback to the child and act to reinforce and reward the child’s positive coping abilities (Hodges, 1994). 126 Race, Ethnicity, Income, and Maltreatment Poverty and race/ethnicity are related in the United States, and both are correlated with maltreatment. Indeed, the racial and ethnic distribution of perpetrators in a substantiated case is similar to the race and ethnicity of victims. During 2012, nearly one half (48.9%) of perpetrators were White, 19.9% were African American, and 18.9% were Hispanic. These proportions have changed little in recent years (U.S. DHHS, 2013a, p. 61). Although the literature is sparse, differences by race and ethnicity should be understood in the context of other known risk factors, especially poverty. The NIS-4 also found significant differences in child abuse rates based on socioeconomic factors. Poor children were three times more likely than other children to experience abuse (Crary, 2010). When income was controlled in analyses, the differences found in maltreatment rates between White and Black children in low-income families were negligible. In fact, larger differences were observed in the “not low income” classification, in which higher rates were observed for African American families as compared to White families. Racial differences in need (Drake, Jolley, Lanier, Fluke, Barth, & Jonson-Reid, 2011) and racial disparities in service provisions and quality (Lorthridge, McCroskey, Pecora, Chambers, & Fatemi, 2011) need to be carefully considered. The preceding discussion offers a brief overview of the individual, family, and community risk and protective factors related to child abuse and neglect. We have placed emphasis on protective factors because they serve to buffer stress for some children and provide important clues for how to strengthen child welfare services. Given differences in family structure, child-rearing practices, and relationship to community, the degree to which these factors are moderated by race and ethnicity is unclear. This is the subject of much current research. In fact a recent literature review noted that the strength of evidence for protective factors among at-risk children and youth varies considerably by type of factor and specific population. As summarized in Table 3.4, moderate levels of evidence were found for selected factors at the individual, relationship, and community levels of influence for all focus population groups (Development Services Group, Inc., 2013). Certainly, some of the protective factors associated with, for example, 127 socioeconomic status and academic success are universal. However, other factors may be conditioned on or differentially more important among African American, Latino, and other children with strong racial, ethnic, or religious backgrounds. From Hodges (1994), these protective factors include: Active extended family: fictive or blood relatives who are active in the child’s life; provides material resources, child care, supervision, parenting, and emotional support to the child (Wilson, 1984). Faith-based affiliation: belongs to and actively participates in a group religious experience (Werner, 1989). Strong racial identity: exhibits racial pride, strongly identifies with ethnic group through clubs, organizations, political, and social-change movements. Close attachment to the ethnic community: resides in the ethnic community, easy access to ethnic resources, including social services, merchants, media (newspaper), and demonstrates a commitment to the ethnic community. Dispositional attributes: activity level, sociability, average intelligence, competence in communication (oral and written), internal locus of control (Werner, 1989). Personal attributes: high self-esteem, academic achievement, assertiveness, quality of adjustment to single-parent household. Supportive family milieu: cohesiveness, extensive kinship network, nonconflictual relations. External support system: involvement of absent fathers, male role models, supportive social environments of various ethnic communities. 128 Source: Development Services Group, Inc. (2013). Protective factors for populations served by the administration on children, youth, and families. A literature review and theoretical framework: Executive summary. Washington, D.C.: U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau, p. 6. Retrieved May 20, 2014, from http://www.dsgonline.com/acyf/DSG%20Protective%20Factors%20Literature%20Review%202013%20Exec%20Summary 129 http://www.dsgonline.com/acyf/DSG%20Protective%20Factors%20Literature%20Review%202013%20Exec%20Summary Risk, Resilience, and Protection in Child Welfare Policy Child welfare policy is slowly but steadily being shaped by research related to risk, resilience, protection, neuroscience, and epigenetics. New materials from the Harvard Center on the Developing Child and landmark books such as Neurons to Neighborhoods reinforce infant and young child stimulation principles outlined by earlier pioneers and make scientific knowledge accessible to a broad audience (Shonkoff & Phillips, 2000). Other child welfare researchers such as Berrick and colleagues (1998) and Maier (1978) have emphasized the importance of paying attention to child development fundamentals (e.g., attachment theory and social learning) in designing child welfare policy and programs. Advances in the treatment of child abuse and neglect have emphasized how children with varied psychological compositions and differing amounts of social support respond differently to various healing approaches (Briere, 1992; Cohen, Mannarino, Zhitova, & Capone, 2003; Kendall-Tackett, 2013). Ecological and diversity perspectives underscore the vital roles that broad community networks and environments play in services and healing. In addition, a recent Institute of Medicine report described a growing array of evidence-based programs for preventing emotional, behavioral, and substance abuse disorders in youth and young adults (O’Connell et al., 2009). We are making progress. Policy and program reforms include strategically focused family-centered services to strengthen parenting; child-centered early intervention and remedial services based on increased understanding of early brain development (Perry & Dobson, 2013; Shonkoff & Phillips, 2000); attempts to embed substance abuse treatment services within child welfare and to strengthen linkages across service delivery systems such as mental health, education, and juvenile justice; use of least restrictive placement environments, which facilitated the closure of hundreds of residential institutions; permanency planning for children to secure a stable family if birth parents are unable to provide care for the child; and aggressive permanency planning for older youth in foster care so they do not age out or emancipate from foster care without a legal 130 guardian and a network of supportive relationships. Three other significant transformations bear mentioning. First, leaders in child protective services, family support, and foster care have identified community collaborations as essential for effective services (Morgan, Spears, & Kaplan, 2003; Pew Foundation, 2008; Schorr & Marchand, 2007). Second, the field has recognized the simultaneous needs of moving all children (i.e., irrespective of background and age) to permanent family situations while also being cognizant of the need to nurture the child development of children who remain involved in the child welfare service system beyond a 3-month protective services intervention (Berrick et al., 1998; Kerman, Maluccio, & Freundlich, 2009). Third, racial and ethnic disproportionality in the provision of services and achievement of permanency outcomes are increasingly acknowledged problems (e.g., Derezotes, Poertner, & Testa, 2005; Fluke, Jones-Harden, Jenkins, & Ruehrdanz, 2011; Hines, Lemon, Wyatt, & Merdinger, 2004; U.S. Government Accountability Office, 2007). A discussion of these and other policy issues follows. 131 Key Child Welfare Policy and Legislation A number of public policies influence child welfare programs and affect the families receiving child welfare services. Listed below are some of the key federal policies that are related to child welfare. These policies include adoption, child protection, income support, education, early intervention, family support, and foster care. (For more information, see Appendix A in Pecora et al., 2009.) Medical care, which is also important for child welfare, is discussed more thoroughly in Chapter 6 of this volume. 132 1970s Child Abuse Prevention and Treatment Act of 1974 (PL 93-247): Provides some financial assistance for demonstration programs for the prevention, identification, and treatment of child abuse and neglect; mandates that states must provide for the reporting of known or suspected instances of child abuse and neglect (Stein, 1984). Juvenile Justice and Delinquency Prevention Act of 1974 (PL 93- 415): Provides funds to reduce the unnecessary or inappropriate detention of juveniles and to encourage state program initiatives in the prevention and treatment of juvenile delinquency and other status offenses (see http://www.ojjdp.ncjrs .gov/about/ojjjjact.txt). Title XIX of the Social Security Act: Provides health care to income- eligible persons and families. One of the sections of this act established the Early and Periodic Screening, Diagnosis, and Treatment program, which provides cost-effective health care to pregnant women and young children (see http://www.ssa.gov/OP_Home/ssact/title19/1900.htm). The Education for All Handicapped Children Act of 1975 (PL 94- 142): This law supports education and social services for handicapped children. The act requires states to (a) offer programs for the full education of handicapped children between the ages of 3 and 18, (b) develop strategies for locating such children, (c) use intelligence testing that does not discriminate against the child racially or culturally, (d) develop an individualized education plan (IEP) for each child, and (e) offer learning opportunities in the least restrictive educational environment possible, with an emphasis on mainstreaming: integrating handicapped children into regular classrooms (see http://www.projectidealonline.org/publicPolicy.php). The Individuals with Disabilities Education Act (IDEA): The Individuals with Disabilities Education Act (IDEA) began as the Education for All Handicapped Children Act of 1975 (PL 94-142) and gave all children with disabilities the right to a free and appropriate public education. This watershed civil rights law resulted from sustained advocacy by parents of children with disabilities. Special education has been shaped by the six core principles that formed the nucleus of the Education for All Handicapped Children Act: (1) zero reject, meaning schools could not opt to exclude any 133 http://www.ojjdp.ncjrs .gov/about/ojjjjact.txt http://www.ssa.gov/OP_Home/ssact/title19/1900.htm http://www.projectidealonline.org/publicPolicy.php children with disabilities from instruction; (2) nondiscriminatory evaluation, by which every child receives an individualized, culturally and linguistically appropriate evaluation before being placed in special education; (3) IEP, a plan delineating current performance, progress on past objectives, goals, and services for the school year, and evaluation of outcomes; (4) least restrictive environment, which is in settings with nondisabled children; (5) due process, which codifies the legal steps to ensure a school’s fairness and accountability in meeting the child’s needs and how parents can obtain relief via a hearing or by second opinions; and (6) parental participation, whereby parents have the right to access their child’s education records and participate in IEP planning (Kirk, Gallagher, & Anastasiow, 1993, pp. 51–52). Another part of IDEA that is important for children served by child welfare agencies is early intervention, which has as its purpose the provision of prevention and treatment services to improve cognitive, social, and emotional development of the youngest children (under the age of 3). Children receiving early intervention services either are considered at risk for delayed development or have been identified as having a developmental disability (Ramey & Ramey, 1998). The Indian Child Welfare Act of 1978 (PL 95-608): Strengthens the standards governing the removal of Native American children from their families. Provides for a variety of requirements and mechanisms for tribal government overseeing and services for children (see http://www.nicwa.org/law/; Plantz, Hubbell, Barrett, & Dobrec, 1989). 134 http://www.nicwa.org/law/ 1980s The Adoption Assistance and Child Welfare Act of 1980 (PL 96-272): This is one of the key laws for child welfare reform because it used funding incentives and procedural requirements to implement a wide range of placement prevention and permanency planning (see http://www.ssa.gov/OP_Home/comp2/F096–272.html; Pine, 1986). Independent Living Initiative (PL 99-272): Provides funding for services to prepare adolescents in foster care for living in the community on an independent basis (Mech, 1988). 135 http://www.ssa.gov/OP_Home/comp2/F096%E2%80%93272.html 1990s Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA): Funds the Temporary Assistance to Needy Families (TANF), the largest income transfer program for poor families. This is part of the nation’s welfare system—administered by the states and funded jointly by state and federal governments. Low-income families of children with disabilities can also receive income transfers through TANF, which is the limited welfare program enacted in 1996 by PRWORA. TANF replaced Aid to Families with Dependent Children (AFDC), which limits program participation (with some exceptions) to 60 months. TANF allows states to exempt up to 20% of their welfare caseload from work requirements, but states have the discretion to establish more strict work participation rules (see http://www.cbpp.org/cms/?fa=view&id=936). Foster Care Independence Act of 1999 (PL 106-169): Authorized the Education Training Voucher (ETV) program. Congress provided federal funding of $42 million for the first time in fiscal year (FY) 2003 and increased funding to $45 million for FY 2004. In both years, the president requested $60 million in his budget (see http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/public_law/p1106_169/p1106_169.htm The voucher program is a component of the Chafee Independent Living Program, which helps older youth leaving foster care to get the higher education, vocational training, and other education supports they need to move to self-sufficiency. Up to $5,000 per year is available to a young person for the cost of attending college or vocational school. ETV funds are distributed to the states using the same formula as the Chafee Independent Living Program under the Foster Care Independence Act. If a state does not apply for funds for the ETV program, the funds are reallocated to other states based on their relative need. Although states are generally doing a good job of distributing these funds, more foster youth could take advantage of the vouchers if their availability were more widely known. An additional $60 million is needed for ETVs for youth leaving foster care at age 18 and those adopted from foster care at age 16 or older (Child Welfare League of America, 2004). Keeping Children and Families Safe Act (PL 108-36): Reauthorizes 136 http://www.cbpp.org/cms/?fa=view&id=936 http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/public_law/p1106_169/p1106_169.htm the Child Abuse Prevention and Treatment Act. Authorizes funds for grants to state child welfare agencies, competitive grants for research and demonstration programs, and grants to states for the establishment of community-based programs and activities designed to strengthen and support families, all of which support services to prevent and treat child abuse and neglect. The act amends the Adoption Reform Act of 1978 (Adoption Opportunities), focusing on the placement of older foster children in adoptive homes with an emphasis on child-specific recruitment strategies and efforts to improve interjurisdictional adoptions. This act also includes amendments to the Abandoned Infants Assistance Act, making aid a priority to infants who are infected with the HIV virus, have a life- threatening disease, or have been exposed perinatally to a dangerous drug. The act also includes an amendment to the Family Violence Prevention and Services Act, extending from FY 2004 through FY 2008 authorization of appropriations for specified family violence prevention programs (see www.naesv.org/Resources/FVPSA ). 137 http://www.naesv.org/Resources/FVPSA 2000 to present The Adoption Incentive Program (PL 108-145): The Adoption Incentive Program was first enacted as part of the Adoption and Safe Families Act in 1997 to promote permanence for children. In 2003, Congress passed the Adoption Promotion Act of 2003 (PL 108-145) to reauthorize the program with modifications. The Adoption Incentive Program is designed to encourage states to finalize adoptions of children from foster care, with additional incentives for the adoption of foster children with special needs. States receive incentive payments for adoptions that exceed an established baseline. The Adoption Promotion Act revises the incentive formula in current law, creating four categories of payment (see http://www.childwelfare.gov/systemwide/laws_policies/federal/index.cfm? event=federalLegislation.viewLegis&id=85). Runaway, Homeless, and Missing Children Protection Act (Title III of the 3 Juvenile Justice and Delinquency Prevention Act of 1974), 4 as Amended by the 5 Runaway, Homeless, and Missing Children Protection Act (PL 108-96): Authorizes funds for the establishment and operation of centers to provide shelter, protection from sexual and other abuse, counseling, and related services to runaway and homeless youth under 18 years of age. The act authorized local groups to open “maternity group homes” for homeless pregnant teens or for those that have been abused. These homes are required to educate runaway youth about parenting skills, child development, family budgeting, health and nutrition, and related skills to promote long-term independence and the health and well-being of youth in their care (see http://www.acf.hhs.gov/programs/fysb/content/aboutfysb/RHYComp and http://www.acf.hhs.gov/programs/fbci/progs/fbci_rhyouth.html). Other landmark pieces of legislation were passed during this time. For example, the Fostering Connections to Success and Increasing Adoptions Act (HR 6893/PL 110-351) of 2008. This law helps children and youth in foster care by ensuring permanent placements for them through kinship and adoption and improving educational and health care outcomes. It will also extend federal support for youth to age 21. The act offers for the first time substantial support to American Indian children residing in child protective custody. Key 138 http://www.childwelfare.gov/systemwide/laws_policies/federal/index.cfm?event=federalLegislation.viewLegis&id=85 http://www.acf.hhs.gov/programs/fysb/content/aboutfysb/RHYComp http://www.acf.hhs.gov/programs/fbci/progs/fbci_rhyouth.html provisions are listed below: Offers federal support to children who leave foster care to live permanently with relative guardians through a federal subsidized guardianship program. Helps relatives connect the children with the services and supports they need by using kinship navigator programs. Includes separate licensing standards to address non-safety licensing requirements that create barriers to children living with relatives in foster care. Provides additional support to older youth and increase their opportunities for success by: Continuing federal support for children in foster care after age 18: The law allows states, at their option, to provide care and support to youth in foster care until the age of 19, 20, or 21. Providing transition support: The act requires child welfare agencies to help youth make this transition to adulthood by requiring, during the 90-day period immediately before a youth exits from care at 18, 19, 20, or 21, the development of a personalized transition plan that identifies options for housing, health insurance, education, local opportunities for mentoring, continuing support services, workforce supports, and employment services. Granting tribes direct access to Title IV-E: The law ensures that Indian tribes have direct access to IV-E funded programs. Improving education outcomes for children who live in out-of- home care by improving educational stability by requiring states to ensure that placement of the child in foster care takes into account the appropriateness of the current educational setting and the proximity to the school in which the child is enrolled at the time of placement. Promoting coordinated health care for children in out-of-home care by requiring that states develop a plan for the oversight and coordination of health, mental health, and dental services for children in foster care. Expands and improves adoption assistance programs Improves the child welfare workforce: The law allows states to be reimbursed for training provided to an expanded group of individuals and organizations including kinship caregivers, court personnel, court-appointed special advocates, and nonagency workers providing child welfare services. 139 Second, in 2010, Child Abuse CAPTA Reauthorization Act of 2010 (PL 111-320) amended the Child Abuse Prevention and Treatment Act (CAPTA), the Family Violence Prevention and Services Act, the Child Abuse Prevention and Treatment and Adoption Reform Act of 1978, and the Abandoned Infants Assistance Act of 1988, to reauthorize the Acts and make other changes to them. In addition to many other provisions, this act authorized grants to public or private agencies to develop or expand effective collaborations between child protective service (CPS) entities and domestic violence service entities. It also reauthorized the Child Abuse Prevention and Treatment and Adoption Reform Act of 1978, including appropriations, through FY 2015. Amendments to the act also required efforts to promote the adoption of older children, minority children, and children with special needs. And it renewed through FY 2014 the authority of HHS to authorize States to conduct child welfare program demonstration projects likely to promote the objectives of title IV-B or IV- E.9 In 2011, H.R. 2883 amended part B of title IV of the Social Security Act to extend the Child and Family Services Program through FY 2016. It included a wide range of provisions, including: Requiring each state plan for oversight and coordination of health care services for any child in foster care to include an outline of the monitoring and treatment of emotional trauma associated with a child’s maltreatment and removal from home, and protocols for the appropriate use and monitoring of psychotropic medications. Requiring each state plan for child welfare services to describe the activities to reduce the length of time that children under the age of 5 years are without a permanent family and activities to address the developmental needs of such children who receive benefits or services. In 2013, the Uninterrupted Scholars Act amended the Family Educational Rights and Privacy Act (FERPA) to allow child welfare agencies access to the student records of youth in foster care. When FERPA was written in 1974, lawmakers intended to protect parental control over their children’s student records. However, the unintended consequence for children in the custody of the state—like those in foster care—was the creation of time- consuming legal hurdles to access to the school records of children in care. This law should address this problem. (See 140 http://www.gpo.gov/fdsys/pkg/PLAW-112publ278/pdf/PLAW- 112publ278 ) Finally, it is likely that some of the provisions of the Affordable Care Act will make it easier for some parents to receive preventive or treatment services as part of a “medical home” and changes in payment structures. The Act should also make it easier for foster care alumni to get and keep some kind of health insurance coverage, even with pre-existing conditions. 141 http://www.gpo.gov/fdsys/pkg/PLAW-112publ278/pdf/PLAW-112publ278 Current Policy Challenges Child welfare faces a number of policy challenges, some of which are exacerbated by the mixed success the United States is having in meeting the basic needs of children; ensuring children’s safety, health, relationships, and opportunities; and supporting families as the foundation for positive child development. These challenges include the following 15 issues. 1. Child maltreatment prevention services are underfunded and lack federal guidance on what would be a coherent approach. Early intervention services have long been recognized as helping families avoid involvement with the child welfare system. Best practices for early intervention programs involve provision of a range of family-centered services that focus on meeting the needs of the child within the context of the family as well as the larger environment. For example, early intervention might include referring parents to job assistance or adult education and providing parents with assistance in obtaining housing and health care. Child-centered early intervention programs have been linked with improved child development across multiple domains (Karoly, Kilburn, Caulkins, & Cannon, 2000; Kilburn & Karoly, 2008). Given advances in prevention science (Jenson & Bender, 2014), it is quite possible that the design, development, and delivery of improved early intervention services could reduce the incidence of child maltreatment. However, implementing early intervention programs will require a more unified leadership with a cohesive plan for family support at both the federal and state levels. Communities interested in early intervention will need to invest public resources in evidence-based programs that support parents and strengthen families. Furthermore, those interested in child welfare must work toward increasing the supply of affordable child care, and increasing the awareness among policymakers of the importance of family economic security. This need is emphasized by the large proportion of children entering child welfare as a result of parental neglect. As previously mentioned, more effective mental health and substance abuse interventions for parents could also reduce youth entry into foster care. 142 A risk, resilience, and protective factor perspective undergirds the philosophy supporting early intervention. Early intervention should aim to disrupt risk processes, promote protective mechanisms, and stimulate resilience. Ideally, early intervention services promote well- being and optimal development by providing comprehensive community-based support services to help improve child developmental outcomes. Two examples of such interventions are Point of Engagement (Marts, Lee, McCroy, & McCroskey, 2008) and the Prevention Intervention Development Initiative in Los Angeles (McCroskey et al., 2009). Unfortunately, these types of services are underfunded, and without Title IV-E waivers or more permanent federal fiscal reforms, states often lack the flexibility to reallocate federal funds designated for placement services to fund family support programs. With few exceptions (e.g., Development Services Group, Inc., 2013), the Administration for Children Youth and Families has not issued a practical framework for guiding child maltreatment prevention. 2. Differential response approaches to child protective services intake need additional testing. New intake approaches are attempting to refer low-risk families (i.e., those with a low risk for a subsequent maltreatment referral) to supportive programs other than child protective services. Although promising, these approaches need further testing and evaluation to clarify the roles of law enforcement; medical, legal, and social services personnel; and voluntary agencies. If new intake procedures accurately distinguish families in which the likelihood of severe maltreatment is low from those in which it is high, these new protocols could complement family support interventions that have been heavily researched and found to be cost- effective. For example, practice, administrative, policy, and other system-reform strategies exist that can improve well-being for maltreated children and accelerate permanency planning. These strategies can safely reduce the number of children in foster care, and those placement-cost savings can be reinvested in higher quality services for the children for whom out-of-home care is the most appropriate option. (For examples of such programs and their cost- effectiveness, see Pecora, O’Brien & Maher, 2014; Washington State Institute for Public Policy Research, 2013. Also see http://www.wsipp.wa.gov/BenefitCost as this website is periodically updated.) 3. Family support services are not funded in alignment with desired 143 http://www.wsipp.wa.gov/BenefitCost outcomes. Family support programs, which include parent hotlines, crisis nursery services, environmental adaptations, personal assistance, and mental health and crisis interventions are often “lifelines.” These services allow families to care for their children at home rather than placing a child in out-of-home care, which is expensive and generally publicly financed (Bruns & Burchard, 2000; Schorr & Marchand, 2007). The goals of family support services include enabling families to raise children at home by reducing stress and by strengthening and enhancing caregiving capacities (Pew Foundation, 2008; Walton, Sandau-Beckler, & Mannes, 2001). Family caregivers’ acceptance and use of formal support services play a significant role in reducing the burdens and stress associated with caring for a child and in helping families obtain services for unmet needs. Across the United States, family support services are usually jointly financed by the federal and state governments, often using Medicaid resources, and are typically administered by state or county governments. Not surprisingly, given the differences among the states in the provision of social services, there is variability across states in the funding levels for family support and in the types of services available (Parish, Pomeranz, & Braddock, 2003). Consequently, these services are often not only underfunded but also among the first to be cut during periods of economic downturns. 4. Changes to key child welfare funding mechanisms require careful consideration. There appears to be growing agreement among policymakers, advocates, and state child welfare directors that comprehensive child welfare finance reform should align federal funding and policies to incentivize and ensure the safety, permanency, and well-being of children and their families. A number of proposals that would allow states to use federal foster care funds not only to support children in out-of-home care but also to support child abuse prevention and post-adoption services have been presented to Congress. For example, several proposals would change the system for funding key child welfare programs, including foster care entitlement under Title IV-E of the Social Security Act. These proposals can be seen as efforts to address the family support issue. However, the downside to these proposals is that the overall budget for children’s services would decrease if all the areas under proposed legislation are considered. Based on what occurs with the 144 federal block grant process for Medicaid and the Supplemental Nutrition Assistance Program (SNAP, formerly the food stamp program), families would no longer have an entitlement. Therefore, educational efforts are needed to inform the public and policymakers of the importance of policies that preserve the open-ended entitlement for key child welfare programs. In addition, child and family advocates need to raise awareness among policymakers and the public that program funds should be tied to performance. Results should be rewarded, and savings due to lowered rates of foster care should be reinvested to improve the quality of child welfare services (Annie E. Casey Foundation, 2014; Annie E. Casey Foundation and the Jim Casey Youth Opportunities Initiative, 2013; Casey Family Programs, 2010a). The following principles outline what is important to address to achieve this vision: Federal funding targeted for child welfare services should be available for any child or his or her family on the basis of risk rather than an income standard but also should be available for a limited time period and for a specific set of services. Federal funding for child welfare should be flexible enough to allow states to address their unique challenges and issues. Federal funding should incentivize and encourage better outcomes for children and their families (Casey Family Programs and the Brookings Institution, 2013) 5. Policies and funding to treat mental health and substance abuse problems must be coordinated with child welfare services. Fragmented funding streams and policies for mental health, substance abuse, developmental disabilities, and child welfare services unduly complicate the treatment of parents and children with co-morbid conditions (Kessler & Magee, 1993). Depending upon the community, over 30% of the families with children who have been placed in out-of-home care also have substance abuse problems (Barth, Gibbons, & Guo, 2006; Besinger, Garland, Litrownik, & Landsverk, 1999). To serve the dual needs of these families, many agency administrators are diverted from other activities while trying to “braid” or cobble together sources of funding to cover the costs of drug treatment and other programs. Such efforts highlight the need for increased program coordination at the federal and state levels to maximize the effectiveness of existing resources (Johnson, Knitzer, & Kaufmann, 2003). This type of increased coordination requires a system of care approach. (For a discussion of systems of care in 145 mental health, see Chapter 5 in this volume.) 6. All youth in high school should receive the tutoring and employment experiences that build work-related skills. Youth preparing to emancipate must have greater access to experiential life skills and classroom-based training. However, systems change is essential to accomplish this goal. Among others, the MacArthur Foundation transition scholars have documented the failure of major American institutions to keep pace with societal changes that require new ways of working (Carnegie Council on Adolescent Development, 1989; First Focus, 2008). 7. Policies should provide fiscal incentives to improve high-school graduation rates and to support postsecondary education and training for children and youth in foster care. Recent changes in the federal Higher Education Act, reauthorized in 2008 as the Higher Education Opportunity Act (HEOA; PL 110-315), provide more consideration of the special needs of children and youth in foster care. Further policy innovations are needed to strengthen elementary and secondary education programs, including special education initiatives. In addition, federal and state policies must maintain the financial viability and array of services within the Medicaid and State Children’s Health Insurance Program (SCHIP) programs for youth in foster care and ensure that no young person leaves foster care without access to appropriate health care. 8. Policies should increase the likelihood that youths will achieve and maintain permanency in a reasonable period through foster care, reunification, relative placement, guardianship, or adoption In many states, a substantial number of children have a case goal of alternative planned living arrangement (APLA), such as emancipation from foster care at age 18 or exit before age 18 via independent living. APLA is not a legal form of permanence, and it does not provide children with a long-term supportive relationship with an adult. Reforms that are needed include crafting policies to ensure that kinship care families have access to resources that allow them to raise healthy children in stable home environments (Casey Family Programs, 2010b). Adoption policy must more thoroughly address how to better respond to the legal concerns expressed in the Multi-Ethnic Placement Act and Inter-Ethnic Adoption Provisions Act. 9. Policymakers need to recognize the seriousness of, and make changes to reduce, racial and ethnic disproportionality and 146 disparity. Although the disproportionate numbers of children of color in the child welfare system, and the disparities in the outcomes of those children have been recognized as ethical, policy, and program issues, much needs to be done to fully address them. First, we need to promote the investment of public resources into gathering accurate data about African American, Native American, Asian American, and Hispanic children who are involved in the child welfare system. This information ranges from the level of access to services of birth parents for children of color in the child welfare system to data concerning use of substance abuse and mental health services both before entering and during their contact with the system (Fluke et al., 2011; Hill, 2007; Hines et al., 2004). Second, using this information, officials must enhance national awareness of the disproportionate number of children of color in the foster care system and pinpoint the reasons for this disproportionality. Finally, communities should launch efforts to reduce disparities as was recently accomplished in Sacramento County (Ellis, Eskenazi, Bonnell & Pecora, 2013). The goal of these efforts should be to remove race and ethnicity as a predictor of outcome in child welfare services. Table 3.5 provides an example of a Point of Engagement strategy used in Los Angeles to reduce racial and ethnic disparities in child welfare. 10. Kinship care funding, licensing, and practice policies need to be aligned. More than 6.7 million children—about 1 out of every 12 U.S. children—are living in households headed by grandparents or other relatives. The number of children raised in relative-headed households has increased significantly. U.S. Census data show that 2.4 million grandparents are taking primary responsibility for the basic needs of their grandchildren. Kinship caregivers often lack the information and range of supports they need to fulfill their parenting role. In an effort to remedy this situation, a group of advocates from child welfare, aging, and research organizations prepared a set of revised kinship care fact sheets (Children’s Defense Fund, 2008). These sheets provide state-specific data and information directing grandparents or other kinship caregivers to support services that can help make their jobs easier. The Fostering Connections legislation (PL 110-351) authorizes federal support for kinship navigators to advise these parents. However, more work needs to be done to help resolve the policy inconsistencies in licensing and support of these families. 11. Tribal access to federal child welfare services funding should be 147 increased and existing infrastructure should be improved. Consistent with their cultures, Native American tribes have exercised jurisdiction over their children, but most tribes have seriously underdeveloped services. Tribal entities need to build a variety of service infrastructures such as management information systems and quality improvement programs. The Fostering Connections legislation enables American tribes to access Federal Title IV-E funds directly. 12. Agency policies should promote better assessment and support of gay, lesbian, bisexual, and transgendered youth in out-of-home care. Few child welfare systems have encouraged staff members and foster parents to protect and nurture gay, lesbian, bisexual, and transgendered (GLBT) youth. Such youth are vulnerable to victimization, depression, and suicide. Because of their sexual orientations, GLBT youth have a higher risk of placement disruption. Special efforts are needed both to assess the needs of these youths and to devise supportive services for them (Mallon, 1999; Wornoff & Mallon, 2006). 13. Cross-systems collaboration should be strengthened. The risk and protective factors related to child maltreatment bear remarkable resemblance to risk and protective factors for other social and health problems. This suggests that a more integrated and coordinated approach to family support and children’s services could be designed to address common risk factors. Income assistance, education, mental health, public health, intimate-partner violence, law enforcement, juvenile justice, and child welfare agencies need to work more toward a common purpose and minimize operating in isolation from each other. (See for example, Chahine, Pecora & Sanders, 2013.) Cross- systems collaboration—sometimes called a system of care—is needed to strengthen provision of services to families with concurrent occurrences of child maltreatment, depression, drug abuse, and partner violence. 14. Transition policies and support for emancipating youth must be overhauled. Too many graduates of the foster care system are undertrained and underemployed. Many youth and young adults are part of a large group of marginalized youth who age out of the system without adequate skills for independent living and without a support system. Children placed in foster care vary widely in their level of preparation for emancipation from foster care in terms of education 148 and income (Courtney et al., 2007; Goerge et al., 2002). Programmatically, child welfare systems should promote investment in culturally relevant services, support, and opportunities to ensure that every youth in foster care makes a safe, successful transition to adulthood. Preparation for independent living must be redesigned to start at the age of 10 years, rather in late adolescence. A comprehensive transition plan should be developed for every child. It should include planning for supportive relationships, community connections, education, life skills assessment and development, identity formation, housing, employment, physical health, and mental health (Casey Family Programs, 2001; Los Angeles County Departments of Children and Family Services/Probation, Youth Development Service, 2013; Wald & Martinez, 2003). Employment training and work experience should be expanded for many youth while they are in care. Policies and incentives should ensure that no young person leaves foster care without housing, access to health care, employment skills, and permanent connections to at least one adult. 15. Performance-based contracting should be fully implemented. Attempts to implement state and county policies to promote performance-based contracting have been hampered by a lack of knowledge of baseline conditions, concrete target goals, and infrastructure funding gaps. Clear performance criteria, cohort-based and longitudinal data analyses, and quality improvement systems must be in place to enable agencies to improve performance-based contracting and the implementation of evidence-based practice models (Mordock, 2002; Wulczyn et al., 2009). 149 Using Knowledge of Risk, Protection, and Resilience to Achieve Service Integration We have described the major policies that influence the well-being of children and families involved with the child welfare system. The lack of service and funding integration were noted as well as many policy developments that illustrate how risk-reduction strategies could improve child welfare services. To disrupt the risk mechanisms that lead to child maltreatment and that complicate recovery from victimization, child welfare agencies need adequate funding, as well as new and more effective ways to link funding to effective programs. Source: Casey Family Programs. (2009). Stories of practice change: What flexible funding means to the children and families of Los Angeles County. Seattle, WA: Casey Family Programs, pp. 7–8. 150 Child welfare policy, performance incentives, and practices lack alignment (e.g., Wulczyn et al., 2009). Critics argue that the child welfare system needs to be overhauled to better address risk factors leading to child abuse and neglect (Edna McConnell Clark Foundation, 2004; Lindsey, 2004; Whittaker & Maluccio, 2002). In addition, the emerging literature on protective processes, which buffer children from risk and promote recovery from victimization, holds potential to influence policy and practice. To underscore the complexity of the challenges incumbent in reform, a case study is presented in the accompanying box. The case describes a family in which multiple forms of child neglect are present. This family situation illustrates how child neglect can have serious consequences for child development. The complexity of this family situation is evident; it is the too-frequent situation in which genuine love for children is interwoven with mental health problems, partner violence, poverty, and deficits in parenting skills. In this scenario, the concepts of risk, resiliency, and protective factors have utility for guiding case decision making and the choice of interventions. 151 Children Who Are Not Headliners This case example involves multiple forms of child neglect. An intergenerational cycle may be at work here: a “passing on of infantilism, mother to daughter, through processes of deprivation leading to detachment (the deprivation-detachment hypotheses), failure to provide stimulation, and the child’s identification with an inadequate role model. Hence the cycle of neglect might be said to derive from a cycle of infantilism” (Polansky, Chalmers, Buttenweiser, & Williams, 1981, p. 43). Although it must be emphasized that generalizing these families is not wise because of their diversity, some of the research data depict a group of neglectful caregivers who are generally (a) less able to love; (b) less capable of working productively; (c) less open about feelings; (d) more prone to living planlessly and impulsively; (e) susceptible to psychological symptoms and to phases of passive inactivity and numb fatalism; (f) more likely to live in a situation of family conflict, to be less organized and more chaotic; (g) less verbally expressive; and (h) less positive and more negative in affect (Gaudin, Polansky, Kilpatrick, & Shilton, 1996; Polansky et al., 1981; Polansky, Gaudin, & Kilpatrick, 1992). Although many families involved with substance abuse never come to the attention of child welfare agencies, when they do they very often are identified as having problems related to child neglect (U.S. Department of Health and Human Services, 1999). In a sense, the parenting/nurturing instinct has been weakened or distorted in its aim, or overwhelmed by the parent’s struggle in personal survival. This stunting or crippling of parenting or nurturing is not often an emergent response to current stress but is predictable from the social history of the parent and the lack of nurturance in his or her childhood (Polansky et al., 1981, pp. 147–157). Some of those risk factors (and family strengths and resources) are illustrated by the following case example. The family consists of Mona Stay, twenty-three, and her common-law husband Frank Brown, aged twenty-six. There are three children: Frank Stay, three and a half, Sylvia Stay, eighteen months, and Wilma, seven months. The Stay-Browns have been together over five years. Although they quarrel and separate periodically, they seem very mutually dependent and likely to remain a couple. Their original referral was from a nurse who had become aware of the eldest child’s condition. He was difficult to discipline, was eating dirt and paint chips, and seemed hyperactive. Although over two, he was not speaking. His father reacted to him with impatience. He was often slapped, and hardly ever spoken to with fondness. The caseworker got Mona to cooperate in taking young Frank in for a test for lead poisoning, and for a full developmental 152 evaluation. This child had had several bouts with impetigo, had been bitten through the eyelid by a stray dog, and had a series of ear infections resulting in a slight hearing loss. Although physically normal, he appeared already nearly a year delayed. Often this child was found outside the house alone when the caseworker came to see the family. On one occasion he was seen hanging from a broken fire escape on the second floor. The worker was unable to rouse his mother, or to enter the house until she got help from the nearby landlord, after which she ran upstairs and rescued the child. Only then did the sleeping Mona awaken! With much effort having been expended on his behalf, this child had been attending a therapeutic nursery. His speech is already improved after four or five months, and his hyperactivity has calmed. He comes through as a lovable little boy. Sylvia is surprisingly pale . . . and indeed, suffers from severe anemia. This child has had recurrent eye infections, and had a bout with spinal meningitis at age three months which, fortunately, seems to have left no residual effects. Much effort has gone into working with Mona concerning Sylvia’s need for proper diet and iron supplement. After a year of contact this is still a problem. The baby was born after the family had become known to the agency. Despite the agency’s urging, Mona refused to go for prenatal care until she was in her second trimester, but she did maintain a fairly good diet, helped by small “loans” from the agency when her money for food ran out. When Wilma was born, she had to remain for a time at the hospital for treatment of jaundice. After she went home, she was left to lie most of the time in her bassinet, receiving very little attention from either parent. At four months of age, Wilma weighed only five pounds and was tentatively diagnosed as exhibiting “failure to thrive” by the hospital. Thereafter the mother avoided going to the clinic, and the caseworker spent much effort concerning the feeding and sheer survival of Wilma. The baby is now slowly gaining weight but is still limp and inactive. In addition to an active caseworker, a homemaker was assigned to this family for months. Much more was involved than trying to help Mona learn to organize her day: she had almost no motivation to get started. Rather than learning how to manage, she tried to manipulate the homemaker into doing her housework for her. However, with time and patience, Mona has been persuaded to go with the caseworker on shopping trips, is learning how to buy groceries to best advantage, and from time to time manages to get the laundry into and out of the laundromat. So far as her plans for herself, Mona has talked of seeking training as a beauty operator, but has never followed through on this or on other positive plans. 153 The family’s sole support is public assistance. Frank Brown, the father, was on drugs earlier in their relationship, but managed to get off them. Now, however, he drinks heavily, and although he manages to work, he never contributes to the household. Mona, apparently, was herself a neglected child, and was removed from her parents in infancy. Placed with an adoptive family, there was constant friction during her growing up, and she ran away from home several times. During her teens, she was placed in an institution for incorrigible girls. Later she spent a period in a mental hospital during which she was withdrawn from heroin addiction. It is a commentary on her life that she regards this period in the adolescent ward as one of her happiest ever. Her adoptive mother is now dead, and her father wants nothing more to do with her, so she was more or less living on the streets when she met with Frank and set up their present establishment. Frank and Mona, despite his obvious exploitativeness, seem to love each other and their children, and to want to keep the family together. They are able to relate to those who try to help them, so at least one is not operating constantly against hostile resistance. Mona is an intelligent woman and now shows adequate ability to handle the children. She can be an excellent cook —when there is food. Yet this remains a disorganized household. Bills are never paid, clothes are thrown around, the children never sleep on clean sheets, trash is piled around the house so that flies and maggots abound. Mona still leaves the youngsters quite alone for brief periods. There is no heat in the house, and the family will soon have to move, with neither any idea where to go nor funds for rent deposits and the like. Mona, at least, is currently wearing an IUD. The Stay-Brown menage was not invented, although of course we have altered names and some facts to protect all concerned. These are real people, and they are clearly involved in child neglect. The failures center on poor feeding, uncleanliness, extremely bad housing, filthy circumstances which make the children prone to infections, lack of medical care, inadequate supervision and protections from danger, lack of intellectual stimulation, inattentiveness to the children bordering on rejection—one could go on. The fine staff trying to help Mona improve her child care finally gave up and closed her case after about fifteen months of effort. The care was improving slowly, if at all, and there were recurrent instances of regression. Frank proved superficially amenable to suggestions when he could be seen, but in fact evaded any real responsibility for the household. The time, money, and—more importantly—motivation for hard work with such families are chronically in short supply. So the decision was made to try to help someone else who might be more treatable. Meanwhile these children are with their parents. Since they have not literally 154 been abandoned, it is uncertain whether a local judge would decide the home is so bad that the children must be removed. If a catastrophe were to occur, if one were to read that these three children had burned to death in a fire, one would be saddened but not greatly surprised. If one of the three were to die of an infectious disease or an undiagnosed appendicitis, one would not be surprised either. For the present, however, they are among the group child- protection workers know well, but that the public does not, because they do not make headlines—or at least not yet. Source: Polansky, Chalmers, Buttenweiser, & Williams, Damaged Parents: An Anatomy of Child Neglect, pp. 5–7. Copyright © 1981. Reprinted with permission of the University of Chicago Press. 155 Summary In this chapter, we have reviewed policies and legislation in American child welfare, and discussed a number of critical issues and potential reforms. A risk and resilience perspective was explored. From the concepts of protection and resilience, models of service that consider child and family development in the context of community and culture may be useful in future child welfare initiatives. In many states, private child welfare programs play a major role in protecting and nourishing maltreated children who were placed in foster care. Policy experts would be wise to consider the roles of public and voluntary agencies when considering ways to improve child welfare services and increase funding. On balance, our review suggests that child welfare needs to adopt a broader framework to protect children from maltreatment. The growing knowledge base regarding risk and resilience, combined with the growing number of studies showing that child maltreatment can be prevented (Pew Foundation, 2008; Schorr and Marchand, 2007), present a clear challenge to design more “upstream” prevention-focused services while concurrently improving services for maltreated children. Meeting this challenge will demand a measure of leadership, funding, cross-systems collaboration, and accountability that is visionary. 156 Questions for Discussion 1. What are the implications of the literature on risk and protective factors for the design of policies and programs for family support, foster care, and permanency planning? 2. What policy changes would you recommend to better integrate service delivery and to provide an evidence-based system of child welfare services for families with children at risk of child maltreatment? 3. In what ways might the increasing federal and state emphasis on measurable outcomes promote service delivery approaches that are culturally appropriate and oriented to child well-being? 4. How will some of the provisions of the Affordable Care Act help some of the parents who are coming to the attention of child welfare agencies? 157 NOTES 1. There were 3 million reports involving the welfare of about 5 million children in 2001 and 1.8 million in 2002. For the most recent federal child maltreatment statistics, see U.S. DHHS (2013a). In 1990, there were an estimated 611,924 victims, based on projections using data from 35 states. See U.S. DHHS (1999, pp. 4–2); for the 2002 statistics, see http://www.acf.hhs.gov/programs/cb/publications/cm02/summary.htm. 2. These data are from the federal Adoption and Foster Care Analysis and Reporting System (AFCARS), which derived these estimates using data from nearly all 50 states and other jurisdictions (e.g., Washington, D.C., and Puerto Rico; U.S. DHHS, 2013b). For total children served in 2012, see U.S. DHHS (2013c). Note that AFCARS data are periodically updated; therefore, the data cited in this chapter may not match the data on the current website. 3. Section 1130 of the federal Social Security Act, enacted in 1994, gave the Secretary of Health and Human Services (HHS) the authority to approve waivers to Title IV-E rules for the purpose of funding demonstration projects in state or county child welfare systems. This authority provides an opportunity for states and tribes that administer Title IV-E funding to use the funds more flexibly in order to test innovative approaches for child welfare service delivery and financing. Across the country, Title IV-E Child Welfare Demonstration Projects are expected to document the benefits of a more balanced array of child welfare services. 4. Permanency roundtables (PRTs) were designed to expedite the permanency planning process by identifying realistic solutions to permanency barriers for youth. A team of professionals, including a facilitator, the youth’s case manager, the case manager’s supervisor, a master practitioner (a local permanency expert), a permanency consultant (an external permanency expert), and others who may be able to contribute to a permanency plan meet for two hours to discuss the youth’s case. The primary desired youth outcome is the achievement of legal permanency (through reunification, adoption, or guardianship). The desired organizational outcomes include increasing staff expertise around permanency and “busting” systemic barriers to permanency. (See 158 http://www.acf.hhs.gov/programs/cb/publications/cm02/summary.htm http://www.casey.org/georgia-permanency-roundtables/.) 5. The concept of epigenetic change—alterations in gene expression that are due to environmental or other reasons not related to DNA—is an important idea in child development. There is ample evidence that subtle changes in the early environment influence adulthood disease appearance; this early environment is not restricted to the fetal period but is expanded to encompass the plastic phase of early child development. Moreover, evidence supports that our genetic background, which is the result of our evolution, is an important contributor to susceptibility to perinatal imprinting. However, rapid adjustment and optimization, which are necessary at times for survival, require a type of plasticity that the genome sequence alone cannot achieve. Without changing the genomic backbone, epigenetic modulation, in reaction to a given environment, results in functional adaptation of the genomic response. Thus, evolutionally acquired genomic susceptibilities and environmentally induced epigenomic modulations occurring early in life impact on later development of human diseases (Tremblay & Harnet, 2008). 6. Family structure reflects the number of parents in the household and their relationship to the child; living arrangement reflects their marital or cohabitation status. Considering both factors, the NIS-4 classified children into six categories: living with two married biological parents, living with other married parents (e.g., stepparent, adoptive parent), living with two unmarried parents, living with one parent who had an unmarried partner in the household, living with one parent who had no partner in the household, and living with no parent. 7. The NIS-4 could identify a grandparent as a child’s caregiver under three conditions: when the grandparent was the child’s primary caregiver, when the primary caregiver did not have a spouse or partner and the grandparent was the secondary caregiver, and when the grandparent was a caregiver and maltreated the child. 8. To contend with missing data on individual items, the NIS-4 analyses combined three indicators into a general measure of socioeconomic status: household income, household participation in any poverty program, and parents’ education. 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Additional Reading
Chibnall, S., Dutch, N., Jones-Harden, B., Brown, A., Gourgine, R., Smith,
J., Boone, A., & Snyder, S. (2003). Children of color in the child welfare
system: Perspectives from the child welfare community. Washington, DC:
U.S. Department of Health and Human Services Administration for
Children and Families Children’s Bureau, Administration for Children and
Families. Retrieved from
http://www.childwelfare.gov/pubs/otherpubs/children/
Child Welfare League of America. (2003). Making children a national
priority: A framework for community action. Washington, DC: Author.
Retrieved from http://www.cwla.org/membersonly/cig021009b
Shonkoff, J. P., & Meisels, S. J. (Eds.). (2000). Handbook of early
childhood intervention (2nd ed.). New York: Cambridge University Press.
Wulczyn, F., Barth, R. P., Yuan, Y. Y., Jones Harden, B., & Landsverk, J.
(2005). Beyond common sense: Evidence for child welfare policy reform.
Somerset, NJ: Transaction Aldine.
Wulczyn, F. H., Orlebeke, B., & Mitchell-Herzfeld, S. (2005). Improving
public child welfare agency performance in the context of the federal child
and family services reviews. Chicago: Chapin Hall at the University of
Chicago. Retrieved from
http://www.chapinhall.org/research/report/improving-public-child-welfare-
agency-performance-context-federal-child-and-family-s
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http://www.childwelfare.gov/pubs/otherpubs/children/

http://www.cwla.org/membersonly/cig021009b

http://www.chapinhall.org/research/report/improving-public-child-welfare-agency-performance-context-federal-child-and-family-s

Web-Based Resources
American Psychological Association, Task Force on Resilience and
Strength in Black Children and Adolescents. (2008). Resilience in African
American children and adolescents: A vision for optimal development.
Retrieved from http://www.apa.org/pi/families/resources/resiliencerpt
Child Trends for key statistical summaries, child and family trend data and
issue summaries, http://www.childtrends.org
Resilience and strength in black children and adolescents,
http://psychcentral.com/news/2008/08/21/resiliency-among-black-
youth/279
U.S. Children’s Bureau for state outcomes and foster care statistics,
http://www.acf.hhs.gov/programs/cb/publications
AUTHORS’ NOTE: This chapter draws from material in the third edition
of The Child Welfare Challenge. We appreciate the advice from that
textbook’s co-authors, James Whittaker, Anthony Maluccio, Richard
Barth, Diane DePanfilis, and Robert Plotnick. Special thanks to the policy
staff of the American Public Human Services Association and Child
Welfare League of America for the policy briefs and position statements
that informed the legislative policy section. Finally, foster care alumni,
practitioners, and foster parents have taught us much about the real
impacts of policy; we appreciate the time they have devoted to improving
the child welfare system.
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http://www.childtrends.org

http://psychcentral.com/news/2008/08/21/resiliency-among-black-youth/279

http://www.acf.hhs.gov/programs/cb/publications

Chapter 4 Education Policy for Children,
Youth, and Families
Andy J. Frey
Myrna R. Mandlawitz
Armon R. Perry
Hill M. Walker
Public education in the United States occurs in the context of a complex
and often contentious system composed of diverse interest groups. Several
competing viewpoints about the primary purpose of education lie at the
heart of debates on education policy. These competing interests include
preparing students for the workforce, teaching basic academic skills,
developing social and cognitive skills, and preparing youth to be
productive future citizens (Fuhrman & Lazerson, 2005). The purpose of
this chapter is to identify and describe significant education policies of the
past century in the context of a risk, protection, and resilience framework.
Herein, we discuss the prevalence and trends for school dropout and
failure; identify and describe the primary risk and protective factors
associated with school adjustment and academic achievement; summarize
past and present education policies; and consider and discuss ways in
which principles of risk, protection, and resilience might be used to
develop or enhance education policy.
182

Trends in School Failure and Academic
Achievement
Public education is often referred to as the great equalizer. This label
suggests that access to education plays a prominent role in the acquisition
of economic and social benefits associated with gainful employment.
Unfortunately, evidence from years of research indicates that access to
quality public education is far from equal. In 2010, nearly 3.1 million
children dropped out of school before earning a high school diploma
(National Center for Education Statistics, 2013). Historically, marginalized
groups have faced severe challenges and discrimination in their attempts to
take advantage of educational opportunities. Despite progress on many
fronts, recent reports have indicated that the American education system is
still struggling to reach all students effectively. Although it is widely
known that a lack of educational attainment has a deleterious impact on
future economic status, many children begin school without the necessary
readiness skills and begin a pattern of failure that leads to dropout and
poor prospects for employment.
Studies have shown that student-specific factors are associated with
dropout and academic failure (Fall & Roberts, 2012; Wang & Fredricks,
2014). These student-specific risk factors include low academic
achievement, student misbehavior, suspensions and expulsions, negative
narrative comments in school records, frequent referrals for in- and out-of-
school problems (Arcia, 2006; Finn, Fish, & Scott, 2008), number of
elementary schools attended, and early involvement in the juvenile justice
system (Sweeten, 2006). In addition to these individual risk factors, larger
environmental influences also affect school failure and dropout rates. The
notion of school engagement is central to the influence of environmental
factors. Students perform better and achieve at higher levels when they
feel a sense of attachment to school, which is characterized by bonding or
connection that occurs through a process of school engagement (Fredricks,
2011). Conversely, students who are unable to establish a connection to
school and thus cannot fully engage in the schooling process are at
increased risk for dropout (Kemp, 2006). Lack of engagement may occur
among students whose families move frequently (South, Haynie, & Bose,
2007) and those who have negative interactions with school personnel or
183

who are minimally involved in extracurricular activities (Kemp, 2006).
For other students, particularly for youth of color, structure and culture in
school are often quite different from those in the home. This disparity
often alienates students and contributes to disengagement and subsequent
dropout (Patterson, Hale, & Stessman, 2007). Youth of color are at
greatest risk for school adjustment problems during the elementary grades,
and they are more likely than other students to become school dropouts
(Patterson et al., 2007; Substance Abuse and Mental Health Services
Administration, 2008). This pattern also contributes to higher dropout rates
in urban areas that are heavily populated by racial and ethnic minorities
(Patterson et al., 2007). As shown in Table 4.1, overall graduation rates
increased slightly from the 2010–2011 to the 2011–2012 academic year.
However, female graduation rates were higher than male graduation rates
over this period of time, and both African American and Hispanic students
had lower graduation rates than their White counterparts. In a recent study,
Carpenter and Ramirez (2007) examined reasons for school dropout and
found that being retained in a grade, or held back, predicted school dropout
for all races, whereas family composition and time spent on homework
were factors related to school dropout only for White and Hispanic
students. Among African American students, the number of suspensions
and level of parental involvement in school predicted dropout (Carpenter
& Ramirez, 2007). Most important, these findings suggest that many racial
and ethnic differences in academic achievement and dropout rates may
stem from key differences in risk status at the family, school, and
neighborhood levels.
184

Source: Stester & Stillwell (2014).
185

Risk and Protective Factors for School
Adjustment and Achievement Problems
The term risk factor was defined by Fraser and Terzian (2005) as “any
event, condition, or experience that increases the probability that a
problem will be formed, maintained, or exacerbated” (p. 5). Risk factors
for school-related problems may be either specific or general in nature.
Within the context of education, nonspecific risk factors such as poverty
are not directly related to school adjustment and achievement problems.
Nevertheless, such factors have the potential to create maladaptive
emotional and behavioral contexts and outcomes, which in turn, can have
an adverse effect on academic performance (Greenberg, Domitrovich, &
Bumbarger, 1999). Nonspecific risk factors may set into motion what
Fraser and colleagues have called a chain of risk (Fraser, Kirby, &
Smokowski, 2004), which can culminate in negative outcomes such as
academic failure.
Other risk factors directly affect the likelihood of school adjustment and
academic failure. For example, factors such as low commitment to
schooling contributes to truancy, poor grades, and poor overall academic
performance (Carnahan, 1994). As shown in Table 4.2, risk factors occur
at the individual, family, school, and neighborhood levels of influence.
Protective factors are characteristics or traits that buffer and moderate
exposure to risk. In high-risk situations, protective factors like attachment
to teachers or other adults at school have the potential to reduce risk and
decrease the likelihood of school-related problems. In the absence of risk,
protective factors have a neutral effect. The concept of promotion is
closely related to protection. Promotive factors are defined as forces that
exert positive influences on behavior, irrespective of the presence or
absence of risk (Sameroff & Gutman, 2004). Examples of promotive
factors include high intelligence and strong social skills, which can
promote positive behavioral outcomes regardless of risk exposure. Table
4.3 summarizes protective and promotive factors that affect academic
performance.
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187

Education Policy: Past and Present
American educational policies and practices are profoundly influenced by
political ideology, which is most frequently viewed in terms of a
conservative or liberal stance. Historically, a conservative view of
education has promoted the idea that individual students have the capacity
to earn—or fail to earn—their place among the academic elite. Policy
approaches based on conservative views tend to emphasize knowledge-
centered education, traditional forms of learning and curricula, respect for
authority and discipline, and the adoption of rigorous academic standards.
In contrast, educational approaches based on liberal perspectives have
tended to support curricula that are responsive to the individual as well as
to social and environmental contexts (Apollonia & Abrami, 1997).
Educational policies and programs in the past 100 years are reviewed and
summarized in Table 4.4. The impact of policies that have been subjected
to evaluation is also discussed.
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189

Early Public Policy
190

191

From its inception, public education was thought of as a social vehicle for
minimizing the importance of class and wealth and for determining who
might excel economically. Social policy in the late 19th and early 20th
centuries was based on the liberal ideas of Horace Mann and John Dewey.
In the mid-19th century, Mann proclaimed that education, more than any
other process, was the great equalizer of people from various walks of life
(Cremin, 1957). Similarly, Dewey’s (1916) philosophy of education held
the role of education as the “leveler” of the socially advantaged and
disadvantaged. Education policy also stemmed from the conservative
notion that mass education was necessary to ensure that the citizenry could
obey the law, vote, pay taxes, serve on juries, and participate in the armed
forces (Derezinski, 2004). The Massachusetts Compulsory School
Attendance Act of 1852 required public school attendance for all able-
bodied children of a certain age unless a child’s parent could establish that
the child was obtaining equivalent instruction outside the public schools.
By 1918, 48 states had adopted similar attendance policies (Derezinski,
2004). This change resulted in programs based on the idea that all children
must attend school and graduate; these assertions were nonexistent before
compulsory attendance laws. At this point, segregated education was
determined to be constitutional, as evidenced by the separate but equal
clause in Plessy v. Ferguson (1896), which supported separate
transportation systems for African American and White people; the ruling
was later applied to children in the context of public school integration.
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Education Policy From 1930 to 1970
In the post-World War I era, education policy was dominated by debates
about the academic and social goals of education and by discussions about
whether all children should receive the same quality education. Although
the focus on curriculum and teaching methods remained, a values-based
debate ensued that was associated with the issues of equity and excellence.
By 1930, the direction of education policy shifted toward equality in
education. During the 1930s, the National Association for the
Advancement of Colored People initiated a campaign to overthrow the
Plessy v. Ferguson (1896) decision, with school desegregation as a major
goal. As the achievement gap between advantaged and disadvantaged
students became increasingly evident, efforts at desegregation in public
education gained momentum and competed for policy attention in the
national spotlight.
The achievement gap between White and African American students as
well as the achievement gap between economically advantaged and
disadvantaged children became the most important educational issues of
the century in the 1940s. The debate that ensued served as a catalyst for
efforts to close the achievement gap and to maximize educational
opportunities for people of color. The integration movement scored a
significant victory in 1954, when the U.S. Supreme Court ruling in Brown
v. Board of Education of Topeka (1954) established that laws assigning
students to schools based on race were unconstitutional. The Supreme
Court ruled unanimously that such laws violated the 14th Amendment’s
guarantee that the rights of all Americans deserved equal protection. The
rationale for the verdict was that separating African American students
from White students could result in feelings of inferiority in students of
color and serve to compromise the quality of their education. It took nearly
two decades for all states to comply with the court’s order to desegregate
schools, and many of the initial advancements achieved by integration
have since given way.
During this same period, conservatives attacked progressive directions in
education, suggesting that the American education system was sacrificing
intellectual goals for social ends. The discussion between the progressives,
who saw the educational arena as the most legitimate vehicle for leveling
the playing field, and the critics, who demanded more academic rigor in
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education, became known as “The Great Debate” (Ravitch, 1983). This
debate was fueled by the launching of the Soviet space satellite Sputnik, an
event that suggested the United States was no longer the world’s leader in
scientific research and development. From the mid-1950s to the mid-
1960s, the pursuit of excellence, standards-based education, curriculum
reform, assessment, and accountability gained momentum. However,
standards-based education would not take center stage in education policy
until the 1980s.
The 1960s witnessed great divisiveness in education policy as illustrated
by the tension evident in the eventual move toward a more liberal reform
orientation. This change mirrored larger societal issues, predominantly the
emphasis on equity issues raised by the Civil Rights Movement. In the
1960s and early 1970s, several influential books highlighted the structural
inequalities in the educational system, particularly for African American
children and children from disadvantaged backgrounds (Clark, 1965; Kohl,
1967; Kozol, 1967; Rosenfeld, 1971). These books, along with a report by
Coleman (1966) entitled Equality of Educational Opportunity, highlighted
the relationship between socioeconomic status and disparity in educational
outcomes. The Coleman report suggested that the composition of the
student body within schools was highly correlated with student
achievement (Sadovnik, Cookson, & Semel, 2001). The implications of
the report were shocking, primarily because Coleman set out to
demonstrate that the achievement gap between African American and
White students could be attributed to the organizational structure of
American schools. The Coleman report justified busing students between
schools and between school districts, suggesting that reassigning poor
students to schools with middle-class students would equalize educational
opportunities. Many researchers, who questioned the premise, method, and
findings, challenged the report.
Other progressive policies also emerged in the 1960s. In 1965, the Head
Start Act funded an innovative preschool program for disadvantaged
children. Head Start was designed to address a host of factors that affected
poor children and their families, and specifically school readiness. The
goal of the program was to increase early school readiness by providing
health, educational, nutritional, family support, social, and other services
to preschool children from low-income households.
Congress also passed the Elementary and Secondary Education Act
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(ESEA) in 1965. Similar to the Head Start Act, the ESEA was passed on
the assumption that inequities in educational opportunities were largely
responsible for the achievement gap between advantaged and
disadvantaged children. ESEA provided funds for schools that had high
percentages of disadvantaged students to compensate for many years of
unequal education under segregation. ESEA has been revised and
reauthorized several times since 1965. Provisions of the act are currently
responsible for funding bilingual education; education for homeless,
migrant, and neglected children; drug education; and teacher training
(Nelson, Palonsky, & McCarthy, 2004).
Title I of ESEA has had the greatest impact on vulnerable and high-risk
youth. Title I has been the largest source of federal funding for poor
children in schools for 40 years (Cook, 2005), serving more than 33.4
million students in more than 66,000 schools in the 2011–2012 school year
(Institute of Education Sciences, 2014). In addition, the Safe and Drug-
Free Schools and Communities (SDFSC) program provides early
screening; remedial academic support; and prevention programming that
addresses issues of violence, substance abuse, sexual abuse, and teenage
pregnancy. Funds support transition programs for youth coming to public
schools from residential and juvenile justice settings as well.
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Education Policy From 1970 to 2000
The 1970s brought new attempts to integrate schools through complex
busing plans and magnet schools designed to attract White students to
neighborhood schools that they would not ordinarily attend (Cecelski,
1994). However, desegregation became increasingly difficult to maintain
as a host of court cases gradually began to undo the Brown mandate. In the
1974 case of Milliken v. Bradley, the U.S. Supreme Court declared that if
segregation was the result of an individual’s choice, school districts could
not be forced to remedy the situation. Put simply, once a district had done
all it could to desegregate its schools, the district was released from further
desegregation orders. Similar rulings led to renewed efforts to achieve a
racial balance in schools in many American cities (Nelson et al., 2004).
In 1975, Congress passed the Education of All Handicapped Children Act
(EHA; PL 94-142), which altered educational patterns for students with
disabilities. EHA provided screening and identification services for
children with a wide range of disabilities and required schools to offer a
variety of services for them based on an individualized education program
developed by a school district representative, teachers, parents, and the
student, as appropriate. The EHA was designed to ensure (a) screening and
identification of children with disabilities, (b) provision of a free
appropriate public education (FAPE) for children with disabilities,
including special education and related services, (c) inclusion of students
in the least restrictive environment with nondisabled students to the
greatest extent possible, and (d) procedural safeguards to ensure students’
right to a FAPE was protected.
In the late 1970s, many proponents of conservative policy pointed to the
government’s inability to solve social problems in the schools. Some
spoke critically of the way in which EHA interfered with individual
freedoms. Many experts argued that progressive reforms had not only
failed to narrow the achievement gap between advantaged and
disadvantaged children but also had exacerbated problems in the schools
related to discipline and other behavioral issues. Anyon (1997) suggested
that this belief was fueled by the publication of A Nation at Risk, a report
on the state of U.S. education issued by the National Commission on
Excellence (1983). The report was issued in 1983 under Terrel Bell,
President Ronald Reagan’s Secretary of Education; it discussed the
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ongoing problems of declining literacy and education standards, leading to
high rates of adult illiteracy and low achievement test scores. The report
recommended that educational policies should strive to improve
educational experiences for all students and to develop more rigorous and
measurable standards to assess academic performance. A Nation at Risk
paved the way for educational reform efforts focused on excellence for all
students, rather than concentrating on subgroups of children such as high-
risk youth or children with disabilities. The report highlighted the failure
of education to ameliorate social problems and blamed past policies for
producing mass mediocrity in education, which supposedly resulted in the
decline of authority and standards in schools.
Subsequently, the focus of most federal, state, and local policy switched to
the improvement of curriculum, school-based management, tightening of
standards and discipline, and the establishment of academic goals and
assessments. School-based management emphasized a structural shift
away from bureaucratic boards of education to local forms of control. New
policies were developed to engage parents, teachers, and administrators in
decision-making processes. Teacher empowerment, a concept closely
related to school-based management, was emphasized as a way to give
teachers more decision-making power within schools. In addition, school
choice options, such as vouchers, charter schools, and magnet schools,
were created to provide parents with alternatives to the traditional public
school offerings.
The EHA was renamed the Individuals with Disabilities in Education Act
(IDEA) in 1990, and “social work services” were added for the first time
in the list of possible related services. The ESEA was reauthorized again in
1994 as the Improving America’s Schools Act. That reauthorization
included the Safe and Drug-Free Schools and Communities Act to promote
safe and drug-free learning environments. The Act also supported
linguistically diverse children and promoted the inclusion and participation
of women in all aspects of education. These funds were used for whole
school reform, compensatory education, remediation for the country’s
most disadvantaged children, and free and reduced-price lunches for
children in need. Partially because the discipline provisions in IDEA made
expelling a student with a severe emotional disturbance nearly impossible,
the Gun-Free Schools Act of 1994 was passed, which allowed ESEA funds
to be given only to those states that adopted zero-tolerance policies for
weapons on school grounds. Public and political concern over discipline-
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related policies also heightened in the mid-1990s with the outbreak of
mass shootings in schools (Jenson & Howard, 1999). This heightened
awareness of the safety risk in the school environment resulted in the
expansion of zero-tolerance policies for less severe infractions. Alternative
schools and increased school security strategies were also implemented to
address school safety issues. However, a substantial body of evidence
suggests that exclusionary discipline measures such as office referrals,
suspension and expulsion, additional security, and other punitive
alternatives exacerbate the very problems they are intended to address
(Skiba, 2002). Furthermore, the evidence supports that children of color,
particularly African Americans, are disproportionately represented among
the students receiving such discipline, which is also evidence of
institutional biases inherent in the use of exclusionary discipline (Skiba,
Michael, Nardo, & Peterson, 2000). The overreliance on punishment and
exclusionary practices in the presence of convincing evidence to suggest
the practices are ineffective has resulted in the development of policies
during the past decade that mandate the use of evidence-based, or
empirically supported, practices.
Head Start, which has served as a laboratory for a variety of prevention,
early intervention, and program evaluation research since its inception in
1965, was expanded in 1995 (Love, Tarullo, Raikes, & Chazen-Cohen,
2006). Specifically, Early Head Start was launched to expand Head Start
services to pregnant women and to children during the birth-to-3-year
period, thereby providing earlier opportunities for preventive
interventions. Federal appropriations for Head Start tripled during the
1990s, both to increase the number of children served and to improve the
quality of programs, but funding has remained level since the early 2000s.
In fiscal year (FY) 2013, the Head Start and Early Head Start programs
served nearly 1 million children and pregnant mothers (Administration for
Children and Families, 2013).
Finally, in 1997, the IDEA was again reauthorized, focusing on ensuring
that children with disabilities were exposed to positive, proactive
interventions. Specifically, IDEA recommended certain measures for any
student whose behavior challenges impeded his or her ability to learn. The
first step was for qualified professionals to conduct a functional behavioral
assessment of the student and then construct a behavior intervention plan
based on that assessment. In addition, a new or revised behavior plan was
mandated after a child with a disability had been suspended for more than
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10 days or before a change of placement to a more restrictive setting (i.e.,
alternative classroom or school). IDEA was also noteworthy for mandating
the inclusion of parents in the planning process for their child.
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Education Policy From 2001 to 2010
The momentum of educational reforms in the 1990s culminated in the
passage of the 2001 No Child Left Behind Act (NCLB). NCLB is the most
sweeping federal reform in education since ESEA was passed in 1965.
Technically, NCLB was the most recent reauthorization of ESEA.
However, NCLB added many new initiatives. For example, NCLB was
designed to create a stronger, more accountable education system, to
change the culture of education, and to use evidence-based strategies that
have been determined effective through rigorous research. Rather than
providing specific resources for at-risk youth, NCLB proposed assisting
children and youth by holding them accountable to high educational
outcomes and standards. NCLB required each state to set clear and high
standards and to put an assessment system in place to measure student
progress toward those standards (Paige, 2002). Specifically, NCLB
required states to test all students annually in Grades 3 through 8 and once
in Grades 10 through 12 in reading and math. Scores reported by states
must be disaggregated by poverty, race and ethnicity, disability, and
English-language proficiency so that potential achievement gaps can be
identified. Schools that fail to make adequate yearly progress toward
identifiable goals are identified for improvement and are subject to
corrective action (Paige, 2002). NCLB mandates that teachers use
strategies that have been shown to be effective. In addition to its emphasis
on early reading programs, NCLB is noteworthy for its attention to the
critical role that parents play in children’s educational experiences. NCLB
has dramatically affected educational practices, which now place a
premium on students meeting standards of learning and assessment and on
school-based management, teacher empowerment, and school choice (e.g.,
vouchers, magnet schools, charter schools, and privatization options).
The Individuals with Disabilities Education Improvement Act of 2004, a
reauthorization of PL 94-142, continued the trend of promoting the
adoption of effective interventions and placed a premium on primary
prevention by altering substantially the screening and identification
procedures for children with learning disabilities. Specifically, the Act
permits school districts to use a process that determines if the child
responds to scientific, research-based intervention as a part of the
evaluation procedures used to assess functional capacity. This modified
method can replace assessment using the discrepancy between ability and
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achievement to identify students with learning difficulties, but data from
this process must be only one component of a comprehensive evaluation.
This approach, referred to as Response to Intervention, has been applied to
academic and behavioral supports in special and routine education.
Batsche et al. (2005) defined Response to Intervention as the practice of
(a) providing effective instruction and interventions based on students’
needs and (b) regularly monitoring students’ progress to guide decisions
about changes in instruction or goals. The model suggests that more
intensive interventions should be considered for individual students based
on their response (or lack thereof) to less intensive, high-quality
interventions.
In 2007, the U.S. Supreme Court struck down voluntary student
assignment plans in Louisville, Kentucky, and Seattle, Washington,
thereby continuing and extending the trend toward resegregation in public
schools. In the 2007 case, Parents Involved in Community Schools v.
Seattle School District No. 1, the petitioners contended that assigning
students to schools solely to achieve racial balance in the schools was a
violation of individuals’ rights guaranteed under the 14th Amendment
(e.g., Equal Protection Clause) as well as the Civil Rights Act of 1964. The
Louisville and Seattle districts argued unsuccessfully that educational and
social benefits such as socialization and good citizenship are derived from
an educationally diverse learning environment and that because racial
diversity was their primary interest, promoting that interest using race-
conscious criteria alone was necessary and justified. Although the justices
were sharply divided in a 5–4 vote, the Court’s opinion allows districts to
use race-conscious measures so long as such measures do not use race to
treat individual students differently “solely on the basis of a systematic
individual typing by race” (Parents Involved in Community Schools v.
Seattle School District No. 1, 2007, p. 7). Even though the decision
appears likely to result in increased educational resegregation, it does not
overtly forbid school districts seeking diversity to pursue that goal by
using race-conscious means.
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Educational Policy From 2011 to 2014
Education policy has been significantly affected by the deepening divide in
the appropriate role of government that has occurred between
conservatives and liberals in the past several years. The advent and
influence of the Tea Party within the Republican Party has further fueled
an already highly charged political climate. Republicans generally support
leaving education decisions to states and local school districts, including
choices about how federal dollars will be spent. They assert that local
communities and school administrators are in the best position to know the
demographics and needs of their students and thus fewer federal mandates
should be attached to how funds are used. On the other hand, Democrats
support stronger oversight by the federal government on the basis of past
inequities in access to quality education and disparities in outcomes across
student populations. They believe a strong federal presence, including
investment in education, is critical to ensuring success for all students.
Those differences in philosophy have affected discussions on a number of
key education issues. Policy themes emerging in the last few years focus
on early childhood education, school choice, college- and career-readiness,
and standards and high-stakes assessments. The importance of evidence-
based practice, professional preparation and evaluation, and school
improvement and reform has been at the forefront in many of these
discussions. The long delay in reauthorizing the ESEA (known as the
NCLB in its current form) has compromised many policy discussions and
decisions. While Congress has not come to consensus on what changes to
the law are needed, there is general agreement the law as enacted in 2002
has not been successful in reducing the achievement gap for the four
subgroups named in the law (i.e., disadvantaged students, racial and ethnic
minorities, students with disabilities, and English language learners).1
Early Childhood Education.
Congress has begun to take a much closer look at the impact of early
education in recent years. The political aspect of the debate focuses on
whether current programs are adequate, and perhaps in some cases even
duplicative, or whether a more expansive approach and investment in early
childhood education is necessary. President Obama proposed the
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Preschool for All program in his FY 2014 and FY 2015 budgets. The FY
2014 budget proposal included a request of $75 billion over 10 years ($1.3
billion for FY 2014) to support state efforts to provide access to high-
quality preschool for all 4-year-old children from low- and moderate-
income families. Preschools would be required to hire teachers with
bachelor’s degrees; provide ongoing professional development; have low
staff–child ratios and class sizes; provide a full-day program; and offer
developmentally appropriate, evidence-based instructional programs as
well as comprehensive support services for children. In FY 2014, Congress
approved $250 million under the Race to the Top authority for competitive
grants to states to create or expand high-quality preschool programs.
Preschool for All also calls for a new Early Head Start-Child Care
Partnership program, administered jointly by the U.S. Department of
Education and the U.S. Department of Health and Human Services to
expand high-quality learning to infants and toddlers. The intention of this
initiative is to link Early Head Start programs with center-based and
family child-care programs that agree to meet Early Head Start program
standards.
School Choice.
The U.S. House of Representatives, under Republican leadership, passed
the Student Success Act in July 2013; this act offers block grants through
several current ESEA programs and expands use of funds for private
school options. Requirements for state standards and high-stakes tests,
including public reporting, are continued, while any requirements related
to highly qualified teachers are eliminated. In October 2013, the Senate
Health, Education, Labor, and Pensions Committee passed the
Strengthening America’s Schools Act. This proposed bill requires the
adoption of academic standards and continuation of testing and is a more
comprehensive federal approach to education. The proposed legislation
also requires states to identify certain categories of schools for
interventions. The bill has yet to be considered by all members of
Congress.
College and Career Readiness.
Federal guidelines require states to adopt college- and career-ready
standards in mathematics and reading/language arts and to conduct
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assessments to measure growth for students in Grades 3 through 8 and at
least once in high school. In addition, rather than the federally imposed
accountability provisions of the law, states must develop their own
differentiated recognition, accountability, and support in all school
districts. Receipt of a waiver from these guidelines also requires adoption
of new teacher and principal-evaluation systems, allowing states to adopt
one system to be used in all its districts or flexibility for school districts to
adopt their own evaluation plans. States with waivers may apply for an
extension of the waiver for the 2014–2015 school year as a full
reexamination of the ESEA seems unlikely in the immediate future.
Standards and High-Stakes Assessments.
In recent years, the education debate in Grades K through 12 has centered
on Common Core State Standards (CCSS). CCSS is a bottom-up effort,
rather than a federal program, initiated by the Council of Chief State
School Officers. Federal involvement in CCSS began when the U.S.
Department of Education tied Race to the Top funding to the adoption of
rigorous state standards, which many people viewed as an endorsement of
CCSS. However, CCSS remains a state-driven process with more than 40
states having adopted these standards, despite critics who label CCSS as
national standards or a national curriculum. Adoption of these standards
remains voluntary. As the political cycle moves toward the next
presidential election, the debate about whether CCSS should be a required
federal program is likely to continue.
Next Steps.
The Obama administration, under the leadership of the U.S. Department of
Education, has taken an activist role in education policy. This activism has
drawn criticism at times from both sides of the political aisle. In addition
to the ESEA waivers, the Administration established several competitive
grant programs first funded under the American Recovery and
Reinvestment Act in FY 2009, including Race to the Top (RTTT) and
Investing in Innovation (i3). Several states have received significant
federal funding under RTTT for which they promised to adopt rigorous
academic standards and use results on aligned high-stakes tests in
evaluating teacher and principal performance. States also agreed to allow
expansion of charter schools and use of alternative certification for
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teachers. The Obama administration has proposed different foci for RTTT
grants in subsequent fiscal years, including a school district rather than
state competition for funds and another iteration targeting early childhood
programs. A proposal to develop an RTTT for higher education was not
funded by Congress. A proposal called Race to the Top—Equity and
Opportunity has yet to be debated by the full Congress. Critics of this
initiative say that states have not been able to deliver on past promises,
citing little improvement in student outcomes. Advocates believe investing
funds in foundational programs such as ESEA and the IDEA will provide
states with the resources necessary to improve academic achievement.
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Summary of Federal Policy
Public education in the United States has witnessed a number of reform
movements in the past century. From the end of World War I until the
mid-1940s, education policy focused on equity and attempted to narrow or
eliminate the achievement gap between advantaged and disadvantaged
youth. From the 1950s to the 1970s, issues of equity dominated federal
education policy. However, policies favoring equity in education were not
without criticism during these years; many critics of equity policies
believed intellectual and academic goals were being sacrificed for social
ends. These attacks created fertile ground for alternative strategies to
spring forth, such as the adoption of standards, curriculum reform, and
accountability systems. Since the mid-1970s, most education policies and
programs have been more closely aligned with the standards-based
education movement, which has focused more heavily on the use of
standardized assessment as a measure of improvement, possibly to the
detriment of addressing non-academic barriers to learning.
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Principles of Risk, Protection, and
Resilience in Education Policy
Evidence exists to both support and criticize the effectiveness of the
policies and programs discussed in the prior section. Next, we briefly
evaluate the extent to which historic and current educational policies and
programs have been based on principles of risk and resilience. We begin
with those that are clearly within this framework.
Several policies illustrate the relationship between risk, protection, and
educational approaches to change and reform. For example, Head Start,
IDEA, and NCLB emphasize principles that are consistent with the models
of risk and resilience discussed earlier in this chapter. Head Start targets
youth who are at highest risk for academic failure because of low
socioeconomic status. The program attempts to bolster school readiness
skills, and this approach is consistent with evidence suggesting that the
preschool years represent a critical developmental phase for prevention
and early intervention services (Reid, 1993). Although IDEA permits
intervention with children before they enter school and targets children at
risk of developing disabilities and school failure, most IDEA funding is
intended for children who are already identified as having a disability. In
addition, NCLB attempts to raise awareness of the achievement gap and
encourages school districts to address the gap by requiring states to report
standard test scores disaggregated by poverty, race/ethnicity, disability,
and English-language proficiency. The recent NCLB emphasis on
standards-based education sets high academic expectations for all students,
and such expectations are an identified protective factor against school
failure and dropout (Furlong & Morrison, 2000).
The emphasis on evidence-based prevention efforts highlighted in IDEA is
compatible with risk and protective factors. This emphasis should result in
improvements to the learning environment, such as school connectedness,
school climate, teacher expectations, family involvement, and community
services to support students and families. Many of these improved
environmental conditions have been highlighted previously as key
protective influences for children (Haberman, 2000; Hawkins, Catalano,
Kosterman, Abbott, & Hill, 1999).
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Other policies appear to ignore principles of risk and resilience at best and
to undermine or contradict such principles at worst. Specifically, standards
such as those promoted in NCLB and CCSS have the potential to be
counterproductive to children and youth who are not able to compete
academically. Standards-based policies may actually be contrary to
principles of risk and resilience because those policies may lower teachers’
expectations of students and subsequently have a negative impact on
achievement. In addition, zero-tolerance policies, particularly those that
apply to minor infractions, have been shown to increase the risk of poor
outcomes among high-risk children in general and among youth of color
specifically (Skiba & Peterson, 1999).
In sum, the application of risk and protective factors to the design of
educational policy is inconsistent. Some policies (e.g., the Compulsory
School Attendance Act, the Head Start Act, EHA, and IDEA), court cases
(e.g., Brown v. Board of Education), and programs (e.g., Head Start and
special education) support the constructs of risk and resilience. Other
policies (e.g., NCLB and Gun-Free Schools Act) and court cases (e.g.,
Plessy v. Ferguson and Milliken v. Bradley) ignore or may even reject the
constructs of risk and resilience. New and sustained efforts are needed to
implement a risk-and-resilience framework in education policy.
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Using Principles of Risk, Protection, and
Resilience to Achieve Integrated
Education Policy
Principles of risk, protection, and resilience can be applied to education
policy in two fundamental ways. One option requires policymakers to
focus efforts on youth who are most likely to experience school adjustment
and achievement problems. Such a strategy tends to concentrate program
and policy efforts on youth from disadvantaged backgrounds because
socioeconomic status is a key risk factor for educational failure (Brooks-
Gunn & Duncan, 1997). A second approach uses knowledge of risk,
protection, and resilience to design promotive educational policies and
programs that are beneficial for all children, regardless of risk exposure.
We begin our discussion with policy recommendations for programs that
promote healthy outcomes for all children and youth.
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Promotive Interventions and Strategies
We recommend educational policies and programs that promote social
competence, develop caring relationships, and create high expectations for
all students. Policies that promote participation in positive academic and
social groups, enhance school bonding or connectedness, and create
positive and safe learning environments should receive priority in national
policy and program debates. Simply adopting effective promotion
interventions and strategies is not sufficient to produce sustainable change.
Specific promotion strategies include the following:
Establishing positive behavioral and rigorous academic expectations
for all students
Making environmental arrangements and providing active supervision
Applying consequences to encourage desired behavior and discourage
undesirable behavior
Developing school and community linkages
Developing school and home linkages (Frey, Lingo, & Nelson, 2010)
Other programs designed to positively affect school culture, such as
conflict resolution, peer mediation, and antibullying strategies, illustrate
the growing emphasis on changing peer and institutional culture and are
likely to have protective value. Recent research has demonstrated that
many strategies and programs work for a short time but that effects quickly
fade; thus, there is a need to learn more about the specific conditions and
settings in which intervention effects can be sustained over time (Duncan,
2009). A report by the Center for Mental Health in Schools (2002)
indicated that school-based reform efforts have been unsuccessful because
projects and services designed to remove barriers to learning are usually
viewed as supplementary services. The result may be seen in the
fragmentation of services, marginalization of professionals, and overall
inadequacies in policy reform. Specialized instructional support personnel
(SISP), including school social workers, school psychologists, speech
language pathologists, school nurses, and school counselors, must be
trained to support the primary mission of schools. Furthermore, policies
are needed to enhance standards while promoting reasonable professional-
to-student ratios for all schools and students.
210

A critically important element in affecting positive change in schools is the
process of enculturation, or “the manner in which a school embeds a
systems change process into its own unique culture, assumes ‘ownership’
of the process, and has the process become a part of business as usual at
the school” (Sailor, Wolf, Choi, & Roger, 2009, p. 664). Policies and
programs should strive to increase service cohesion by addressing the need
for multiple interventions within schools in an integrated fashion. Walker
and colleagues (1996) suggested that prevention efforts have generally
lacked coordination and integration because no comprehensive strategic
plan for coordinating and linking behavioral supports existed at the school
or district level. Evidence from efficacious school-based practices also
supports the need to attend to interactions among key individual and
environmental factors. Over the past several decades, our knowledge of
“what works” in school-based prevention programs has increased
dramatically (Jenson & Bender, 2014). For example, it is widely believed
that interventions are more effective if they are integrated and coordinated
with other interventions along a continuum of support representing
primary, secondary, and tertiary levels of intervention (Dunlap, Sailor,
Horner, & Sugai, 2009). Within this continuum, the promise of primary
prevention is increasingly emphasized because it not only is efficient and
effective but also increases the likelihood that the needs of students with
elevated risk status will be targeted for intervention. We believe that
targeted educational policies and programs should focus on schools that
have high percentages of students living in poverty and that identification
of and intervention with high-risk students should occur as early as
possible. Examples of targeted policies and programs are reviewed next.
211

The Role of Targeted Interventions and
Strategies
212

Redistribution of Tax Dollars to Support Schools in
Low-Income Neighborhoods
The most obvious recommendation for using principles of risk and
protection in targeted educational policy may involve school financing.
Nearly 50% of school funding comes from local property taxes (Nelson et
al., 2004). Therefore, adequately funding schools in low-income
neighborhoods is an ongoing and persistent challenge to policy officials
and school administrators. To address this problem, a larger percentage of
school financing may need to come from state and federal taxes rather than
from local tax bases. Equalizing the funding base between advantaged and
disadvantaged communities is not likely to produce equal educational
outcomes, given variations in individual, family, neighborhood, and
community risk factors across schools and communities. Furthermore,
providing more money to disadvantaged schools would require people in
wealthy districts to partially fund poor districts, which is a practice that
runs counter to the beliefs of many Americans. However, such a strategy
may well be necessary to create positive change and promote effective
policies based on principles of risk and protection.
213

Early Identification and Intervention at the Point of
School Entry
Between 9.5% and 14.2% of children up to 5 years old experience social
or emotional problems that adversely affect their functioning and
development (e.g., school readiness skills), with children living in poverty
being more likely to experience these problems (Brauner & Stephens,
2006; Duncan, Brooks-Gunn, & Klebanov, 1994). Whether in preschool or
early elementary school, the importance of early screening for risk factors
that lead to poor educational outcomes cannot be overstated. Given the
proper tools, it requires minimal effort for educators to predict—with great
accuracy—which children will require extensive academic or behavioral
supports. Systemwide screening, particularly for emotional and behavioral
indicators leading to school failure, may be a cost-effective strategy to
improve educational outcomes. We believe that school readiness skills
should be the primary focus of policy reforms and recommend increased
funding for intervention programs that target these skills.
As noted, several federal programs, such as those promoted through Title
IV and Title V funds, provide nonspecific funding to address a wide range
of educational issues. Title I is consistent with the risk-and-protection
framework because the primary criteria to access these funds are linked to
students’ socioeconomic status. However, there is no mandate requiring
that interventions created with these funds address known risk and
protective factors. In addition, there are no mandates requiring the funds,
or a portion of the funds, to be used for evidence-based practices.
Policymakers should address these gaps in funding mandates to ensure that
funds are used for effective early intervention programs that have
sustained effects. For example, early intervention programs that focus on
family-risk factors are particularly promising; Duncan and Brooks-Gunn
(2000) reported that interventions targeting parenting practices can
mediate up to half of the impact of poverty on child development.
The presence of high-quality primary prevention programs is increasingly
being recognized as a necessary prerequisite for more intensive
interventions (Greenberg, 2004; Scott, Anderson, Mancil, & Alter, 2009).
In sum, a series of policy and system reforms is needed to improve the
condition of the country’s schools. Principles of risk, protection, and
resilience promotion offer a framework for thinking more systematically
214

about a continuum of education policy defined by levels of service.
Moreover, integration of policy and programs across other systems of care
should be a part of such a continuum.
215

Targeted and Intensive Strategies to Integrate
Education Policy
It is both important and challenging to envision integrating educational
policies and programs across service domains such as child welfare,
substance abuse, mental health, juvenile justice, developmental
disabilities, and health. In many respects, the compartmentalized approach
used to channel federal and state funding as well as the isolated
educational training of professionals in each problem area runs counter to
the vision of cohesive integrated services. Given the number of children
involved in the educational system, the number of hours children spend in
school, and the numbers of families and communities that can be linked by
mobilized schools, we believe that the education system is an ideal context
in which to identify children in need of services across many domains. The
following case study demonstrates how services can lack integration and
coordination.
Cross-system funding for education, health, and social services may be one
means for achieving integrated policy. Cross-system funds could be used
to
provide early screening to identify children most at risk;
promote school readiness skills for high-risk youth;
deliver comprehensive services and case management to children who
display signs of adjustment problems before the second grade;
provide seamless access to and provision of educational, health, and
social services through support service providers and family resource
or youth service centers; and
implement primary prevention programs at key developmental stages.
An integrated approach to service delivery would be very beneficial to
youth such as Jeremy and his foster parents in several ways. First, if the
services provided by his teacher, learning specialist, school social worker,
counselor, caseworker, probation officer, and psychiatrist were monitored
and coordinated, each provider would know what other services Jeremy
was receiving and how he was functioning in other aspects of his life. Such
an approach could reduce redundancy in service provision and likely
would be more cost-effective. An integrated service-delivery system
would facilitate communication between professionals and allow each
216

provider easy access to the information the other providers possess.
Furthermore, an integrated approach would also produce one set of goals,
one treatment plan, and one system to evaluate progress. In addition, an
integrated strategy would likely make it easier for his foster parents to
attend the requisite meetings associated with each service. Last, it is
exciting to imagine the range and quality of services that could be put in
place if the requisite departments of education, juvenile justice, and child
welfare shared costs, problem ownership, and approaches for all the
services directed toward complex cases such as Jeremy’s. Most important,
if an integrated approach had been in place to offer assessment and service
delivery early in Jeremy’s life, it is possible his early antisocial behavior
and school failure would have raised warning flags that might have altered
Jeremy’s path to later destructive outcomes.
217

A Case for Integrated Service Delivery
Jeremy is a 14-year-old male who was physically and sexually abused as a
young child. His mother was incarcerated when he was 6 years old, and her
parental rights were terminated when Jeremy was 8 years old. He
experienced six out-of-home placements before age 10, when he was finally
placed in a stable foster care home with loving and supportive parents.
Jeremy has struggled socially and emotionally in school since kindergarten,
but he was not identified for special education services under the severe
emotionally disturbed (SED) category until his current foster parents
advocated for an evaluation at age 11 years. He has done well in some
settings, but he was suspended 13 times last year during his first year of
middle school. Jeremy has been convicted twice for misdemeanor charges
and is currently on probation.
He receives a variety of support services from a learning specialist and a
school social worker at his middle school, a counselor at the local mental
health agency, and a child protection caseworker. Jeremy reports to a
probation officer regularly and sees a psychiatrist yearly for medication
monitoring. These individuals have never met together, and many of the
services provided to Jeremy are duplicated across settings.
218

Concluding Remarks
Education policy in the past century has vacillated among liberal,
progressive, and conservative ideologies, which has led to inconsistent and
constantly changing priorities and practices in schools. According to
Anyon (1997), education policy continues to revolve “around the tensions
between equity and excellence, between the social and intellectual
functions of schooling, and over such questions as, ‘Education for whom
and support for whose interests?’” (p. 87). Policy directed at the nation’s
schools has lacked a guiding set of consistent values and principles.
Principles of risk, protection, and resilience offer real promise as a
systematic method of designing and enhancing education policy and
programs based upon such policy. Policymakers at all levels would do well
to incorporate these principles into the nation’s struggling educational
system.
219

Questions for Discussion
1. What are the major risk factors for school failure? Which of these risk
factors should receive the most attention in educational policy and why?
2. What educational policies and programs over the past 100 years have best
served the concept of risk and resilience? Why?
3. What have been the major trends in policy and practice reform since 2000?
4. What factors inhibit the integration of policies and programs across problem
domains?
5. What are some possible solutions to the barriers to the integration of
policies and programs across problem domains?
220

NOTES
1. To address this concern, the U.S. Department of Education offered
states the option of applying for waivers of certain provisions of NCLB,
including loosening requirements for determining adequate yearly progress
and student proficiency, identification of schools for improvement or
specific corrective actions, and highly qualified teacher plans. Certain
provisions of the law specifically cannot be waived, including civil rights
requirements. Forty-three states, the District of Columbia, and Puerto Rico
have received flexibility waivers.
221

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Additional Reading
Fraser, M. W., Kirby, L. D., & Smokowski, P. R. (2004). Risk and
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childhood: An ecological perspective (2nd ed., pp. 13–66.). Washington,
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positive behavior support. New York: Springer. doi:10.1007/978–0-387–
09632–2
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for youth with antisocial and violent behavior. Exceptional Children, 66,
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Bethesda, MD: National Association of School Psychologists.
230

Web-Based Resources
Center on Education Policy, http://www.cep-dc.org/
Education Commission of the States, http://www.ecs.org/
Education Policy Institute, http://www.educationalpolicy.org/
Education Policy and Leadership Center,
http://www.eplc.org/about_description.html
231

Home

Your Education Policy Team.

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Chapter 5 Child Mental Health Policy
Promise Without Fulfillment?
Mary E. Fraser
Paul Lanier
Children and their families are our nation’s most valuable and perhaps
most endangered resource. Today’s children and families face
unprecedented challenges, including exposure to persistent poverty,
alcohol and other drugs, and violence. It is no wonder that one of every
five children and adolescents in the United States has a diagnosable
emotional or behavioral disorder that can lead to school failure, alcohol or
other drug use, violent conduct, or suicide (Burns et al., 1995; Costello,
Mustillo, Erkanli, Keeler, & Angold, 2003). The prevalence and impact of
mental, emotional, and behavioral disorders makes children’s mental
health a major public health concern in this country (Perou et al., 2013).
According to the Surgeon General’s (1999) report on mental health, at
least 1 in 10 young people, or as many as 6 million youth, meet the criteria
for serious emotional disturbances (SED). Prior prevalence estimates have
ranged from 9% to 26% (Brauner & Stevens, 2006); the most recent
research indicates a 22.2% lifetime prevalence of SED among adolescents
(Merikangas et al., 2010) and a 5.7% prevalence in school populations (Li,
Green, Kessler, & Zaslavsky, 2010). Children and adolescents with SED
have symptoms that substantially disrupt their social, academic, and
emotional functioning. Many children are in out-of-home placements or
are at risk for such placement. Although many youth with SED have
multiple social and health problems that lead to referral or involvement in
the mental health, special education, child welfare, and juvenile justice
systems (Brauner & Stephens, 2006; Brendenberg, Freidman, & Silver,
1990), only 59% of children with mental health needs receive any type of
formal mental health care (Commonwealth Fund, 2006).
Studies indicate that the prevalence of SED is higher among certain groups
of children. Children suffering from SED are more likely to be male, low-
income, and from a racial/ethnic minority group (Mark & Buck, 2006;
Wagner, Kutash, Duchnowski, Epstein, & Sumi, 2005). Among special
232

education students, those identified as having an emotional disturbance
have poorer social skills, communication skills, cognitive and academic
functioning, and are more likely to change schools and be suspended or
expelled (Wagner et al., 2005).
The 7-year National Adolescent and Child Treatment Study (NACTS)
identified a number of risk factors that are common among youth with
SED. Researchers leading the investigation found that youth with SED had
poorer social skills, lower academic achievement, less financial
independence, and more limited interpersonal relationships than youth
without SED (Greenbaum et al., 1996). In addition, the study showed that
youth with SED were more involved in substance abuse and illegal activity
than youth with no SED symptoms.
Without comprehensive policies and interventions that diminish risk and
strengthen protection for youth with SED, the adult outcomes for these at-
risk youth can be expected to be poor. This forecast is supported by a body
of literature on risk factors associated with emotional and behavioral
problems in childhood as well as a growing body of evidence on protective
factors that mitigate the effects of these problems. Because children with
SED are found in all public child-serving agencies, public policies that
promote cross-agency, integrated approaches to providing effective risk
and protection interventions are needed.
This chapter reviews the literature on risk and protective factors related to
emotional and behavioral disorders in children and adolescents and
summarizes the complex evolution of child mental health policy in the
United States. Two case examples of state policies that were designed to
improve and integrate services for youth with SED are described. Finally,
suggestions are made for future policies that combine the risk and
resilience perspective with integrated service structures.
233

Prevalence of Child Mental Health
Disorders
A defining feature of the mental health field is the use of a system of
classification that relies on diagnostic categories linked to service
strategies, both psychosocial and pharmacological. One of the primary
classification sources used in the United States is the Diagnostic and
Statistical Manual of Mental Disorders (DSM), published by the American
Psychiatric Association (2000). This manual was recently updated with
publication of its fifth edition (DSM-5) but most recent studies are based
on the fourth edition (DSM-IV-TR). Table 5.1 displays the most common
DSM-IV-TR diagnoses found in children and youth. The first column
shows the diagnostic prevalence rates for each disorder within the
subgroup of youth who have SED based on findings from the NACTS
study. Public health surveillance of mental disorders among children has
improved in recent years, providing valuable updates to previous general
population prevalence estimates. The second column includes lifetime
prevalence estimates of disorders for children aged 3 to 17 years from the
2007 National Survey of Children’s Health (NSCH) and the 2011 National
Health Interview Survey (NHIS). The third column includes lifetime
prevalence estimates for adolescents aged 13 to 18 years from another
nationally representative survey using a diagnostic interview, the National
Comorbidity Study-Adolescent Supplement (NCS-A) (Merikangas et al.,
2010).
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Greenbaum et al. (1996)
Perou et al. (2013)
Merikangas et al. (2010)
Anxiety is the most common mental health problem found in childhood
and adolescence (Merikangas et al., 2010). Anxiety manifests in a variety
of forms, including phobias, separation anxiety disorders, generalized
anxiety disorders, and obsessive-compulsive disorders. Phobias are
unreasonable fears. One of the most common phobias among children and
adolescents is social anxiety disorder, which is characterized by an
unremitting fear of embarrassment in social and performance situations
that sometimes leads to full-blown panic attacks. Children and adolescents
with this disorder tend to avoid social situations and try to avoid going to
school.
Separation anxiety disorder occurs in about 8% of adolescents
(Merikangas et al., 2010) and is characterized by irrational fears that
parents will be killed or taken away, which may lead to clinging behavior,
difficulty falling asleep at night, and inability to participate in school and
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social events away from home. The disorder can last for many years and
can be a precursor to panic disorder and agoraphobia experienced as an
adult.
Generalized anxiety disorder is characterized by excessive and persistent
worry. Children and adolescents with this anxiety disorder tend to be
perfectionists and insecure.
Obsessive-compulsive disorder is characterized by recurrent, time-
consuming, obsessive, or compulsive behaviors that cause distress or
impairment. The obsessions may be intrusive images, thoughts, or
impulses. Compulsive behaviors, such as hand washing and other cleaning
rituals, are considered to be attempts to displace obsessive thoughts.
Prevalence estimates range from 1% to 2.3% for children and adolescents
(Perou et al. 2013; APA 2000).
Posttraumatic stress disorder (PTSD) is a prolonged, pathologic anxiety
that occurs in both adults and adolescents following a severe trauma. The
onset of PTSD in adolescence is common and may impair the acquisition
of life skills needed for independent, self-sufficient living. PTSD is
common among youth who have been victims of physical or sexual abuse
and who have witnessed violence in their homes or neighborhoods. An
estimated 5% of adolescents suffer from PTSD in their lifetime
(Merikangas et al., 2010).
Depression in children and adolescents usually presents in two different
forms. A diagnosis of major depressive disorder requires either a
depressed, irritable mood or a diminished interest or pleasure in activities.
Accompanying symptoms must include some combination of significant
weight change, either gain or loss; sleep disturbance; loss of energy or
feelings of extreme fatigue; psychomotor agitation or retardation; feelings
of worthlessness or inappropriate guilt; diminished ability to think or
concentrate; and recurrent thoughts of death. These symptoms must be
present for at least 2 weeks and produce significant functional impairment.
Diagnostic criteria for dysthymia also require a depressed or irritable mood
that has continued for a period longer than 1 year and requires many of the
same accompanying symptoms as major depression. Although the
description of dysthymia appears similar to that of major depressive
disorder, the symptoms of major depressive disorder are more debilitating
than those of dysthymia. However, dysthymia tends to be chronic, more
persistent, and longer lasting than major depressive disorder.
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A disruptive behavior disorder, conduct disorder, is based on a repetitive
and persistent pattern of behavior in which the basic rights of others or the
major age-appropriate social norms or rules are violated. Characteristic
behaviors of conduct disorder include aggression toward persons or
animals, destruction of property, deceitfulness, and theft. Girls with a
conduct disorder are prone to early sexual activity and homelessness.
About 40% of youth with a conduct disorder develop an antisocial
personality disorder and become involved in the criminal justice system.
Those with an early onset of conduct disorder have a worse prognosis and
are at higher risk for adult antisocial disorder. Conduct disorder frequently
co-occurs with attention deficit and hyperactivity disorder.
Oppositional defiant disorder (ODD) is typically characterized by problem
behaviors such as persistent arguing, habitual fighting, and frequent loss of
temper. Children and adolescents with this disorder frequently test limits,
deliberately refuse to comply with adult requests, and intentionally annoy
others. These behaviors lead to difficulties with family members, peers,
and teachers. ODD is sometimes a precursor of conduct disorder.
As implied by the name, attention deficit and hyperactivity disorder
(ADHD) is made up of two distinct sets of symptoms. Although these two
problems often co-occur, one set of symptoms can be present without the
other. Children with attention deficit disorder have difficulty paying
attention and are easily distracted. These children are often disorganized,
and they have difficulty following through with tasks. The symptoms of
hyperactivity include the compulsion to move that may be expressed as
fidgeting, squirming, or wriggling around when seated or getting up and
moving around the room. Children with ADHD often perform poorly at
school and have difficulties with peer relationships. Hyperactive behavior
is often associated with the development of conduct and oppositional
defiant disorders.
Eating disorders, such as anorexia nervosa and bulimia nervosa, are the
most fatal mental disorders, with 10% of cases ending in death (Steiner &
Lock, 1998; Arcelus, Mitchell, Wales, & Nielsen, 2011). The prevalence
of eating disorders is a particular concern because these disorders are
among the most common chronic illnesses of adolescent girls, following
obesity and asthma (Lucas, Beard, O’Fallon, & Kurland, 1991; Stice &
Agras, 1998). Anorexia nervosa is characterized by a distorted body image
that triggers an intense fear of gaining weight. The symptoms of bulimia
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nervosa include recurrent episodes of binge eating and purging.
Although rare, childhood schizophrenia is a serious illness. Children with
schizophrenia may experience auditory and visual hallucinations and feel
detached from the real world. It is sometimes difficult to distinguish
between childhood schizophrenia and autism. Onset of adult schizophrenia
usually occurs between puberty and young adulthood. Children with an
earlier onset of schizophrenia generally experience symptoms that are
longer lasting and more severe (American Psychiatric Association, 2000).
In this chapter, the terms serious emotional and behavioral disorders and
SED are used interchangeably. Although not diagnostically specific, either
term may include any or several of the diagnostic categories described
above. However, readers should note that simply having a diagnosis of one
of these disorders does not mean that a child is seriously emotionally
disturbed or impaired. Moreover, it is important to recognize that the
different diagnostic categories relate to different risks and intervention
strategies. For example, children with eating disorders differ markedly
from those with conduct disorders. Thus, child mental health policies must
address a wide range of behaviors and conditions that are differentially
categorized by diagnostic labels and terms such as SED.
238

A Risk, Protection, and Resilience
Perspective on Mental Health Disorders
Allen-Meares and Fraser (2004) outlined a set of empirically supported
principles to describe the concepts of risk, protection, and resilience. These
principles inform our discussion of mental health disorders and child
mental health policy. Allen-Meares and Fraser argued that (a) identifiable
risk and protective factors exist for social and mental health problems in
childhood, (b) cumulative risk is generally more predictive of
developmental outcomes than any single risk factor, (c) some risk factors
are more responsive than others to change strategies, (d) reduction of risk
can produce improved outcomes, and (e) more salutary outcomes occur
when risk factors are reduced and protective factors are increased. In
addition, Allen-Meares and Fraser noted important differences between
protective and promotive factors. Protective factors reduce, suppress, and
buffer risk but are neutral (i.e., have no effect) in the absence of risk. In
contrast, promotive factors, which are the opposite of risk factors, operate
actively to promote positive developmental outcomes for all youths.
Universal prevention strategies focus on promotive factors, whereas
targeted interventions strengthen protective factors to reduce known risks.
We apply these definitions to the discussion that follows.
Most serious childhood emotional disorders are considered to be biosocial
in nature. Although children endure countless negative life experiences,
most children are naturally resilient. That is, when faced with adversity,
children tend to make self-righting adaptations. However, such adaptations
do not happen in isolation. Resilience results from the nexus of individual
effort and environmental conditions that facilitate adaptations. Most
people share the viewpoint that mental health problems emerge in children
and adolescents when there is a biological vulnerability combined with
exposure to adverse environmental factors (Surgeon General, 1999). The
principles of risk and resilience can be used to better understand not only
which biological and environmental factors might predict serious
emotional and behavioral disorders in children and adolescents but also
which children should be targeted for prevention and early intervention
efforts. A touch point for this chapter, these principles can also be used to
determine which protective factors should be bolstered to promote
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resilience.
240

Risk Factors
241

Biological Risk
Shown in Table 5.2, biological risk factors can occur at either the
individual or family level. Common examples of biological risk factors
include genetics, chemical imbalances, and damage to the central nervous
system through trauma or prenatal exposure to alcohol and drugs.
Researchers have established clear genetic links to some conditions,
including ADHD, mood and anxiety disorders, and childhood
schizophrenia (R. Goodman & Stevenson, 1989; Jellinek & Synder, 1998;
Maziade & Raymond, 1995; Rutter, Silberg, O’Conner, & Simonoff,
1999). Although the genetic mechanism of many disorders remains
unclear, having a parent, sibling, or even a grandparent with a mental
health problem increases a person’s odds for developing a mental disorder.
Gender is correlated with the diagnosis of certain emotional and behavioral
disorders in children. For instance, girls are at greater risk than boys for
internalizing mental health problems such as depression, anxiety, and
suicide (Spirito et al., 1993). Adolescent girls are about twice as likely as
boys to be diagnosed with mood, anxiety, and eating disorders, whereas
boys are twice as likely as girls to be diagnosed with a conduct disorder
and ADHD (Merikangas et al., 2010; Nolen-Hoeksema & Girgus, 1994;
Perou et al., 2013; Piquero & Chung, 2001; Robins, 1991; Rogers,
Resnick, Mitchel, & Blum, 1997; Ross & Ross, 1982).
Once a child is diagnosed with one disorder, the risk of having additional
mental problems and co-morbid disorders is increased. Children and youth
with a history of psychiatric disorder have been found to be three times
more likely to have a subsequent diagnosis of psychiatric disorder. It is not
unusual to see a progression from one diagnosis to another, such as from a
diagnosis of depression to a diagnosis of anxiety and from a diagnosis of
anxiety back to a diagnosis of depression. Similarly, a common diagnosis
pattern might start with ADHD and move to ODD or start with a diagnosis
of anxiety and conduct disorder and expand to include a diagnosis of
substance abuse. Sequential diagnosis may be more common among girls
(Costello et al., 2003).
Evidence supports that a child’s difficult early temperament is related to
emotional and behavioral problems later in life. Agitated and tearful
infants have been found to show symptoms of anxiety by the age of 4
242

years (Kagan, Snidman, & Arcus, 1998). Connections between difficult
infant temperaments and conduct disorder have also been observed (Olds
et al., 1998).
243

Environmental Risk
A child’s social environment is an equal—or possibly more important—
determinant of later mental health problems than constitutionally based
factors (Sameroff & Gutman, 2004). Bronfenbrenner’s (1979) ecological
model of child and adolescent development stressed the importance of
contextual factors, including families, communities, and social institutions.
Children and youth at high risk for serious emotional disorders are more
likely to be raised in environments that heighten the effects of biological
vulnerability (Caspi, Taylor, Moffitt, & Plomin, 2000; Resnick & Burt,
1996). Some of the more common environmental risks that exacerbate
vulnerability include poverty, dysfunctional family, exposure to violence,
and parental psychopathology or criminality.
Poverty is often associated with mental health problems in children and
adolescents. Children with SED have been found to be overrepresented in
low-income families (Mark & Buck, 2006). Werner and Smith (1992)
found that low parental income was the single greatest predictor of
emotional disturbances in youth under 18 years of age. Although African
American and Latino youth have also been found to be overrepresented in
SED samples (Mark & Buck, 2006), the factor of race/ethnicity, once
thought to be a strong predictor of certain emotional and behavioral
problems, loses its strength when adjusted for income (Neal, Lilly, &
Zakis, 1993; Peeples & Loeber, 1994; Robins, 1991; Siegel, Aneshensel,
Taub, Cantwell, & Driscoll, 1998). Moreover, early childhood poverty has
been shown to have an association with depression, antisocial behavior,
adolescent anxiety, and adolescent hyperactivity (McLeod & Shanahan,
1996; Pagani, Boulerice, Tremblay, & Vitaro, 1997).
Poverty is also associated with increased violence and substance abuse
(Rutter, 1985; Spearly & Lauderdale, 1983). The Children’s Defense Fund
(1995) has estimated that, each year, between 3 million and 10 million
children are witnesses to domestic violence. On the basis of a nationally-
representative survey, Finkelhor and colleagues estimated that 20.3% of
children witness family assaults in their lifetime (Finkelhor, Turner,
Ormrod, & Hamby, 2009). Witnessing violent acts can have long-term
deleterious effects on children (Jenkins & Bell, 1997).
Exposure to substantial incidents of violence can impair a child’s capacity
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for emotional regulation (Gerrity & Folcarelli, 2008). In turn, a child’s
problems with controlling his or her anger and modulating mood can
seriously complicate the child’s ability to perform in school and to develop
healthy peer relations (Fairbank, Putnam, & Harris, 2007). Child abuse and
neglect can negatively affect both neurological and psychosocial
development, including the formation of personal morals and values, the
capacity for relationships, the development of respect for social institutions
and mores, and the ability to comply with rules of social conduct (Putnam,
2006). Although the risk process is not well understood, the experience of
physical and sexual abuse increases a child’s risk for major depressive and
anxiety disorders (Dykman et al., 1997; Flisher et al., 1997; Silverman,
Reinherz, & Giaconia, 1996), conduct disorders (Livingston, Lawson, &
Jones, 1993), ADHD (Wolfe, Sas, & Wekerle, 1994), and eating disorders
(Douzinas, Fornari, Goodman, Sitnick, & Packman, 1994).
Trauma exposure is widespread. For example, a longitudinal study of
children living in a primarily rural area in North Carolina found that, by
the age of 16 years, more than 67% of the children reported exposure to at
least one traumatic event (Copeland, Keeler, Angold, & Costello, 2007).
Those events included child maltreatment or domestic violence, a major
medical trauma, traffic injury, traumatic loss of a significant other, or
sexual assault (Copeland et al., 2007). Although the role that trauma
exposure plays in the development of various disorders is not clear,
experiencing trauma appears to affect emotional regulation and the
processing of social information.
Similarly, poor social and economic conditions have been correlated with
family pathology, child abuse, and poor parental supervision. However,
the causal pathway is uncertain. It may be that poverty itself does not
cause poor mental health outcomes in children and adolescents. Instead,
living in poverty may produce poor child mental health outcomes because
the parental experience of financial strain and economic loss diminishes
some parents’ capacity to provide involved and supportive parenting
(Linver, Fuligni, Hernandez, & Brooks-Gunn, 2004; Oyserman, 2004).
Another environmental pathway of poverty may be related to nutrition.
Even after controlling for poverty status, food insecurity has been found to
increase the risk for adolescent mental health disorder (McLaughlin et al.,
2012).
Dysfunctional parenting—rejection, neglect, maltreatment, and inability to
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provide appropriate structure and supervision—is associated with
increased risk of emotional and behavioral disorders in children and
adolescents (Johnson, Cohen, Kasen, Smailes, & Brook, 2001; Resnick &
Burt, 1996). In one review, Loeber and Stouthamer-Loeber (1996) noted
that poor parental supervision and lack of parental involvement were
among the strongest correlates of conduct disorder in children. Other
research has linked harsh, abusive, and inconsistent discipline patterns to
serious conduct problems in children (Lahey et al., 1995; Robins, 1991;
Shaw, Gillion, Ingoldsby, & Nagin, 2003). In stressed or large families,
parental attention can be in short supply and may be unduly focused on
negative behaviors. Because such behaviors garner much-desired parental
attention, the negative and aggressive behaviors are reinforced, which may
lead to patterns of antisocial behaviors (Surgeon General, 1999).
In addition, a number of studies have linked poor family management and
emotional climate to depression in children. As compared with families
raising children who are not depressed, families of children with
depression tend to be less emotionally expressive, more hostile, more
critical, and less accepting. Families with depressed children also have
family structures that are less cohesive, more disorganized, and more
conflictual in nature than families without depressed children (Gilbert,
2004).
Parents who are depressed themselves find it hard to provide consistent
discipline, supervision, and emotionally positive interactions with their
children (Wilson & Durbin, 2010). Children and adolescents of parents
with depression have been found to be at increased risk for internalizing
and externalizing disorders (S. H. Goodman, et al., 2011; Wickramaratne
& Weissman, 1998). Not surprisingly, parental mental illness itself is
associated with poor parenting ability (Oyserman, Mowbray, Allen-
Meares, & Firminger, 2000).
Negative life events have also been associated with poor emotional and
behavioral outcomes in children and adolescents (Gerrity & Folcarelli,
2008; Goodyer, 1990; Kessler, 1997; Tiet et al., 2001). Examples of
negative life events include multiple moves; loss of a parent through death,
divorce, or out-of-home placement; physical assault; exposure to violent
acts; and injury. A longitudinal study found that suicidal ideation in 16-
year-olds was strongly predicted by early adversities such as childhood
maltreatment, residential instability, and community violence (Thompson
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et al., 2012).
In a 1999 review of the mental health research literature, the U.S. Surgeon
General noted that exposure to emotional abuse and physical violence
disrupted the normal development of children and adolescents and had
profound effects on mental, physical, and emotional health. The review
found that children’s exposure to abuse and violence was associated with
characteristics such as insecure attachment; impaired social functioning
with peers; and psychiatric disorders such as PTSD, ADHD, conduct
disorder, and depression (Surgeon General, 1999). When compared with
peers who did not experience adverse events in childhood, adults who
experienced four or more categories of childhood adverse events (e.g.,
having witnessed violence, having a parent who abused alcohol or drugs,
or having lived in poverty) had a 4- to 12-fold increased risk for
alcoholism, drug abuse, depression, and suicide attempts (Felitti et al.,
1998).
Certain groups of disorders are more closely associated with negative life
events than are others. In addition, the effect of negative life events also
appears to differ by gender. For example, depression is associated with
loss and grief, particularly in girls (Breier et al., 1988; Goodyer, 2001;
Moore, Rohde, Seeley, & Lewinsohn, 1999). The earlier a child
experiences the loss of a parent or caretaker, the more severe the outcome.
Being a victim of a crime, a violent act, or an assault is strongly associated
with PTSD and conduct disorder in both girls and boys (Famularo,
Kinscherff, & Fenton, 1992); however, the association between being a
victim of crime, violence, or assault and the occurrence of ODD is
particularly strong among girls (Tiet et al., 2001). Among boys, a parent
being arrested and jailed is strongly associated with conduct disorder and
dysthymia, whereas among girls, parental arrest is more often associated
with conduct disorder and overanxious disorder.
In sum, a number of risk factors are associated with emotional and
behavioral disorders in children and adolescents. These risk factors can be
grouped at the individual, familial, and extrafamilial levels. The level of
individual risk appears to be related to the number of risk factors a child
has in various domains (Fergusson, Horwood, & Lynsky, 1994; Rutter,
1979). Moreover, cumulative risk appears to be more important than any
single risk factor (Sameroff & Gutman, 2004).
Indeed, it is estimated that nearly half of children entering kindergarten
247

have at least one risk factor (Zill & West, 2001). Similarly, the Adverse
Childhood Experiences Study, which was conducted in a primary-care
setting, found that more than 50% of respondents had experienced at least
one type of adverse experience in childhood and that 25% reported more
than two types (Felitti et al., 1998). Moreover, increased exposure to
adverse experiences in childhood is related to a greater likelihood of
developing a variety of behavioral, health, and mental health problems,
including smoking, multiple sexual partners, heart disease, cancer, lung
disease, liver disease, sexually transmitted diseases, substance abuse,
depression, and suicide attempts (Lu, Mueser, Rosenberg, & Jankowski,
2008). Table 5.2 summarizes risk factors for mental health disorders at the
individual, familial, and extrafamilial levels.
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Protective Factors
Protective factors reduce risk. Indeed, the impact of risk factors on
children’s outcomes can be moderated by protective factors. Furthermore,
just as a greater number of risk factors are associated with increased risk,
resilience can be a function of the number of protective and promotive
factors present in a child or adolescent’s life (Sameroff, Bartko, Baldwin,
Baldwin, & Seifer, 1999). Garmezy (1993) identified three broad sets of
variables that have potential to operate as protective factors. These
variables include (a) child characteristics, such as easy temperament,
cognitive skills, and social skills; (b) family characteristics, such as
families that are marked by warmth, cohesion, and structure; and (c) the
social characteristic of having a support system available. As shown in
Table 5.3, social-adaptive behavior is an important protective factor that is
related to most emotional and behavioral disorders.
According to the NACT longitudinal study of youth with SED, risk can be
mitigated with adaptive social behavior, such as interpersonal relationship
skills or coping skills (Armstrong, Dedrick, & Greenbaum, 2003). Good
communication skills have also been found to be protective against
hospital readmissions among children with SED (Greenbaum et al., 1996).
Life history reports of adolescents treated for mental health problems
indicate that young people who had positive life outcomes tended to have
had more stable living situations, better family relationships, and more
positive relationships with peers. In addition, children who seemed to
prevail over adversities were more goal-oriented and experienced more
successes and fewer stresses (McConaughy & Wadsworth, 2000). Findings
from studies sponsored by the World Health Organization have suggested
that adversities such as the long-term disability associated with childhood
schizophrenia can be minimized through supportive relationships with
family or community members (Hopper & Wanderling, 2000). Thus, just
as poor parenting practices are risk factors for many antisocial behaviors
(Loeber, Farrington, Stouthamer-Loeber, & Van Kammen, 1998), warm,
supportive family relationships and parental monitoring appear to function
as protective factors for both boys and girls (Fraser, 2004; Green, 1995;
Santilli & Beilenson, 1992). Table 5.3 shows protective factors for mental
health disorders summarized at the individual, familial, and extrafamilial
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levels.
250

History of Child Mental Health Policy in
the United States
Whereas risk and protection are relatively new concepts, the concept of
childhood mental illness has a history dating to the late 19th century. The
first discussion in a textbook of psychological problems in children was
Maudsley’s chapter on “The Insanity of Early Life” in 1867 (Hergenhahn,
2001; Parry-Jones, 1989). However, the prevailing thought was that people
could not “go mad” until they had reached adulthood. Children and
adolescents who exhibited serious emotional or behavioral symptoms were
hospitalized or imprisoned alongside adults. A public system devoted
solely to child mental health did not emerge for another 100 years.
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Precursors of Mental Health Policy
The earliest public mental health efforts on behalf of children were a result
of changes that came about at the turn of the 20th century in approaches to
handling “wayward” youth. Public policy in juvenile justice was changing
from an approach that focused on punitive measures to an approach that
sought corrective measures. The nation’s first juvenile court was
established in Chicago in 1899. In 1909, several members of the Hull
House Association board became impressed with the new juvenile courts
and created the Juvenile Psychopathic Institute to study the problems of
juvenile offenders. The institute’s first director, William Healy, MD, was a
pioneer in the field and applied emerging psychiatric theory related to
children and adolescents to individualize treatment of juvenile offenders.
Growing from Healy’s influence, juvenile court clinics developed across
the country, providing the first publicly funded community mental health
services to troubled youth. Even though mental health theory and practice
provided a foundation for much of the evolving juvenile justice and child
welfare policies, no formal child mental health policy had yet been
developed (Jones, 1999).
During the 1920s, juvenile court clinics began serving more than just
children with antisocial problems, and they became attached to a variety of
new structures such as charities, universities, and teaching hospitals.
Referred to as child guidance clinics, their major areas of concentration
became school and home problems. Child guidance clinics primarily
served children and adolescents with internalizing problems, and the
clinicians used Freudian and Ericksonian developmental theories in
addressing those problems.
The federal government first became involved in child mental health
policy in the 1930s through the advocacy of the federal Children’s Bureau,
which supported the development of a child mental health field and
advocated for the expansion of child guidance clinics. Child guidance
clinics became the major source of mental health care for children and
youth until the 1970s.
World War II brought an unexpected focus to the mental health needs of
children. Because of the huge military draft, life histories were available
for hundreds of thousands of young soldiers from varied backgrounds and
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socioeconomic levels. By the end of the war, it was apparent that soldiers
who had had behavior problems as children were much more likely to be
prematurely discharged, disciplined, wounded, or killed (Schowalter,
2003). The country learned that mental illness is blind to both color and
income and that the outcomes of mental health problems are costly to both
individuals and society.
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Community Mental Health Centers
In 1963, President John F. Kennedy signed the Mental Retardation
Facilities and Community Mental Health Center Act, which changed the
face of mental health care nationally. Focused primarily on adults with
mental illness, the law established funding for community mental health
centers. These centers were designed to provide mental health services in
community rather than in hospital settings. Similar to the child guidance
movement that had preceded it, the Community Mental Health Center Act
provided mental health services to only a small percentage of children with
SED. The act did not mandate that affordable mental health services be
provided to all children in need (Lourie & Hernandez, 2003), and little, if
any attention was afforded to prevention or early intervention.
However, advocacy efforts on behalf of children and youth with emotional
problems continued to grow, which eventually led Congress to establish
the Joint Commission on Mental Health of Children. In its 1969 report, the
commission found that millions of children and youth were not receiving
the mental health services they needed. Moreover, many of those receiving
care were served in inappropriately restrictive settings such as state
psychiatric hospitals. In 1975, Congress acted to require community
mental health centers to serve children and adolescents.
Despite the congressional mandate to provide mental health services to
children and adolescents, community mental health centers were slow to
respond. A report issued by the President’s Commission on Mental Health
(1978) strongly criticized community mental health centers for their failure
to address the needs of children and youth with serious emotional and
behavioral problems. President Jimmy Carter’s Mental Health
Commission also noted that few communities were providing either the
number or the continuum of services needed. Therefore, the commission
recommended that a community-based network of integrated services be
developed to meet the needs of seriously emotionally disturbed children
and adolescents.
Although similar recommendations had been voiced throughout the 1970s,
it was not until the 1982 publication of Jane Knitzer’s widely read book,
Unclaimed Children, that Congress mobilized to take action. Knitzer
boldly stated that of 3 million children and adolescents with SED in the
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United States, 2 million did not receive the services they needed.
Furthermore, Knitzer reported that at least 40% of hospital placements for
children were in inappropriately restrictive settings, including facilities for
people with mental retardation and adult psychiatric hospital wards. She
observed that most states had no specific policies for children with SED
and noted that millions of “unclaimed” children were adrift in the public
health, mental health, education, juvenile justice, and child welfare
systems, and these children were not receiving appropriate mental health
services (Knitzer, 1982).
255

Systems of Care
Knitzer (1982) documented a lack of services; poor coordination among
service agencies; overuse of residential and institutional care; and failure
of the federal, state, and local governments to respond to the crisis. In
suggesting ways to improve these conditions, she coined the term system
of care to describe a new approach to mental health. In 1984, Congress
appropriated funds to the National Institute of Mental Health (NIMH) to
establish a national agenda to deal with the problems outlined by Knitzer.
In response, NIMH created the Child and Adolescent Service System
Program (CASSP).
Following the example of the innovative Community Support Program for
adults with serious and persistent mental illness, CASSP focused on the
needs of children with SED by providing financial incentives to states to
develop systems of care to serve these children. The CASSP initiative was
the first federal mental health program to clearly identify youth with SED
as its target population. CASSP created a movement and momentum for
change. It became the vehicle for the development and articulation of
federal and state child mental health policy.
The CASSP program was based on the following four assumptions:
1. Children and adolescents with serious emotional disorders are found
in all of the nation’s public health, mental health, education, juvenile
justice, and child welfare systems.
2. Most children and adolescents with serious problems are served in
more than one of these agencies at the same time.
3. Regardless of the agencies with which children are affiliated, the
mental health needs of children have been overlooked and have not
been addressed appropriately.
4. Few states have planning mechanisms to identify children and
adolescents who are served across multiple systems.
The policy imperative in the CASSP initiative was to develop a multi-
agency approach to the delivery of mental health services.
In a widely circulated monograph, Stroul and Friedman (1986) defined
Knitzer’s concept of a system of care (SOC) as “a comprehensive
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spectrum of mental health and other necessary services, which are
organized into a coordinated network to meet the multiple and changing
needs of children and adolescents with severe emotional disturbances and
their families” (p. iv). These authors stated that an SOC should be a
community-based, child-centered, family-focused, and culturally
competent approach to integrating services. The multiple needs of each
child and family should be met by providing a full range of services,
including mental health, substance abuse, health, social, educational, and
vocational services, with case management providing the mechanism to
guide the family toward the appropriate mix and timing of services. Figure
5.1 illustrates a model SOC for mental health service delivery.
The ideal SOC includes enough flexibility to allow services to be tailored
to the specific needs of the child and family involved, regardless of which
agency has overall responsibility for the child or which system provided
the services. For example, a child or adolescent with an SED might have
psychological needs that require intervention by a mental health center,
special education needs filled by the school system, and residential needs
for a structured living environment provided by a social services agency.
Stroul and Friedman’s (1986) outline of an SOC was used as the blueprint
by the CASSP program for organizing child mental health services across
the country. To receive federal funding, states were expected to create a
protocol for interagency cooperation that would effectively coordinate all
child-serving agencies and services. Coordination and cooperative
development were to start at the state level and then be replicated at the
local level. States were urged to develop strategies and methods for
pooling financial resources among agencies so that all needed services
could be provided, regardless of the child’s service eligibility or insurance
coverage. By the fall of 1990, all 50 states and the District of Columbia
had received CASSP grants. By 1995, all states had at least one state-level,
full-time, child mental health specialist working to develop a statewide
system of care (Davis, Yelton, Katz-Leavy, & Lourie, 1995).
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Systems of Care and Mental Health Policy
The policy of creating SOCs to serve the mental health needs of the
nation’s youth was formally endorsed in 1992 when Congress passed the
Children’s and Community Mental Health Services Improvement Act, also
referred to as the Children’s Mental Health Initiative (CMHI). (See Table
5.4 for a listing of federal mental health policy initiatives.) This act created
a program called the Comprehensive Community Mental Health Services
for Children and Their Families. Administered by the Center for Mental
Health Services in the Substance Abuse and Mental Health Administration
(SAMHSA), this program provided grants to states to expand the SOC
concept. To date, this program is the largest federal initiative supporting
the development of children’s mental health services.
Figure 5.1 A System of Care Framework for Children and Adolescents
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By the close of the 20th century, at least half of the states had enacted laws
requiring some sort of SOC (Davis, Yelton, & Katz-Leavy, 1995). The
Children’s and Community Mental Health Services Improvement Act
provided nearly $460 million in federal funding to 67 local SOCs that
served more than 40,000 children across the country (Center for Mental
Health Services, 1999). Now, many years after their initial authorization,
SOCs continue to be the primary policy approach to governing public
mental health systems. Experts in this area now propose that “some
elements of the system of care philosophy and approach can be found in
nearly all communities across the nation” (Stroul & Friedman, 2011, p. 2).
Congress continues to provide annual funding through a competitive grant
structure to states wishing to enhance their SOCs. The CMHI has invested
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over $1.6 billion in grants to all 50 states and many territories and
American Indian/Alaska Native communities to develop sustainable SOCs
(Stroul & Friedman, 2011). The major principles underlying this approach
remain intact.
Ongoing issues related to the implementation of SOCs are apparent
particularly when one looks at where children receive mental health
services. The SOC approach demands that services be family-driven,
child-centered, and delivered in a least-restrictive community-based
setting. However, many children have symptoms that require a higher level
of care and need longer-term services at facilities where they can receive
constant professional supervision. Children with SED commonly require
placement in a psychiatric residential treatment facility (PRTF). These
placements are extremely costly, and advocates have questioned the legal
and ethical acceptability of their use. There is also concern that the lack of
community-based mental health services is driving the use of these
services more than child need.
Given the major expense of PRTFs to the Medicaid system, the federal
government initiated a waiver demonstration program in ten states to serve
children with SED in their homes and communities. The evaluation of this
program was completed in 2013 and concluded that children in the waiver
program maintained and often improved their clinical functional status
(Urdapilleta et al., 2013). On average, state Medicaid costs were never
more than a third of the PRTF costs, saving about $40,000 per child. While
there will likely always be children with SED that may require care in a
PRTF or other institutional setting, this evaluation demonstrated that most
children can be served in their home or community. This has the advantage
of maintaining natural supports with the child’s family, peers, and school.
The major challenge is ensuring that services are available and accessible
in every community. From a policy and cost-effectiveness standpoint, it
makes sense to invest in developing community-based program
infrastructure, adequately reimbursing providers, and supporting
workforce development to avoid these more expensive and restrictive care
settings.
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Service Integration Within a System of Care
A growing body of literature has described the overall characteristics of
children with SED and their families (Epstein, Cullinan, Quinn, &
Cumblad, 1995; Quinn & Epstein, 1998; Wagner et al., 2005). Most of
these studies indicated that children with SED have a number of common
risk factors, including inadequate social skills, poor academic
performance, family violence, alcohol and drug use, and mental illness.
Despite these commonalities, there is no single system of mental health
care for these youth. In fact, more youth with SED are found in other
service systems than are treated within the child mental health system. For
example, up to 80% of all children entering the juvenile justice system
have mental health disorders (President’s New Freedom Commission on
Mental Health, 2003), and researchers have estimated that 20% of
incarcerated youth have SED, which is double the rate of SED found in the
general population (Mears & Aron, 2003). Nearly 20% of children with
SED are involved in the child welfare system; a staggering 70% of youth
with SED receive mental health services from local school systems (Burns
et al., 1995).
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262

It is clear that children in these separate systems need appropriate mental
health care that is tailored to meet their individual needs. Over the past 20
years, mental health leaders, policymakers, and service providers have
been struggling with how to best integrate mental health services into these
systems. The most common state-level integration approaches involve
coordinating mental health, child welfare, and juvenile justice services
using one of the following three structures:
1. Separate agencies are maintained as individual departments. In this
model, coordination of services is accomplished through formal
interagency planning structures.
2. A part or all of the three agencies (mental health, child welfare, and
juvenile justice) are housed within a single umbrella department, such
as a department of human services. Each division maintains its own
staff, policy development process, and budget. Coordination is
facilitated because each agency reports to a single department
director, and departmental rules and procedures that might inhibit
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service integration can be changed without legislative intervention.
3. The three agencies are combined into a single departmental agency,
with a single agency budget and policy-making body.
A quick review of these three options might lead a person to conclude that
combining all child services into a single agency would be the most
advantageous option. However, such an arrangement has costs as well as
benefits. Single, integrated agencies tend to be quite large, making
management time-consuming, cumbersome, and often inefficient. Turf
issues remain problematic. In addition, many child advocates object to the
fact that the allocation of funds across different child populations would
occur within a single budget process that might not be open to the public
for review and comment.
States have found that restructuring alone does not overcome turf issues,
policy conflicts, leadership challenges, and inadequate or disproportionate
funding. Arguably the most important elements of successful service
integration are agreeing on a common target population and blending
funding streams so that an appropriate set of individually tailored services
can be provided. Which agency provides the actual services may not be as
important as having an arrangement in place so that services are provided
to children who need them, regardless of the child’s custody status or the
family’s financial ability to pay for services.
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Systems of Care Implementation Evaluations
On the clinical level, integrated SOCs appear to produce positive
developmental outcomes for children and adolescents involved in them.
The Comprehensive Community Mental Health Services for Children and
Their Families program is evaluated annually by SAMHSA. Findings from
these evaluations have been detailed in “short reports,” provided on the
SAMHSA website (SAMHSA, 2009). These evaluations have used parent
and teacher reports of youth behavior as well as youth self-reports from
model SOCs. The findings have indicated that youth served in these SOCs
demonstrate positive benefits as compared with their pre-enrollment
behavior, including fewer emotional and behavioral problems, improved
school performance, and less likelihood of engaging in harmful behaviors.
Despite the positive outcomes of model SOCs, and notwithstanding the
large level of federal and private foundation support allocated to states,
SOCs have proven difficult to implement. The model requires many
systems-level alterations, including developing links among child-serving
agencies, creating a continuum of community-based services, blending
funding streams, developing interagency policy, and organizing treatment
teams to coordinate care.
The Center for Mental Health Services conducted reviews of SOC
implementation in 1995 and 2002. Researchers from both reviews found
substantial changes had occurred in each funded site. Indeed, changes in
policies and procedures had been made that facilitated cross-agency
training, programming, and co-location of services. The researchers also
found changes that enhanced interagency communication and
collaboration. Even so, no site had implemented all the aspects required of
a comprehensive SOC model. (Stroul, 2006; Vinson, Brannan, Baughman,
Wilce, & Gawron, 2001).
A number of interagency coordination issues emerged as significant
barriers in the SOC approach. Sometimes called “turf problems,” these
issues revolved around poor interagency collaboration, which was
attributable to factors such as a lack of trust, a sense of competition, a fear
of sharing resources, and a lack of understanding regarding the partner
agencies’ mandates and capacities. In addition to these turf problems, the
greatest barrier to full-scale change was likely the sheer amount of time
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required to develop meaningful collaborations (Behar, 2003).
At the state level, many states have also struggled to sustain and expand
their SOC approach after the federal funding period (Stroul & Manteuffel,
2007). Few states are able to support child mental health services with
state dollars that are not also attached to federal Medicaid funds. The
Medicaid program was created in 1965 as a health-care financing program;
it is governed by federal rules and is jointly managed by federal and state
authorities. Medicaid pays for about 50% of all mental health services
provided to poor children and adolescents (Kenny, Oliver, & Poppe,
2002). Thus, policies flowing from federal and state Medicaid offices are
as influential on state child mental health delivery systems as the federal
policy initiatives that come through NIMH or the Center for Mental Health
Services.
Unfortunately, state spending limits for Medicaid and expansion initiatives
for mental health services are frequently in conflict. Although federal
Medicaid policies have become more flexible over the past years, most
state policies on Medicaid spending have become increasingly restrictive.
Because Medicaid spending has been the highest growth factor in most
states’ budgets, state-level Medicaid policies are frequently focused on
cost containment, especially in times of economic downturn or recession.
In turn, the state mental health departments try to stretch their limited
funds by matching state appropriations to federal Medicaid funds. In
addition, the Medicaid program has inherent limitations and barriers
related to supporting SOC structures.
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The Fort Bragg Study
During the early 1990s, the Department of Defense and NIMH funded a
major research study to test the impact of developing comprehensive and
coordinated continuums of care for youth with SED at Fort Bragg, North
Carolina. The demonstration program sought to fill the service gap
between outpatient therapy and inpatient hospitalization by providing non-
clinic-based services such as in-home crisis stabilization, afterschool group
treatment, therapeutic foster care, and crisis management.
The Fort Bragg study demonstrated substantial system improvements,
including increased service capacity, enhanced collaboration among
service agencies, and reduced use of hospitals and residential treatment
facilities. However, the demonstration program did not produce significant
clinical outcomes with regard to alleviation of symptoms, increased
functioning, or reduction of impairments (Bickman et al., 1995). The
findings of the Fort Bragg project were in line with the evaluation results
of the Robert Wood Johnson Foundation Mental Health Services Program
for Youth program, which examined the development of SOCs in eight
communities over a 10-year period (Cross & Saxe, 1997; Johnsen,
Morrissey, & Calloway, 1996).
These disappointing findings caused ongoing debate in the child mental
health field. Some researchers have advocated for a change in policy
emphasis from system development to service effectiveness (Salzer &
Bickman, 1997), whereas others continued to support large systems
reforms (Hernandez & Hodges, 2003). Recent policy discourse has
suggested requiring simultaneous system reform and the delivery of
evidence-based interventions (Burns, 2001; Rosenblatt & Woodbridge,
2003). Although the risk-and-resilience framework for targeting
interventions is not yet widely used within the mental health field, many
policy leaders and advocates are focusing attention on identifying and
using evidence-based practices that will provide cost-effective client-level
improvements.
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Evidence-Based Care and Mental Health Policy
In 1998, the American Psychological Association (APA) convened a
special task force to systematically evaluate the evidence base (i.e., the
available evidence from empirical research using rigorous scientific
methods) for treating individual disorders in children and adolescents
(Chambless & Ollendick, 2001). In its report, the APA Task Force
determined two levels of criteria against which to evaluate the evidence
base of particular interventions. The first, more rigorous criterion was
“well established,” and the other, less rigorous, was “probably
efficacious.” The major distinction between the two criteria is the strength
of the supporting evidence. A well-established treatment is one that has
been shown to be superior to either a placebo or another treatment,
whereas a probably efficacious treatment needs to be shown only as
superior to the outcomes of either a waiting list condition or a no-treatment
control group. Evidence of the effectiveness of well-established treatments
must be supported by at least two separate research teams. Using these
criteria, Lonigan, Elbert, and Johnson (1998) conducted a review of
psychosocial interventions for children and adolescents and found that
most did not meet the first level of empirical support. In the years since the
Lonigan et al. review, several more well-established treatments have been
shown to be effective for children and adolescents with diagnoses of
anxiety, ADHD, autism, bipolar disorder, conduct disorder/ODD, phobia,
or depression. These treatments include behavioral parent training and
classroom behavior modification for ADHD and parent training, functional
family therapy, and multisystemic therapy for conduct disorder and ODD.
In addition, graduated exposure, participant modeling, and reinforced
practice were found to be well-established interventions for children and
adolescents with phobias.
A number of other treatments, including those based on cognitive-
behavioral therapy, have been identified. Cognitive-behavioral techniques
have been shown to be effective for children with ADHD; depression;
anxiety disorders, including PTSD; conduct disorders; and phobias. In
addition, several skills-training interventions appear to be effective for
children with major depression and conduct disorders. Other promising
interventions include (a) school-based contingency management for
children with ADHD and conduct disorders (Brestan & Eyberg, 1998);
Pelham, Wheeler, & Chronis, 1998); (b) classroom-based social skills
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training for conduct problems, which is delivered in combination with
parent training and systematic communication with teachers (Fraser, Day,
Galinsky, Hodges, & Smokowski, 2004; Reid, Eddy, Fetrow, &
Stoolmiller, 1999); (c) classroom-based social skills training for
elementary school-aged children with depression (Gillam, Reivick,
Joaycox, & Seligman, 1995); (d) parent-mediated behavioral interventions
for child disruptive behavior problems (Comer et al., 2013; McMahon &
Kotler, 2008); and (e) home visiting and early interventions for child
socioemotional development (Avellar & Supplee, 2013; Heckman, 2006).
Many of the interventions commonly used in the child mental health
system either have not been tested in controlled research investigations or
have not met the scientific rigor necessary for inclusion in the APA Task
Force Report. Examples of this lack of scientific rigor include studies
assessing the effects of partial hospitalization, day treatment, case
management, and home-based services (Surgeon General, 1999).
Unfortunately, no single resource exists for the increasingly long list of
evidence-based interventions. SAMHSA developed the National Registry
of Evidenced-Based Programs and Practices (available at
http://nrepp.samhsa.gov). Over 200 behavioral health interventions for
children and adolescents are reviewed on this database. Several
professional and advocacy organizations have also created listings of
evidence-based services for children and youth. Several of these resources
are listed at the end of this chapter.
Given all of the policy rhetoric, it is surprising that no national legislation
has yet been drafted to support evidence-based practices. However, many
states are beginning to enact legislative language that requires the use of
empirically supported interventions in child mental health SOCs. In this
context, state mental health statutes often include the requirement to create
interagency SOCs, within which evidence-based services are provided to
children with SED and their families.
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http://nrepp.samhsa.gov

Risk, Protection, and Resilience
Framework and Mental Health Policy
The risk, protection, and resilience perspective provides a promising new
framework in which to develop new mental health policies as it offers a
valuable cross-problem, multidisciplinary approach for individually
tailored interventions within an integrated SOC. Although it is not yet used
widely within the mental health field, there are several good examples of
its potential benefit. The Ventura County System of Care and the Willie
M. Program will be described here as case examples. The Willie M.
Program, which grew out of a class action lawsuit, provides a good
example of using the risk and resilience framework to individualize care.
The Ventura County System of Care was enacted by state statute and
required its county agencies to work together. Ventura County’s success in
providing integrated services to SED youth led to statewide legislation
supporting SOCs and has opened the door for multi-agency prevention and
early intervention approaches targeted at children and youth at risk for
mental health problems.
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Program and Case Example
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The Willie M. Program
The Willie M. Program grew out of a class action lawsuit (Willie M. et al. v.
James B. Hunt, Jr. et al., 1980) filed against the State of North Carolina on
behalf of children with serious emotional disorders (SED) and aggressive
behavior who were institutionalized because of inadequate community-based
care. Seeing the negotiations to settle the lawsuit as an opportunity to
improve the service structure, administrators in the North Carolina Division
of Mental Health, Developmental Disabilities, and Substance Abuse
Services (MH/DD/SAS) created a comprehensive continuum of community-
based care for high-risk and hard-to-manage children and adolescents with
SED.
To be represented and served under the class action suit, youths had to meet
criteria as a class member: be younger than 18 years old; have a serious
emotional, mental, or neurological disorder; have a history of violent or
chronically aggressive behavior; have been placed in public custody, such as
institutions, or be at risk of such placement; or have been denied access to
needed treatment or educational services. Although many youths met the
criteria, four youths were ultimately named as plaintiffs in the litigation.
Willie M., the first of four plaintiffs, was an 11-year-old boy diagnosed as
emotionally disturbed with unsocialized aggression.
The North Carolina Department of Human Services avoided a trial by
agreeing to the court’s complaints and demands. Each member of the class
was guaranteed individualized treatment in the least restrictive setting
possible. The treatment was to be based on the child’s needs rather than the
availability of service providers to provide a service or set of services. If
needed services did not exist, such services were to be created.
Leaders within the Division of MH/DD/SAS welcomed the challenge and
advocated for the development of local systems of care (SOCs) within which
they could create and provide services to class members. The Willie M.
Program became among the first model SOCs in the country, serving as
many as 1,500 severely aggressive youth with SED a year; two thirds of
them lived in specialized foster care or group homes. The SOC required
cooperative arrangements among the multiple agencies serving these youth.
Court officers monitored the interagency relationships, making sure that
public education, child welfare, and juvenile justice personnel worked in
concert with the Division of MH/DD/SAS on behalf of these children.
Comprehensive case management, also called wraparound case
management, was the primary tool used to tailor services to the individual
needs of members of the class action lawsuit. Each class member was
required to have an individual habilitation plan. Beginning in 1995, the
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individual habilitation plan was based on an assessment process that
reviewed both risk and protective factors.
An Assessment and Outcomes Instrument (AOI) was created to assess and to
measure the progress of children in the Willie M. Program. The instrument
used a risk and protective factor perspective and measured both fixed
characteristics (i.e., factors that could not be changed through intervention,
such as the loss of a parent) and dynamic characteristics (i.e., factors that
were malleable in treatment, such as school performance). Risk factors
included family-level characteristics (e.g., living in poverty; parental loss;
parental mental health and substance abuse problems, parental criminality,
and large family size) and individual-level characteristics (e.g., fetal
substance exposure, neurologic or developmental disorders, poor mother-
infant attachment, difficult or shy early temperament, witness to violent acts,
and history of physical and sexual abuse, school failure, and delinquent
behavior). Of the possible 30 risk factors assessed by the AOI, each of the
Willie M. class members had experienced an average of 13 risk factors—a
number that far exceeds most definitions of a high-risk youth (e.g., Rutter,
1979). Consistent with the literature on risk and conduct disorders, most
Willie M. class members with poor behavioral outcomes had histories of
negative parent–child interactions and poor academic performance. Better
behavioral outcomes were predicted by protective factors such as having
good skills in areas such as problem solving, interpersonal relationships, and
reading; having social support networks available, including involvement
with family members and prosocial peers; and having a parent who was
consistently employed (Vance, Bowen, Fernandez, & Thompson, 2002).
Each member’s individual rehabilitation plan specified interventions that
were likely to result in positive behavioral changes. Because most risk
factors associated with Willie M. class members were fixed historical
experiences and family features that were not amenable to change, few
options were available that would reduce the impact of those risk factors on
current behaviors. However, evaluations of the Willie M. Program found
that strengthening protective factors was directly associated with improved
behavioral outcomes (Bowen & Flora, 2002; Vance et al., 2002). Depending
on individual needs, protective factors such as reading skills, relationships
with adults, social skills, positive beliefs and attitudes, and involvement in
community activities were strengthened through a variety of targeted
interventions. In addition, parental and caretaker positive discipline skills
were strengthened. The protective factors that were found to be strongly
associated with behavioral improvement included increased levels of home
and school social skills. Interventions targeting these factors included
teaching skills in anger management, empathy development, and making and
keeping friends (Bowen & Flora, 2002). Because of these positive
behavioral changes, youth served in the Willie M. Program attended school
more often and had fewer arrests. Class member and family satisfaction with
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services was high. As an individualized SOC was successfully developed,
the Willie M. class action lawsuit was resolved in 2000.
The Willie M. Program in North Carolina was both successful and
expensive. The court demanded the provision of needed services, regardless
of cost. Many state legislators resented this open-checkbook approach. As
costs went up for class members’ services, appropriations to other parts of
the mental health system declined or were not increased accordingly. Once
the class action lawsuit was resolved and its mandates removed, funding for
the Willie M. Program was reduced and realigned within the Division of
MH/DD/SAS.
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Ventura County System of Care
In 1985, the California State Legislature passed a landmark bill (AB 3920)
authorizing a demonstration program to integrate mental health services
across a core group of service systems, including child welfare, public
education, and juvenile justice. The legislation provided for creation of a
comprehensive, coordinated system of care (SOC) and facilitated
interagency cooperation by integrating numerous federal and state statutes
that addressed public mental health services for children and by amending
various statutes and regulations. Ventura County was selected as one of three
demonstration sites under Assembly Bill 3920. As part of the demonstration
program, all child-serving agencies in Ventura County were required to
engage in interagency planning and to develop interagency protocols and
agreements that emphasized providing services to children in their homes or
in the least-restrictive setting.
The Ventura County System of Care had five interdependent components as
outlined in the enabling legislation: (a) a clearly defined target population,
(b) a systemwide goal to preserve family unity and locally based treatment,
(c) a commitment to developing collaborative programs of services and
standards tailored to individual needs of children and their families, (d) a
continuum of service options and settings that cross agency boundaries, and
(e) a mechanism for system evaluation.
Client outcomes for the Ventura County System of Care reflected a cross-
agency perspective. The overarching goal was for children with serious
emotional disturbances to remain or to be reunified with their families, to
attend and progress in public schools, and—as appropriate—to desist from
problem behavior such as delinquency and drug use. A cross-agency target
population experiencing serious emotional disturbance (SED) was identified,
including populations within each agency that had been mandated for
services. The target population included emotionally or behaviorally
disordered youth, such as (a) court dependents whose histories included
neglect, physical or sexual abuse, multiple foster home placements,
residential treatment, and psychiatric hospitalization; (b) court wards for
whom the public sector had legal responsibility because of delinquent
behavior and who were at risk of out-of-home placement; (c) special
education pupils who required mental health services to benefit from their
Individual Education Plans; and (d) children who were not part of a formal
agency other than mental health and who were at risk of out-of-home
placement to state hospitals or residential treatment.
Mental health treatment was integrated into the service systems of the other
major child-serving public agencies. The county mental health department
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was given responsibility for serving the mental health needs of the targeted
children involved in the public school, child welfare, and juvenile justice
systems. Mental health staff located their services in places where targeted
children lived and went to school, a step that required reorganization of the
Department of Mental Health. Most of the mental health staff was deployed
to agency and school settings to provide or supervise mental health services
in those settings. Depending on the needs of the agency, mental health staff
provided consultation, assessments, case management, counseling, day
treatment, special day classes, in-home care, family therapy, enriched foster-
home care services, or crisis intervention.
The state legislation that created the demonstration project also facilitated
the blending of categorical funds so that each agency domain was enabled to
determine the array of mental health services it needed. Specific roles and
relationships between agencies were delineated in interagency agreements
and facilitated by a number of interagency coordinating mechanisms. An
interagency juvenile justice council became the policy-making body of the
county system. This policy-making body was created to serve as a vehicle
for identifying problems, developing interagency solutions, and working
through agency conflicts. The council’s permanent members included the
county counselor, public defender, district attorney, sheriff, chief
administrative officer of the juvenile court, director of probation, a member
of the board of supervisors, the superintendent of schools, the director of the
Department of Child Welfare, and the director of the Department of Mental
Health. Still in operation today, the council reviews all agency budgets and
looks for ways to mingle and coordinate funding streams.
The Ventura County demonstration project met the system-level
performance outcomes required by the statute. By integrating mental health
services into each system, more children were served—especially children
from ethnic minority backgrounds—and fewer youth required placement in
restrictive and costly state hospitals or residential treatment centers. The
project netted a substantial savings to the state. The demonstration program
was expanded to more counties in 1989. In 1992, the California State
Legislature enacted the Children’s Mental Health Services Act, which
expanded the SOC model to all counties. In 2001, the legislature enacted a
law requiring an agency-integrated SOC statewide (Stortz, 2003).
California can be a beacon for other states. Its formal adoption of SOC
principles and policies in statute has provided fiscal incentives for many
local county collaborations. The state’s shift to the rehabilitative option for
federal Medicaid billing has allowed clinical staff to work outside of their
offices and support field-based, in-home, and wraparound service delivery
models. A state match to the federal EPSDT (Early and Periodic Screening,
Detection, and Treatment) program has provided an important fiscal engine
to expand and sustain services and supports to children and youth 0 to 21
years old. Most recently, the California Mental Health Services Act
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(Proposition 63), enacted in 2007, has provided additional and ongoing state
funds to further transform the mental health system in California with
increased funding for mental health promotion, prevention, and early
intervention services to children and adolescents statewide (Hodges,
Ferreira, Israel, & Mazza, 2007).
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Criticisms of Child Mental Health Policies
Child mental health policies in the United States have been widely
criticized over the past 50 years. The mental health services and programs
resulting from these policies have been described as fragmented, spotty,
nontargeted, and generally ineffective (Joint Commission on the Mental
Health of Children, 1969; Knitzer, 1982; Lourie & Hernandez, 2003;
President’s Commission on Mental Health, 1978). In response to this
criticism, Congress supported the creation of SOCs to coordinate and
enhance mental health care to youth with SED. Private funding sources,
such as the Robert Wood Johnson and Annie E. Casey foundations, also
contributed millions of dollars to develop model SOCs across the country.
Unfortunately, the evaluations of many of these model programs have
produced only mixed results.
Although supportive of the SOC concept, child mental health advocacy
groups such as the Federation of Families for Children’s Mental Health
and the Child and Adolescent Network (a branch of the National Alliance
for the Mentally Ill) remain frustrated by and critical of the slow process of
implementation. These advocacy groups have not seen policy rhetoric
translated into significant changes at the child or family level. These
criticisms were echoed in both the Surgeon General’s (2000) National
Action Agenda and the report of the President’s New Freedom
Commission on Mental Health (2003). The Surgeon General (2000) stated
that despite the existence of mental health programs in many communities,
the nation lacked a basic infrastructure for adequate mental health care,
and that “unmet need for services remains as high today as it was 20 years
ago” (p. 13).
Two years after the Surgeon General’s report, President Bush signed
Executive Order 13263 establishing the President’s New Freedom
Commission on Mental Health. The executive order charged the
commission with the responsibility of conducting a comprehensive study
of the problems and gaps in the nation’s mental health service system. In
his cover letter to the President’s New Freedom Commission on Mental
Health (2003) final report, Michael Hogan, chair of the Commission,
wrote,
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Today’s mental health care system is a patchwork relic—the result of
disjointed reforms and policies. Instead of ready access to quality
care, the system presents barriers that all too often add to the burden
of mental illnesses for individuals, their families, and our
communities. (p. 1)
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Transformation of the Mental Health
System
As a way to address these gaps and fundamentally transform how mental
health care is delivered in America, the New Freedom Commission on
Mental Health’s report recommended a public health model of mental
health care that would support mental health promotion and early
intervention efforts as well as direct treatment services. SAMHSA
followed up on the commission’s report by creating a Federal Mental
Health Action Agenda and inviting key federal agencies to help propose a
set of action steps to address the commission’s vision and to move its
agenda forward (SAMHSA, 2005). The key federal agencies contributing
to this agenda of action steps included the departments of Education,
Housing and Urban Development, Justice, Labor, and Veterans’ Affairs,
all the divisions within the Department of Health and Human Services, and
the Social Security Administration.
In 2009, Kathryn Power, director of the Center for Mental Health Services,
reported that the federal government was committed to the transformation
of the mental health system. It appears that “transformation of the mental
health system” is fast becoming the 21st century’s de facto policy on child
mental health. However, it remains unclear how this policy will evolve
under the Patient Protection and Affordable Care Act (ACA), judicial
decisions, and other legislation.
280

Transforming Mental Health in Early Childhood
Clearly, part of the transformation will involve placing greater emphasis
on early childhood. A child’s early experience lays the foundation for
lifelong mental health. A key element of the country’s emerging mental
health system will be an acknowledgement of the importance of promoting
mental health in early childhood. The parent–child relationship is perhaps
the most important area on which to focus. Because of what we know
about the importance of healthy attachment for brain development and also
because we know that parenting behavior can be improved with evidence-
based interventions, socioemotional development will be emphasized.
Although genetic liability and environmental risk may be challenging to
change, we can help parents learn about child development and the
importance of providing a nurturing environment. Many parents did not
have positive examples from their own caregivers and may lack a role
model or source of support to help raise their own child. Many researchers
in diverse fields of economics and child development are bringing a
message to policymakers that the best investment we can make is in our
youngest citizens. There are several examples of ways to develop and
expand federal policy based on compelling evidence from rigorous
longitudinal research.
To help pregnant women and new parents in their roles as caregivers,
home visiting has been a successful public health strategy for over a
century. Many countries have universal home visiting programs in which
every family receives at least one visit in the home environment to check
in, answer questions, and provide referrals. Although the United States
does not offer universal home visiting, the most rigorous research
demonstrating the impact of home visiting on a broad range of outcomes,
including child development, was generated from programs implemented
in the United States.
The Nurse-Family Partnership (NFP) is one home-visiting model that has
led the field. Work by David Olds and his colleagues across three
randomized-controlled trials have tracked outcomes for mothers and their
infants for well over a decade (Olds, 2013). NFP is provided to first-time
at-risk mothers, beginning prenatally with visits by nurses and continuing
until the child’s second birthday. Findings indicate sustained
improvements for the mother and child including decreased child abuse
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and neglect and improved outcomes in child development. Another
promising home-visiting model, Attachment and Biobehavioral Catch-up
(ABC), has demonstrated impacts on stress neurobiology and behavior
regulation in young foster children (Dozier et al., 2008).
Building on these research findings and the growing literature
demonstrating the need for primary prevention strategies beginning at
birth, advocates successfully pushed for a federal investment in home
visiting. The Maternal, Infant, and Early Child Home Visiting (MIECHV)
program authorized by the Patient Protection and Affordable Care Act in
2008 provided five years of funding for state grants to expand home
visiting services. The program was recently re-authorized for an additional
six months.
Notwithstanding, home visiting alone is not sufficient to promote healthy
child development. A comprehensive set of services and support for all
parents is needed. The challenge of the early childhood system will be to
develop strategies to ensure that the right program reaches the right family
at the right time. The Centers for Disease Control and Prevention (CDC) is
currently developing a strategy known as Essentials for Childhood. The
program provides a roadmap for states and communities to cultivate “safe,
stable, and nurturing relationships and environments” for children. While a
major focus is on the prevention of child abuse and neglect, both of which
are risk factors for child mental health disorders, promoting positive
relationships and environments is a shared strategy for enhancing
protective factors for child mental health. The Essentials for Childhood
strategies focus on changing social norms and public policies to reflect the
importance of healthy child development using the best available
information.
Early childhood systems could also benefit from improved integration
across agencies to remove service silos. For example, the child welfare
system is mandated by law to ensure the well-being of children in care.
Outcomes for children in foster care consistently fall well behind those for
other children, particularly in areas of mental health. However, children
under the care of the state should be those receiving the best services. This
issue has recently received attention from policymakers and has sparked an
explicit focus on promoting child socioemotional well-being for child
welfare systems. One obvious strategy is to ensure that maltreated children
have access to trauma-informed mental health interventions. This will
282

require improved coordination of child welfare and mental health services.
The child care setting is another sector of early childhood policy that can
have an impact on child emotional development. Some of the strongest
research demonstrating the return on investment for early childhood comes
from enhanced child care programs such as the Chicago Child–Parent
Centers and the Perry Preschool Project (Temple & Reynolds, 2007).
While child care programs focus primarily on school readiness, research is
demonstrating that socioemotional skill development, and not just the
traditional academic focus on building intellectual knowledge, may be the
key to improving later outcomes for disadvantaged populations. Federal
child care settings such as those provided by Head Start are critical to the
development of the social skills and emotional regulation needed to
succeed in school. President Obama recently proposed a plan that would
provide universal high-quality preschool, including socioemotional skills
training, for every 4-year-old child in America.
283

Transforming Mental Health Through the Affordable
Care Act
The transformation of the mental health system will be driven largely by
the implementation of the ACA. The ACA is a complicated policy that is
being implemented in several phases over many years. States also have a
great deal of discretion in reforming their health-care systems, so there will
be significant variation in how the law is interpreted. At this point, the full
impact of the ACA is unclear. However, we highlight three themes that
may improve the accessibility and quality of services for children: parity
of physical and mental health, the focus on prevention and early
intervention, and the integration of physical and behavioral health care.
Behavioral health care includes a range of prevention and treatment
services related to mental health and substance abuse.
Under the ACA, all benchmark insurance plans must provide a set of
“essential health benefits.” Pediatric care and behavioral health services
are examples of this class of services that must be covered in all plans.
Furthermore, the ACA mandates full parity for mental health and
substance abuse services. These services cannot have higher copays or
different coverage limits compared with physical health services in the
same plan. This aspect of the law attempts to lower barriers to mental
health services related to out-of-pocket costs or limitations in certain
insurance plans. Advocates have been fighting for mental health parity for
years, and prior successes laid the groundwork for guaranteeing its
inclusion in the ACA.
An overarching theme of the ACA is prevention. Although much of the
focus is targeted at costly preventable physical health outcomes, there is
also a clear emphasis on early detection of mental health problems in
children and expansion of evidence-based preventive interventions. The
National Prevention Council was formed as part of the ACA and is
beginning to set recommendations to prioritize prevention efforts. Mental
and emotional well-being is listed as one of seven priority areas in the first
National Prevention Strategy. The first recommendation in this priority
area is to “promote positive early childhood development, including
positive parenting and violence-free homes.” Also outlined in the ACA,
appropriations for mental health screening have been directed to support
the expansion of behavioral health services in federally qualified health
284

centers. Screening for child depression in primary care centers is one of a
fairly short list of federally endorsed preventive services. Many preventive
services that will now be offered to parents may also have an indirect
impact on preventing child mental health problems by targeting the risk
factors discussed earlier. For example, women’s preventive services,
including domestic violence screening, are provided with no copay.
The details of how service-integration strategies will be implemented are
still evolving. However, the basic idea is that the delivery system for
health services, including mental health services, should be easier to access
for patients with less duplication and complexity in the system. This
benefits patients but also should make the health-care system more
efficient and reduce unnecessary cost. One strategy will be to shift the
financing structure away from a fee-for-service, volume-driven algorithm
to an outcomes-driven algorithm. Providers delivering different types of
services to the same pool of patients will have an incentive to work
together through some arrangement such as an accountable care
organization or health home. It makes sense to have clinical social
workers, pediatricians, school nurses, and others on the same page
regarding the care plans of children and, administratively, to have a shared
incentive to produce better child-centered outcomes.
Integration of behavioral health into primary care is also a core strategy of
another major federal program. Project LAUNCH (Linking Actions for
Unmet Needs in Children’s Health), funded by SAMHSA focuses on
children (up to 8 years of age) and provides five-year grants to
communities to improve service delivery for children’s mental health.
There are many exciting and innovative examples of communities bringing
child mental health into the primary-care office. This program also
supports mental health consultation in child care settings and enhanced
home visiting services that target child socioemotional development.
Service coordination for child mental health has been attempted in prior
SOC efforts with mixed success. It remains to be seen how integration
with primary-care systems will affect access to high-quality mental health
care and service coordination for all children.
285

Summary
In 2008, the National Center for Children in Poverty published a study as a
25-year follow-up to Jane Knitzer’s heralded report, Unclaimed Children:
The Failure of Public Responsibility to Children in Need of Mental Health
Services. In the intervening years, although there has been an explosion of
knowledge about the biological and social determinants of mental
disorders in childhood and about ways of providing preventive and
treatment services, the report found that state policies and the SOCs in
place for most troubled children and youth appear all too similar to those
criticized 25 years earlier (Cooper et al., 2008).
This is not to say that there has been no change. The vast majority of states
were found to have taken tangible steps to improve their mental health
delivery systems for children. However, a closer analysis revealed that
those changes, while promising, were often limited in scope and depth.
Although all 50 states reported that they had incorporated SOC values and
principles into their delivery systems, only 18 states had taken steps to
sustain these efforts through legislation and regulation, practice standards,
and strategic planning. Too few resources were expended for states to
develop a workable, comprehensive policy framework for addressing the
needs of children and youth with serious mental health conditions. Even
fewer resources had been committed by states to implement service
systems and approaches grounded in the public health framework of
mental health prevention, promotion, and early intervention (Cooper et al.,
2008).
Much can be learned, however, from the Ventura County System of Care
and the Willie M. Program case examples provided in this chapter. In
addition, lessons about the effectiveness of mental health policies and
programs can be derived from many other state and local efforts on behalf
of children and adolescents with mental health problems. Based these
examples and a growing base of evidence-supported program, at least four
core strategies for policy reform in child mental health should be
considered:
1. Structures should be developed to integrate mental health services
into key child-serving agencies, such as public education, child
286

welfare, and juvenile justice.
2. Systematic assessment should identify malleable risk and protective
factors.
3. Evidence-based interventions should be selected and provided to
reduce risk and strengthen protective factors.
4. Services should be developmentally and culturally appropriate and
sequenced sufficiently early in childhood to disrupt negative
developmental trajectories.
Mental health disorders can often be identified in young children and
adolescents (Kenny et al., 2002). It is unfortunate that these disorders are
not usually diagnosed and treated until youth are older. State legislatures
spend millions of dollars annually treating older youth with serious
emotional and behavioral disorders. Too often, these funds are expended in
the juvenile justice and child welfare systems, which begs the question,
“Are these efforts too little, too late?” Increasingly, many experts think
this is the case.
In many communities, mental health services are now being integrated into
public schools through programs such as school-based health clinics.
These clinics improve access to primary health care and provide a less
stigmatized entry into mental health services for many youth (Wu, Katic,
Liu, Fan, & Fuller, 2010). School-based health clinics provide preventive
and early intervention screenings for many health conditions that inhibit
learning. Regular screenings for emotional and behavioral problems can
also be incorporated into clinic services.
For these reasons, schools may be the best public setting in which to
identify troubled children and to link them with appropriate services. More
than 52 million youth attend U.S. public schools (President’s New
Freedom Commission on Mental Health, 2003). The integration of mental
health and public school policies has the potential to save public money
and private heartache by positioning resources to detect and treat mental
health problems before they become florid disorders.
The good news is that some federal policymakers are taking notice and
have proposed legislation that emphasizes mental health promotion and
risk prevention in school settings. For instance, in 2007, Senators
Christopher J. Dodd, Pete Domenici, and Edward M. Kennedy proposed
legislation that would fund local education agencies to expand school
mental health efforts through community–family–school partnerships.
287

Two other recent Senate bills reflect growing federal support for school-
based mental health services: House of Representatives Bill 3003, the
School-Based Health Clinic Establishment Act of 2009; and Senate Bill
1034, the Healthy Schools Act of 2009. Although these measures did not
pass into law, prevention-, promotion-, and treatment-oriented school-
based mental health initiatives continued to gain resonance with
policymakers, culminating in the inclusion of school-based health centers
(SBHCs) in the ACA.
Becoming a federally authorized program is a historic victory for SBHCs,
as it recognizes them as part of the federally supported health-care system.
This historic health reform legislation allows eligible SBHCs to receive
funds supporting management and operation of programs, salaries for
health-care professionals and other personnel, purchase or lease of
equipment, construction projects, and training. However, the SBHC
authorization will be a hollow victory unless it is followed by
appropriations. Currently, only capital improvements have been funded,
with no federal financial support for the actual provision of mental health
services in SBHCs. Until funds are appropriated, only limited federal
support exists for SBHC operations, leaving little hope for the expansion
that has been called for by many, including U.S. Department of Health and
Human Services’ Secretary, Kathleen Sebelius (2010): “We are thrilled
that part of the [health reform] legislation calls for an expanded footprint
of school-based health clinics. . . . I can’t think of a better way to deliver
primary and preventive care to not only students, but their families, than
through school-based clinics.”
Although there is still much work to do, this is an exciting time for child
mental health policy. The coming years may yield a massive improvement
in the availability of mental health services as federal policies and
programs such as the ACA and Project LAUNCH are implemented in
states. The focus on prevention, screening, and early detection coupled
with the broad dissemination of evidence-based interventions holds
promise to make a dramatic impact on the course of mental illness and the
public health burden at a population level. As with any policy, the details
of how these policies are implemented and strategies for continued
sustainability when federal funding and oversight is removed are
absolutely critical to maintaining any progress that is made. Ensuring
adequate funding and the availability of a well-trained workforce are key
challenges to overcome at the federal and state policy levels.
288

We now know a great deal about risk and protective factors for childhood
mental health disorders. Arguably the most important is that identifying,
diagnosing, and treating high-risk children early may interrupt
developmental trajectories that lead to poor outcomes in adolescence and
adulthood. Improving our abilities to prevent or minimize these poor
outcomes should become the goal to which mental health, child welfare,
public education, and juvenile justice policymakers and leaders direct their
concerted efforts.
289

Questions for Discussion
1. What child mental health policies and practices have inhibited the
integration of mental health services into other child-serving systems such
as juvenile justice and child welfare?
2. Are there reasons to keep child-serving agencies organizationally separate at
the state level? Local level?
3. Given what we know about risk factors for a variety of emotional and
behavioral disorders, how can we combine mental health and public
education resources to support prevention and early intervention strategies?
290

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Additional Reading
Allen-Meares, P., & Fraser, M. W. (2004). Intervention with children and
adolescents: An interdisciplinary perspective. Boston: Allyn & Bacon.
Burns, B. J., Phillips, S. D., Wagner, H. R., Barth, R. P., Kolko, D. J.,
Campbell, Y., & Landsverk, J. (2004). Mental health need and access to
mental health services by youths involved with child welfare: A national
survey. Journal of the American Academy of Child & Adolescent
Psychiatry, 43(8), 960–970.
Center for Mental Health Services. (1999). Annual report to Congress on
the evaluation of the Comprehensive Community Mental Health Services
for Children and Their Families Program. Atlanta, GA: ORC Macro.
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E199/default.asp
Costello, E. J., Angold, A., Burns, B. J., Stangl, D. K., Tweed, D. L.,
Erkanli, A., & Worthman, C. M. (1996). The Great Smoky Mountains
Study of youth: Goals, design, methods, and the prevalence of DSM-III-R
disorders. Archives of General Psychiatry, 53, 1129–1136. PMID:
8956679
Gerrity, E., & Folcarelli, C. (2008). Child traumatic stress: What every
policymaker should know. Durham, NC: National Center for Child Trauma
Stress. Retrieved from
http://www.nctsnet.org/nctsn_assets/pdfs/PolicyGuide_CTS2008
Mark, T. L., & Buck, J. A. (2006). Characteristics of U.S. youth with
serious mental disturbances: Data from the National Health Interview
Study. Psychiatric Services, 57, 1573–1578.
Merikangas, K.R., He, J., Burstein, M., Swanson, S.A., Avenevoli, S., Cui,
L.,  . . . Swendsen, J. (2010). Lifetime prevalence of mental disorders in
US adolescents: Results from the National Comorbidity Study-Adolescent
Supplement (NCS-A). Journal of the American Academy of Child and
Adolescent Psychiatry, 49(10), 980–989.
National Alliance for the Mentally Ill. (2001). Families on the brink: The
311

http://mentalhealth.samhsa.gov/publications/allpubs/CB-E199/default.asp

http://www.nctsnet.org/nctsn_assets/pdfs/PolicyGuide_CTS2008

impact of ignoring children with serious mental illness. Arlington, VA:
Author.
President’s New Freedom Commission on Mental Health. (2003).
Achieving the promise: Transforming mental health care in America.
Rockville, MD: U.S. Department of Health and Human Services.
Retrieved from http://www.mentalhealth
commission.gov/reports/FinalReport/toc.html
Substance Abuse and Mental Health Services Administration. (2005).
Transforming mental health care in America: The federal action agenda:
First steps. Rockville, MD: Author.
Surgeon General. (1999). Mental health: A report from the Surgeon
General. Washington, DC: Department of Health and Human Services.
Retrieved from http://mental
health.samhsa.gov/cmhs/surgeongeneral/surgeongeneralrpt.asp
Surgeon General. (2000). Report of the surgeon general’s conference on
children’s mental health: A national action agenda. Washington, DC:
Office of the Surgeon General. Retrieved from
http://www.surgeongeneral.gov/topics/cmh/childreport.html
312

http://www.mentalhealth commission.gov/reports/FinalReport/toc.html

http://mental health.samhsa.gov/cmhs/surgeongeneral/surgeongeneralrpt.asp

http://www.surgeongeneral.gov/topics/cmh/childreport.html

Web-Based Resources (General)
Bazelon Center for Mental Health and Law, http://www.bazelon.org/
Federation of Families for Children’s Mental Health, http:/www.ffcmh.org
Mental Health America, http://www.nmha.org/
National Alliance for the Mentally Ill,
http://www.nami.org/Hometemplate.cfm
National Institute of Mental Health, http://www.nimh.nih.gov/
Substance Abuse and Mental Health Services Administration,
http://www.mental health.samhsa.gov/
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Home

http://www.ffcmh.org

http://www.nmha.org/

http://www.nami.org/Hometemplate.cfm

http://www.nimh.nih.gov/

http://www.mental

Web-Based Resources (Evidence-Based
Practices)
Association for Cognitive and Behavioral Therapies & Society of Clinical
Child and Adolescent Psychology. (n.d.). Evidence-based mental health
treatment for children and adolescents. Retrieved from
http://www.effectivechildtherapy.com/
National Child Traumatic Stress Network. (2010). Empirically supported
treatments and promising practices. Retrieved from
http://www.nctsnet.org/nccts/nav.do? pid=ctr_top_trmnt_prom
Substance Abuse and Mental Health Services Administration. (2007). A
guide to evidence-based practices on the web. Retrieved from
www.samhsa.gov/ebpWebGuide/index.asp
Substance Abuse and Mental Health Services Administration. (2010).
National registry of evidence-based practices: NREPP. Retrieved from
www.nrepp.samhsa.gov/
314

http://www.effectivechildtherapy.com/

http://www.nctsnet.org/nccts/nav.do? pid=ctr_top_trmnt_prom

http://www.samhsa.gov/ebpWebGuide/index.asp

http://www.nrepp.samhsa.gov/

Chapter 6 Health Policy for Children and
Youth
Kathleen A. Rounds
William J. Hall
Guadalupe V. Huitron
315

Purpose and Overview of Health Policies
for Children and Youth
The primary purpose of health policies aimed at children and youth is to
provide access to preventive and medical care. Access is defined as the
ability to obtain needed care, and lack of access is an indication of unmet
health care needs (Shi & Singh, 2001). Access to health care encompasses
a number of dimensions, including
Availability: Does the service exist?
Cultural acceptability: Is there a fit between the cultural belief
systems and languages of the client and the provider?
Convenience: Does the client have transportation to the service, and
can the client access the service at a convenient time?
Affordability: Can the client pay for the service, or does the client
have private or public insurance to cover the cost? (Anderson, 1995;
Donabedian, 1973)
The U.S. health-care environment is distinguished from health-care
systems in other industrialized nations by three critical features. First, the
United States is the only country in the Western world that does not have
universal health-care coverage for its children and adolescents (Stein,
1997). The full implementation of the Patient Protection and Affordable
Care Act (ACA) will increase coverage considerably, but universal
coverage will still not be a reality in the United States (Nardin, Zallman,
McCormick, Woolhandler, & Himelssem, 2013). Second, the U.S. health
care system is a heavily privatized delivery system financed by public
dollars. In 2011, federal, state, and local dollars constituted about 52% of
all health-care expenditures (National Center for Health Statistics, 2014).
The current system is an amalgam of private and government sources that
operates in a market-oriented, commodity-driven economy in which many
of the key players are motivated by profit margins (Halfon & Hochstein,
1997; Shi & Singh, 2001). Third, in large part, U.S. health care is a poorly
coordinated, fragmented system (Institute of Medicine of the National
Academies, 2012).
Halfon and Hochstein (1997) posed two major policy questions regarding
the delivery of health care for children and youth. The first question is
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referred to as the “insurance question.” It focuses on expanding access to
health insurance for children and youth in addition to the elimination of
nonfinancial barriers to access (e.g., outreach and transportation). Halfon
and Hochstein labeled the second question the “systems question.” it asks
how health-care services might be organized and integrated with other
systems to meet the needs of children and youth more effectively.
Federal health-care policies affect all children, youth, and their families.
However, these policies have a more dramatic effect on low-income
households, which are disproportionately African American, Latino, or
other racial/ethnic minorities. The public insurance programs Medicaid
and Children’s Health Insurance (CHIP) have made a significant positive
difference in coverage for minority children who are more likely to have
health problems and be uninsured than White children (Kaiser
Commission on Medicaid and the Uninsured, 2013). Even with these
federal programs, gaps in eligibility for Medicaid and CHIP have left large
numbers of minority children without insurance. Researchers have found
that children who lack insurance coverage or experience insurance
instability (i.e., disruptions in coverage) are significantly more likely to
lack a usual source of care, to delay care, or to have unmet medical needs
than children with insurance (Cassedy, Fairbrother, & Newacheck, 2008).
Starfield (2008) noted that having both insurance and a usual source of
care are critical; the insurance is the pathway to a usual source of care,
which then leads to children receiving needed services. The ACA
addresses insurance gaps through provisions aimed at expanding and
stabilizing insurance coverage and through promoting “patient-centered
medical homes” (PCMH). These increase the likelihood that all children
and youth will have a usual source of care.
Because of special vulnerabilities, some federal health-care policies
specifically target infants, very young children, or adolescents. For
example, eligibility for public health-insurance programs (e.g., Medicaid)
has been expanded to provide access to greater numbers of infants and
young children, who otherwise would likely have unmet health needs. This
policy change was based on the recognition that a child’s early years are
important not only for preventive care (i.e., well-baby checkups and
immunizations) but also for screenings to detect developmental and health
problems. Adolescents are another developmentally vulnerable group
because they have a high likelihood of engaging in high-risk behaviors
(e.g., unprotected sex, substance use, smoking) that have long-term health
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consequences. During early adolescence, most youths develop health
behaviors that persist into adulthood (Greydanus, Patel, & Greydanus,
2003).
Federal health policy also targets children who meet the definition of
“children with special health care needs.” However, uncertainty over
which children made up this population prompted the Maternal and Child
Health Bureau [MCHB] of the U.S. Department of Health and Human
Services [DHHS] to form a work group expressly to establish a clear
definition. This definition has been adopted by the DHHS as well as the
American Academy of Pediatrics: “Children who have, or are at increased
risk for, chronic physical, developmental, behavioral, or emotional
conditions and who also require health and related services of a type or
amount beyond that required by children generally” (McPherson et al.,
1998, p. 138). Based on this definition, and according to the 2011/12
National Survey of Children with Special Health Care Needs, 19.8% of
U.S. children between the ages of 0 and 17 years have special health-care
needs. The prevalence of special health-care needs has been estimated at
23% of U.S. households with children (Child and Adolescent Health
Measurement Initiative, 2013). However, these rates do not include
children in the at-risk category that is encompassed in the definition used
by the MCHB (Bethell, Read, Blumberg, & Newacheck, 2008).
In this chapter, we review the prevalence of four health problems
experienced by children and youth: low birth weight, asthma, overweight
and obesity, and sexually transmitted infections. We identify the risk and
protective factors associated with these health problems. We summarize
the historical development of child health policy and examine ways in
which child health policy has been based on risk and protective factors.
Using a case example, we discuss strategies for integrating health care
with other service systems that serve children and youth.
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Risk and Protective Factors for Health
Problems in Childhood and Adolescence
Infants, children, and adolescents in the United States experience a range
of health problems, with the most frequent being low birth weight, asthma,
overweight or obesity, and sexually transmitted infections. In this chapter,
we focus on the prevalence of these health problems; health disparities
associated with race, ethnicity, and socioeconomic status; and risk factors
across multiple system levels. (See Table 6.1 for prevalence data on low
birth weight, asthma, overweight, and obesity.) This section concludes
with a discussion of protective factors related to access to health-care
services.
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Low Birth Weight
Infants with low birth weight (LBW) are defined as those weighing less
than 2,500 grams (about 5.5 pounds). The incidence of LBW in the United
States increased nearly 20% between 1990 and 2006 and is a serious
public-health concern because it can lead to adverse health outcomes
throughout life. In 2012, the rate was 7.99%, a 3% dip from the 2006 high
of 8.26%. The rate of infants born in 2012 with very low birth weight
(VLBW), that is, weighing less than 1,500 grams, also edged downward to
1.42% from a 2006 high of 1.49% (Martin, Hamilton, Osterman, Curtin, &
Mathews, 2013). LBW and VLBW infants are at increased risk for a host
of health and developmental problems, including neonatal mortality,
neurodevelopmental disorders, respiratory distress syndrome, cardiac
problems (March of Dimes Foundation, 2014), and delayed cognitive
functioning (Reuner, Hassenpflug, Pietz, & Philippi, 2009). Compared
with infants of normal birth weight, LBW infants face a greater than
fivefold increase in risk of death during their first year and VLBW infants
incur a 100-fold increase risk of death in their first year (Martin et al.,
2013).
Racial and ethnic disparities in the incidence of LBW and VLBW infants
present a serious public-health issue in the United States. The rate of LBW
live births among non-Hispanic African American mothers in 2012
(13.18%) was about 2 times the rate reported for either non-Hispanic
White mothers (6.97%) or Hispanic mothers (6.96%; Martin et al., 2013).
In addition, non-Hispanic African American mothers were nearly 2 times
more likely to have a VLBW live birth than non-Hispanic White mothers
or Hispanic mothers (2.94%, 1.13%, and 1.2%, respectively; Martin et al.,
2013). Researchers are increasingly examining the impact of maternal
stress, particularly stress caused by maternal perceived racism
(Dominguez, 2008; Holland, Kitzman, & Veazie, 2009; Rosenthal &
Lobel, 2011) and the role of living in hypersegregated residential areas
(Love, David, Rankin, & Collins, 2010; Osypuk & Acevedo-Garcia, 2008)
and their contribution to low birth weight. Using a life-course approach to
explain birth outcome disparities, Lu et al. (2010) developed a model that
accounts for the life-long cumulative effect of experiencing racism and
social inequality and the resulting allostatic load and its impact on birth
outcomes.
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A variety of factors, including genetics, lifestyle, and environmental
conditions, can substantially affect birth weight. Maternal characteristics
that are risk factors for LBW include smoking or drug use during
pregnancy, limited or late prenatal care, and the number of previous
pregnancies (Institute of Medicine of the National Academies, 2006). In
the decades since Simpson’s 1957 report on the prenatal effects of
maternal smoking, smoking during pregnancy has become well established
as one of the most preventable risk factors for LBW (Bailey, McCook,
Hodge, McGrady, 2012; Rogers, 2008). According to the CDC Pregnancy
Risk Assessment Monitoring System (PRAMS) in 2010, 12.3% of
pregnant women smoked during their pregnancy and 10.7% smoked
during the last trimester of their pregnancy (Tong et al., 2013).
Researchers analyzing 2002 birth data estimated that 5% to 8% of very and
moderately preterm births and 13% to 19% of term LBW deliveries could
be attributed to maternal smoking during pregnancy (Dietz et al., 2010).
Early childbearing (i.e., maternal age 15 years or younger) has been noted
as a significant risk factor for preterm delivery and low birth weight. In a
systematic review of 20 studies, Gibbs, Wendt, Peters, and Hogue (2012)
found a relationship between maternal age and LBW; as maternal age
increased, this association decreased. Their review provides evidence that
very young maternal age (15 years or younger) has a negative, biological
impact on preterm delivery and birth weight. Most likely, biological as
well as social factors contribute to this relationship. Although early
childbearing occurs across the socioeconomic spectrum, researchers
investigating maternal age trends have argued that the incidence of early
childbearing is disproportionately high among ethnic minority and
impoverished young women (Chen, Wen, Fleming, Yang, & Walker,
2008). Chen and colleagues noted that the poverty faced by many young
women also contributes to their delayed entry into prenatal care, to their
inadequate weight gain during pregnancy, and to their increased incidence
of perinatal medical complications. The nutritional demands of normal
physiological development during adolescence may be one factor
contributing to the increased prevalence of LBW among newborns of
adolescent mothers because these demands create a maternal–fetal
competition for nutrients (Kramer & Lancaster, 2010). This competition
may be exacerbated in low-income families, which often experience food
insecurity because they cannot afford food and live in communities where
nutritional foods may be less available or cost-prohibitive.
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Note. Overweight is defined as Body Mass Index (BMI) at or above the 85th
percentile and lower than the 95th percentile; obesity is defined as a BMI at or
above the 95th percentile (Centers for Disease Control and Prevention [CDC],
2014a,b,c; Ogden, Carroll, Kit, & Flegal, 2014).
In the last three decades, the United States experienced a significant
increase in the rate of multiple births, which—in part—was the result of
delayed childbearing and increased use of fertility drugs and procedures.
These increases in multiple births, particularly twin births, had a
significant impact on the increased incidence of LBW, preterm delivery,
and prenatal mortality in the United States (Boulet et al., 2008). However,
the rising incidence seems to have peeked. Between 1980 and 2009, the
number of twin births doubled in the United States. In 2012, the twin birth
rate was 33.1 per 1,000 total births, unchanged from 2009 to 2011 (Martin
et al., 2013). Similarly, between 1980 and 1998, the rate of higher-order
multiple births increased from 37 to 193.5 births per 100,000 live births.
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The rate in 2012 was 124.4 per 100,000 births, which is more than a one-
third reduction from the 1998 high (Martin et al., 2013).
323

Asthma
Asthma, a long-term lung disease that is characterized by recurrent periods
of inflammation in the airways, shortness of breath, coughing, and
wheezing, is the most common chronic illness and the most prevalent
cause of disability among children in the United States (Williams,
Sternthal, & Wright, 2009; Wu, Smith, Bokhour, Hohman, & Lieu, 2008).
Indeed, the prevalence of childhood asthma has more than doubled since
1980 (Akinbami, Moorman, Garbe, & Sondik, 2009). Approximately 10
million U.S. children and adolescents have been diagnosed with asthma at
some point in their lives, representing 14% of the U.S. population younger
than 18 years (CDC, 2013a). Over half of children with asthma reported at
least one attack in the past year (CDC, 2014a). During an asthma attack or
episode, a child’s airways narrow, making it difficult to breathe, often
resulting in wheezing. Asthma is the third leading cause of hospitalization
among children under the age of 15 years, and each year asthma accounts
for more than 14 million missed school days (American Lung Association,
2012). Asthma is the second most costly health problem among children in
the United States (Soni, 2014).
Racial and ethnic minority children have higher rates of asthma. Lifetime
and current prevalence rates of asthma were higher for both African
American children (22% and 16%, respectively) and Hispanic children
(14% and 9%, respectively) as compared with White children (12% and
8%, respectively) (CDC, 2013a). In addition, compared with White
children, African American children are 4 times more likely to be
hospitalized because of asthma and 5 times more likely to die from asthma
(Wu et al., 2008).
Although the exact causes of asthma are not fully understood, an array of
risk factors increases children’s risk of developing asthma; many of these
risk factors are related to poverty. Low socioeconomic status and family
income are associated with both previous asthma diagnosis and incidence
of asthma attacks (Williams et al., 2009). Children living below the federal
poverty level (FPL) are more likely to have been diagnosed with asthma
(19%) than those living between 100% and 200% of federal poverty
guidelines (14%) and those living at or above 200% of the FPL (12%)
(CDC, 2013a). Children receiving Medicaid are much more likely to have
been diagnosed with asthma (18%) at some point in their lives than
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children with private insurance (12%) (CDC, 2013a).
Social and environmental factors are associated with increased risk for the
development of asthma during childhood and adolescence. Exposure to
tobacco smoke, most commonly from parental smoking in the household,
increases the likelihood of developing childhood asthma as well as
exacerbating existing asthma (Baena-Cagnani, Gomez, Baena-Cagnani, &
Canonica, 2009; Gerald et al., 2009; Lawson, Janssen, Bruner, Hossain, &
Pickett, 2014). Research also indicates that prenatal exposure to tobacco
smoke increases the risk that a child will subsequently develop childhood
asthma (Baena-Cagnani et al., 2009; Midodzi, Rowe, Majaesic, Saunders,
& Senthilselvan, 2010). Other environmental risks include dust mite, cat,
and cockroach allergens (Subbarao, Mandhane, & Sears, 2009; Wang et 
al., 2009). One study showed that exposure to cockroaches at some point
in childhood significantly increased the risk for developing childhood
asthma, and exposure to cockroach allergens during infancy was
associated with a twofold increase in the risk of developing asthma
(Salam, Li, Langholz, & Gilliland, 2004). Research suggests that poverty
at the individual, household, and community levels is directly associated
with both increased risk of developing asthma and increased risk of
experiencing greater severity of asthma attacks (Midodzi et al., 2010;
Subbarao et al., 2009; Thakur et al., 2013; Williams et al., 2009).
Other health-related factors also affect children’s risk of asthma. There is
evidence of an association between LBW and childhood asthma (Ahmad et
al., 2009; Midodzi et al., 2010). In addition, overweight and obese children
and adolescents not only are more likely to develop asthma but also are
more likely to develop severe asthma, which is associated with more
frequent hospital and clinic visits for asthma-related issues (Black, Zhou,
Takayanagi, Jacobsen, & Koebnick, 2013; Liu, Kieckhefer, & Gau, 2013).
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Overweight and Obesity
Since the 1960s, the prevalence of overweight and obese children and
adolescents in the United States has tripled (Ogden & Carroll, 2010).
Overweight and obesity are terms that refer to ranges of body weight that
exceed what is considered healthy for a given height. Overweight is
defined as a body mass index (BMI) at or above the 85th percentile and
lower than the 95th percentile, and obesity is defined as a BMI at or above
the 95th percentile for youth of the same age and sex (Barlow & Expert
Committee, 2007).
Almost one-third (32%) of children and adolescents in the United States
are overweight or obese (15% and 17%, respectively) (Ogden et al., 2014).
Prevalence rates of obesity increase with age: 8% of children between the
ages of 2 and 5 years are obese, 18% of children between the ages of 6 and
11 years are obese, and 21% of adolescents between the ages of 12 and 19
years are obese. Rates of overweight and obesity do not differ markedly by
gender. On the other hand, there are significant differences by
race/ethnicity. Rates of overweight and obesity are highest among
Hispanic (39%) and Black (35%) children, with White (29%) and Asian
(20%) children showing lower prevalence rates (Ogden et al., 2014).
Childhood and adolescent obesity is associated with a number of health
problems, including high blood pressure, high cholesterol, impaired
glucose tolerance, insulin resistance, type-2 diabetes, sleep apnea, asthma,
bone and joint problems, fatty liver disease, gallstones, heartburn, and low
self-esteem (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007; Han,
Lawlor, & Kimm, 2010; Sutherland, 2008; Swartz & Puhl, 2003; Taylor,
Theim, & Mirch, 2006).
Various risk factors predispose children and adolescents to become
overweight and obese. Emerging research suggests that maternal obesity
during pregnancy may be associated with childhood obesity (Catalano et
al., 2009; Dabelea, 2007; Kral et al., 2006; Lawlor et al., 2008). Children’s
dietary behaviors also influence their weight. Strong evidence supports the
relationship between the consumption of sugar-sweetened beverages and
child obesity (Moreno & Rodriguez, 2007). Children’s food and beverage
intake is highly dependent on what is available at home, which is highly
dependent on the availability and cost of foods and beverages in local food
outlets (Powell & Bao, 2009). Researchers found that higher prices for
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fresh fruits and vegetables in neighborhood food outlets were significantly
associated with higher BMIs among children (Powell & Bao, 2009). In
addition, lower-income children and adolescents are more likely to be
obese than their higher-income peers (Ogden, Lamb, Carroll, & Flegal,
2010). Other dietary risk factors for child obesity include buying lunch at
school, eating dinner without parental supervision, missing breakfast, and
consuming fewer calories at breakfast and more at dinner (Moreno &
Rodriguez, 2007). In terms of health education for children and
adolescents, 18% of U.S. school districts do not require that elementary,
middle, and high schools teach students about nutrition and dietary
behavior. In addition, 31% of U.S. school districts do not require that
elementary, middle, and high schools teach students about physical
activity and fitness (CDC, 2013b).
Low levels of physical activity are associated with childhood obesity
(Jimenez-Pavon, Kelly, & Reilly, 2010). Approximately 40% of U.S.
school districts do not require that elementary schools provide students
with regularly scheduled recess. In addition, 8% of districts do not have a
policy requiring physical education for middle and high school students
(CDC, 2013b). Engagement in sedentary activities, such as watching
television, playing video games, using a computer, and using the
telephone, is associated with child obesity (Marshall, Biddle, Gorely,
Cameron, & Murdey, 2004). Higher levels of screen time are associated
with lower family income and the presence of a television in a child’s
bedroom (He, Harris, Piché, & Beynon, 2009). On the other hand,
protective factors include participating in sports and after-school programs
(He et al., 2009).
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Sexually Transmitted Infections
Sexually transmitted infections (STIs) are a significant health problem
facing adolescents in the United States. Compared with older adults,
adolescents and young adults are at increased risk for acquiring STIs
(CDC, 2014b). Although those between the ages of 15 and 24 years
represent only 25% of the sexually experienced population in the United
States, this age group accounts for almost half of the estimated 20 million
new STI cases each year (CDC, 2014b).
Unprotected sexual intercourse can lead not only to STIs but also to
unwanted pregnancy; therefore, teen pregnancy rates are considered to be
an indicator of rates of high-risk sexual behavior. The most recent data
show that 57 out of 1,000 women between the ages of 15 and 19 years
became pregnant in 2010 (Kost & Henshaw, 2014). In other words,
approximately 6% of teens became pregnant in 2010. This rate represents a
30-year low in the teen pregnancy rate due to significant drops between
2008 and 2010. Nonetheless, 82% of teen pregnancies are unplanned
(Finer & Zolna, 2011). The connection between unintended teen
pregnancies and STI risk is crucial because risky sexual behaviors that
may result in pregnancy also place teens at high risk for STIs.
It is difficult to estimate national STI rates because states have different
reporting requirements. Currently, chancroid, chlamydia, gonorrhea,
syphilis, HIV, and hepatitis B are the only STIs reported by every state to
the CDC (Workowski & Berman, 2010). The accurate collection of
incidence and prevalence data is profoundly inhibited by the wide
variation in the quality of surveillance data at local and state levels as well
as the lack of standardized state reporting mechanisms for many common
STIs, including genital herpes (herpes simplex viruses type 1 and type 2)
and human papillomavirus. Disparities in reporting between public and
private health-care providers further challenge accurate STI data
collection, resulting in the potential underestimation of STIs diagnosed in
the private health sector (Rounds, 2004). In addition, many STIs can be
asymptomatic and remain undetected, which further contributes to the
underestimation of STI rates among adolescents (Rounds, 2004). Lack of
access to health care—a significant issue among many adolescents—may
also add to the underestimation of STI rates.
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Chlamydia and gonorrhea are the most prevalent among the STIs that
states are required to report to the CDC, and each can cause serious health
consequences if undetected or left untreated, particularly in young women
(CDC, 2014b). In 2012, nearly 69% of all reported chlamydia infections
(for which data on age were available) were among young people between
the ages of 15 and 24 years (CDC, 2014b). Among women in 2012, the
highest age-specific reported prevalence rates of chlamydia were in young
women between the ages of 15 and 19 years and those between the ages of
20 and 24 years, with 3,291 and 3,695 cases per 100,000 females,
respectively. These rates were significantly higher than those among males
in the same age groups (CDC, 2014b). Compared with many other STIs,
syphilis is relatively rare among U.S. adolescents and young adults. The
prevalence rates of syphilis for 2012 are based on estimates of reported
cases and indicate about four reported cases per 100,000 persons 15 to 19
years old and 15 reported cases per 100,000 persons 20 to 24 years old
(CDC, 2014b).
Approximately 58% of gonorrhea infections reported in 2012 were among
those 15 to 24 years old (CDC, 2014b). In 2012, the incidence was highest
among women between the ages of 15 and 24 years old and among men
between 20 and 24 years old (CDC, 2014b). For young women (15 to 19
years old) in 2012, there were 521 cases of gonorrhea per 100,000 (CDC,
2014b). Among young men (15 to 19 years old) in 2012, the gonorrhea
incidence rate was significantly lower, at 239 cases per 100,000 (CDC,
2014b).
As previously noted, states are not required to report cases of herpes
simplex virus and human papillomavirus to the CDC (Workowski &
Berman, 2010). Both of these viral infections can be asymptomatic and,
therefore, are frequently transmitted to others by those unaware of their
infection. There is little precise information about the prevalence or
incidence of either STI among adolescents in the United States, although
both are widely prevalent among young people. However, the prevalence
of these STIs is an important public health concern because prior exposure
to STIs has been linked to predisposition for contracting the HIV virus
(CDC, 2014c).
The overall U.S. STI rates do not reflect the disproportionate impact of
STIs on certain high-risk adolescent populations such as youth involved
with the juvenile justice system. Youth in the juvenile justice system have
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elevated rates of engaging in sexual risky behavior and have higher rates
of STIs than their peers. These rates may be attributable to three factors:
Youth involved in the juvenile justice system report onset of sexual
activity at younger ages and with more partners than their peers; youth
involved in the juvenile justice system are disproportionately African
American, and African Americans are disproportionately affected by STIs;
and youth involved in the juvenile justice system have higher rates of
psychiatric disorders, which are associated with engaging in high-risk
sexual behaviors, than the general population (Elkington et al., 2008). The
prevalence rates of chlamydia and gonorrhea in juvenile detention settings
are consistently higher than in any other subpopulation group (CDC,
2012). In 2011, the overall chlamydia prevalence rate was 16% among
adolescent females entering juvenile correction facilities and 6% among
young men entering juvenile correctional facilities (CDC, 2012). The
median site-specific gonorrhea rate among adolescent females entering
juvenile correctional facilities in 2011 was 3%, compared with 1% among
males (CDC, 2012).
Human immunodeficiency virus (HIV), the virus that over time leads to
acquired immunodeficiency syndrome (AIDS), disproportionately affects
adolescents in the United States. In 2010, 26% of all new HIV infections
in the United States occurred among young people 13 to 24 years old, the
majority of whom acquired the virus through sexual transmission (CDC,
2014c). Within this age group, gay, bisexual, and other men who have sex
with men are particularly affected by HIV/AIDS (CDC, 2014c). The large
majority of new HIV/AIDS cases among male adolescents 13 to 19 years
old were attributed to male-to-male sexual contact (CDC, 2014c). In
addition, there is a racial disparity in the HIV/AIDS epidemic in the
United States, with African American adolescents disproportionately
affected. The link between HIV and other STIs is important because the
presence of an STI places an individual at greater risk for contracting HIV
when exposed to the virus through sexual contact (CDC, 2014c).
As compared with older adults, many biological, developmental, and
social factors place sexually active adolescents at higher risk for
contracting STIs. Table 6.2 presents a summary of risk factors associated
with adolescents’ risky sexual behaviors. Adolescents are more likely than
are older adults to have unprotected sex and multiple sex partners (either
concurrent or sequential), which increases the risk of exposure to an STI-
infected partner (Monasterio, Hwang, & Shafer, 2007). According to the
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Youth Risk Behavior Survey, 41% of all sexually active adolescents
reported not using a condom during their last sexual intercourse and 22%
of sexually active youth reported having used alcohol or other drugs before
their last sexual intercourse (Kann et al., 2014). As compared with young
men, the higher rates of STIs among young women appear to be based in
both behavior and physiology. Behaviorally, young women have a greater
likelihood of choosing older, experienced sexual partners, which increases
their potential exposure to STIs (Manlove, Terry-Humen, & Ikramullah,
2006). The higher rates of STIs among young women are also accounted
for, in part, by anatomy, which makes females physiologically more
susceptible to many STIs than males (Manlove et al., 2006).
Research has shown that there is a link between childhood sexual abuse
and re-victimization and high-risk sexual behaviors (Lalor & McElvaney,
2010). Adolescent females who self-report a history of childhood and
adolescent sexual abuse are more likely to have had consensual intercourse
at a younger age, to have not used birth control, to have had multiple sex
partners, and to have used alcohol or drugs during their most recent sexual
experience (Senn, Carey, & Vanable, 2008). Morrison-Beedy, Carey,
Feng, and Tu (2008) found that adolescent females with a history of
psychological distress were at increased risk for multiple adverse sexual
and reproductive health outcomes. Lee, O’Riordan, and Lazebnik (2009)
posited that depressed individuals may engage in risky sexual behaviors as
a way of coping with depressive symptoms. In a study of African
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American adolescent females, a history of depressive symptoms was
associated with a greater number of lifetime sexual partners, history of
STIs, and previous or current pregnancy (Lee et al., 2009). Adolescents
may face numerous barriers to accessing high-quality STI prevention and
treatment services. Lack of insurance or alternative payment source, lack
of youth-friendly services, lack of transportation, and confidentiality
concerns can all inhibit adolescents from accessing quality services that
address sexual health needs (Monasterio et al., 2007).
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Access to Care as a Protective Factor
Although research has clearly identified biological, developmental,
lifestyle, and environmental risk factors associated with health problems,
research on protective factors has been more limited. In the case of
children and youth at risk for poor health outcomes, access to health care is
a protective factor. A host of factors that facilitate access to health care
may also be seen as providing a protective effect. Health insurance and
health-care-delivery models that make health care accessible (e.g.,
community-based care, school-based care, convenient hours, support
services, perceived confidentiality among adolescents, and culturally
competent services) have a major impact on whether services are
accessible and used. Access to health care (i.e., an acceptable provider is
available, the individual can get to the provider, and the individual has
health insurance to pay for medical care) serves as a protective factor when
a child needs medical care (Fraser & Terzian, 2005). That is, access to
medical treatment may reduce or buffer the effect of the health condition.
For example, ongoing medical treatment for asthma reduces the likelihood
that a child will experience an acute episode requiring treatment in the
emergency room. Access to health care can also serve as a protective
factor by interrupting a chain of risk (Fraser & Terzian, 2005). For
instance, early medical treatment for chlamydia, combined with counseling
and education on safe sexual practices, may reduce the likelihood that an
adolescent girl will develop long-term reproductive-health problems. As a
protective factor, access to care can also prevent or block the onset of a
risk factor (Fraser & Terzian, 2005). One example is the case of a mother
whose access to ongoing preventive health services may prevent her young
child from becoming at risk for obesity.
Access to health services, or the lack thereof, is closely related to the
discussion of poverty-related risk factors identified for each of the
previously discussed childhood and adolescent health problems. According
to U.S. national data, older adolescents, racial/ethnic minorities, sexually
active youth, and uninsured youth are more likely to have neglected health
care—a significant risk factor for a wide array of health problems (Kaiser
Commission on Medicaid and the Uninsured, 2013).
The availability of health insurance as one component of access to care is a
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critical protective factor to increase the likelihood that children and
adolescents will have a usual source of care, which increases their
likelihood to receive health care. Children and adolescents without health
insurance, either public or private, are more likely to lack a usual health
care provider, to have unmet health needs, and to miss at least annual
contact with a health-care provider (DeVoe, Petering, & Krois, 2008). It is
estimated that 10.9% of children in the United States had no form of health
insurance in 2007; this percentage dropped to 6.6% in 2012 (Kaiser
Commission on Medicaid and the Uninsured, 2013). Between 2002 and
2012, among children in families with income just above the poverty level
(100% to 199% of poverty guidelines), the percentage of uninsured
children under the age of 18 years dropped from 17.0% to 10.4%, while
the percentage with coverage through Medicaid or the Children’s Health
Insurance Program (CHIP) increased from 38.6% to 57.3%. In 2011 to
2012, 28.4% of uninsured children did not have a usual source of health
care, compared with 1.7% of children who were covered by private
insurance and 3.1% of those who were covered by Medicaid (National
Center for Health Statistics, 2014).
Although the absence of insurance coverage is a major factor related to
access to health care, health insurance alone may not be enough to ensure
that children and adolescents receive needed health-care services,
particularly among those who are low income (DeVoe et al., 2007). As
previously noted, having a usual source of care may reduce many barriers
to accessing health-care services, although it does not ensure that such
services will be used or received when needed (Szilagyi, Schuster, &
Cheng, 2009). Many nonfinancial factors also appear to affect health-care
accessibility and utilization. These factors include delivery system
structure, provider availability and cultural competence, preventive care
education, enabling services (e.g., transportation and translation), child
care, and appointment reminders (Newacheck, Hung, Park, Brindis, &
Irwin, 2003).
334

Risk, Resilience, and Protection in Health
Policy for Children and Youth
In this section, we present a brief overview of the development of child
health policy from the beginning of the 20th century to the present. We
also examine the effectiveness of health policies in meeting the health-
care needs of children and youth. We conclude by discussing the extent to
which policy has been based on risk and protective factors.
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Historical Development of Child Health Policy
Child health policy has developed in a piecemeal way, with policy
initiatives often having been episodic responses to the failure of the private
marketplace (Barr, Lee, & Benjamin, 2003). Although the federal
government was involved to some extent in responding to children’s health
and mental health needs through the establishment of the Children’s
Bureau in 1912 and then later through the establishment of the Maternal
and Child Health service system, it did not become heavily involved in
financing health care for children and youth until the establishment of the
Medicaid program in 1965. Table 6.3 provides a chronological listing of
major policy initiatives and their primary purposes.
At the turn of the 20th century, living conditions were so poor for many
American families that the average state infant mortality rate was 150 per
1,000. In some industrial cities, it was as high as 180 per1,000 (Margolis
& Kotch, 2013). In response to this high infant mortality rate, social
workers joined forces with public health workers and advocates from the
fields of education, medicine, and labor to lobby for the passage of
legislation to establish the Children’s Bureau in 1912 (Margolis & Kotch,
2013). The Children’s Bureau was initially created with a mandate to study
the problem of infant mortality and address the problem by disseminating
information on promising interventions to the states. Based on the success
of the Children’s Bureau, Congress passed the Sheppard-Towner
Maternity and Infancy Act in 1921, creating the first national maternal and
child health program that provided grants-in-aid to states. The Sheppard-
Towner Act represented the first federal effort to establish a maternal and
child health infrastructure within the states, and it laid the groundwork for
future collaboration between state and federal governments to address
maternal and child health (Kessel, Jaros, & Harker, 2003; Margolis &
Kotch, 2013). During the 8 years for which the act was in effect, the
number of permanent maternal and child health centers and state child
hygiene and welfare programs increased.
The Sheppard-Towner Act was not renewed in 1929, and the Great
Depression had a major impact on the ability of states to provide maternal
and child health services. These events contributed to an increase in infant
mortality across the nation. In response to rising infant mortality rates and
the widespread poverty among women and children, Title V of the Social
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Security Act was passed in 1935. Title V had three parts that were
administered under the Children’s Bureau: (1) Maternal and Child Health
Services (MCH) enabled states to expand services that had been provided
by the Sheppard-Towner Act; (2) the Services for Crippled Children’s
Program enabled states to locate and provide medical and other services
for children who had “crippling conditions”; and (3) Child Welfare
Services enabled states to provide services to homeless, dependent, and
neglected children (Kessel et al., 2003). Title V funding through the
Services for Crippled Children’s Program was the only source of federal
funding for children with special health-care needs (the majority of whom
needed orthopedic treatment as a result of the polio epidemic) until 1965,
when the Medicaid program was established.
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Title V has been amended numerous times over the past decades. The
Omnibus Budget Reconciliation Act of 1981, PL 97-35, consolidated
seven Title V categorical programs into a block grant program. The
Omnibus Budget Reconciliation Act of 1989 (OBRA ’89), PL 101-239,
introduced stricter requirements for state planning and reporting regarding
use of Title V funds. OBRA ’89 gave authority to the Maternal and Child
Health Bureau to help develop systems of care for children with special
health-care needs and their families and expanded the mission of related
programs to promote the development of community-based systems of
services (McPherson et al., 1998). State health departments administer the
Title V MCH Services Block Grant Program (Maternal and Child Health
Bureau, n.d.). The federal government requires states to conduct a
statewide needs assessment every 5 years and to submit a plan for meeting
those needs. Title V block grant funds are used primarily for service
system development to reduce infant mortality and the incidence of
disabilities and to provide and ensure access to health care for women of
reproductive age, access to preventive and primary care services for
children, and access to family-centered, community-based, coordinated
care for children with special health-care needs.
The Medicaid program was enacted in 1965 as a joint state and federally
funded health insurance program for women who were on public
assistance and their children and other persons who were elderly, blind, or
disabled. Each state administers its own Medicaid program according to
federal guidelines. The federal government provides matching funds for
some of the state Medicaid costs (on average about 57% of costs are
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matched). In 1967, the Early and Periodic Screening, Diagnosis, and
Treatment Program (EPSDT) was created as a unique prevention
component of the Medicaid program to ensure that children receiving
Medicaid would receive preventive health services in addition to acute and
chronic medical care (Sardell & Johnson, 1998). The EPSDT program
requires states to offer age-appropriate screenings and immunizations,
follow-up diagnostic services, and medical treatment. Because many states
never fully implemented their EPSDT program, and to increase the
number of children receiving preventive care, Congress included
provisions in OBRA ’89 that expanded the EPSDT program. The
expanded provisions required states to conduct aggressive outreach and
case-finding efforts as well as to provide enabling services such as case
management, transportation, and translation services (Rosenbach & Gavin,
1998).
During the 1980s and 1990s, the rates of children and youth covered by
private health insurance substantially declined. This decline was the result
of several factors, including the loss of manufacturing jobs, which often
offered employees and their families affordable health insurance, and the
concomitant rise in lower-paying service jobs, which often did not offer
employees health insurance. The proportion of workers who were hired to
fill contract or part-time positions, which typically do not carry health
insurance benefits for the worker or his or her family, also increased. In
addition, during this period, the cost of health insurance for employers rose
significantly, and many employers changed policies to cover only the
employee and not the family (Moniz & Gorin, 2014).
To deal with the loss of private health insurance coverage and the resulting
increase in uninsured children and youth, Congress passed a series of
Medicaid expansions beginning in the mid-1980s. For example, the
Omnibus Budget Reconciliation Act of 1989 (OBRA ’89) required states
to cover pregnant women and children up to the age of 6 years with family
incomes that were up to 133% of federal poverty guidelines. The early
expansions focused solely on infants and young children. Later, the
Omnibus Budget Reconciliation Act of 1990 (OBRA ’90) mandated
coverage of adolescents up to 16 years of age with family incomes of as
much as 100% of the federal poverty guidelines (Newacheck, Brindis,
Cart, Marchi, & Irwin, 1999).
These Medicaid expansions began the “delinking” of Medicaid and public
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assistance status. This delinking process was finally completed in 1996
with the passage of the Personal Responsibility Work and Opportunity
Reconciliation Act (PRWORA) (Moniz & Gorin, 2014). PRWORA
separated the determination of eligibility for Medicaid from receipt of
public assistance, which was called Temporary Assistance for Needy
Families (TANF). The federal government required states to provide
Medicaid coverage for children up to the age of 5 years in families with
incomes of as much as 133% of the poverty guidelines and to cover
children from the ages of 6 to 19 years old in families with incomes at or
below the FPL.
The Balanced Budget Act of 1997 created the State Children’s Health
Insurance Program (SCHIP) to address the large number of uninsured
children of low-income working families who were not eligible for
Medicaid because their family income exceeded the eligibility criteria.
Unlike Medicaid, SCHIP is not an entitlement program. Under federal
legislation, states have been given tremendous flexibility to use SCHIP
allocations to create separate SCHIP programs, expand their Medicaid
programs, or develop a combination of both. States are also allowed to
determine SCHIP eligibility; among the states, eligibility ranges from less
than 200% to 400% of the federal poverty guidelines. State dollars are
matched by federal dollars. States with lower per capita income receive a
higher federal match rate. States are also allowed to require monthly
premiums or copayments for participation in their SCHIP programs. In
2009, premiums were required by 35 states, with some premiums as high
as $100 or more per month (Henry J. Kaiser Family Foundation, 2009).
The success of SCHIP has been highly variable and largely dependent on
each state conducting aggressive and effective outreach, enrollment, and
renewal efforts. Because of barriers to enrollment and renewal, many
eligible children are currently not enrolled. In addition, because of
constraints on state budgets, outreach efforts have been reduced in many
states, and some states have enacted measures to restrict coverage in their
SCHIP programs (Henry J. Kaiser Family Foundation, 2009).
In 2009, Congress passed the Children’s Health Insurance Program
Reauthorization Act (CHIPRA) and increased the funding by $33 billion
with the expectation that 4.1 million additional children would be covered
by 2013 (Moniz & Gorin, 2014). The Children’s Health Insurance
Program (now called CHIP) is currently authorized through 2019;
however, funding is only guaranteed through 2015.
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Landmark health-care-reform legislation, The Patient Protection and
Affordable Care Act (ACA), was signed into law by President Barack
Obama in March 2010. The overall goals of the ACA are to (1) expand
health insurance coverage, (2) increase focus on prevention, and (3)
improve health-care efficiency and reduce costs (Hellerstedt, 2013). Key
provisions of the act that affect children and youth include (1) eliminating
lifetime caps on insurance coverage; (2) preventing states from reducing
the income eligibility threshold for CHIP, extending CHIP through 2019
with funding through 2015, and providing funding for increased outreach
efforts to enroll eligible children; (3) requiring insurers to cover
comprehensive screenings and preventative care at no cost to the patient;
(4) mandating Medicaid coverage for children aging out of the foster care
system up to the age of 26 years; (5) barring insurance companies from
denying coverage for pre-existing conditions; (6) allowing families to
purchase child-only insurance packages from the Exchanges; (7) allowing
young adults to remain on their parents’ insurance until they reach 26
years of age; (8) establishing a $200 million federal authorization program
to expand school-based health centers; and (9) including $1.5 billion for
the Home Visitation Grant Program to implement evidence-based
maternal, infant, and early childhood visitation models (First Focus, 2012).
Under the ACA, individuals are required to have minimal health insurance
coverage or pay a penalty; federal subsidies or tax credits may be used to
help offset costs for low- and middle-income people who must purchase
individual plans.
Since the enactment of the ACA, numerous cases have been filed against
specific provisions of the Act. In June 2012, the U.S. Supreme Court
upheld the constitutionality of the ACA but ruled that the ACA mandated
expansion of Medicaid coverage would not be required for states. This
expansion would have covered adults under the age of 65 years, including
many low-income parents with incomes up to 133% of the FPL. Also, at
the time of this writing, the Halbig v. Burwell case is working its way
through the federal court system; this case challenges the health-care
insurance subsidies used by close to 5 million Americans who bought
insurance through the Exchange established by the federal government
(Perkins & Singh, 2014).
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The Degree to Which Policy Has Been
Based on Risk and Protective Factors
As stated earlier in this chapter, for many children and youth, access to
care serves as a protective factor in the face of health risk. Federal health
policy has primarily attempted to address risk factors associated with poor
health outcomes by increasing access to preventive and medical care
services. It has been addressed in two ways: (1) through the creation of
public health insurance programs for low-income children (e.g., Medicaid
and CHIP, and provisions of the ACA) and (2) through supporting
infrastructure development to ensure that services are delivered in a
coordinated and accessible manner (primarily through Title V of the Social
Security Act and, most recently, the ACA).
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Protective Role of Health Insurance
Numerous studies have demonstrated the key role that health insurance
plays in increasing access to health care for children and youth
(Newacheck et al., 1999; Newacheck, Pearl, Hughes, & Halfon, 1998).
Beginning in the 1980s, with the expansion of eligibility for Medicaid, and
extending through the implementation of the CHIP program, and
provisions of the ACA, the federal insurance safety net has covered an
increasing percentage of low-income children. A study of the New York
state SCHIP program demonstrated that enrollment in SCHIP reduced
preexisting racial/ethnic disparities in unmet need and access to and
continuity of care among 2,290 children (Shone, Dick, Klein, Zwanziger,
& Szilagyi, 2005). Kempe and associates (2005), in a study of Colorado’s
SCHIP program, found that one year after enrollment, families (N = 480)
reported improved access to care, a decrease in unmet medical needs, an
increase in routine-care visits, and a higher perception of quality care.
Experts argue that the most effective way to ensure that children have
health insurance coverage and receive needed care is to approach
insurance coverage at the family level as opposed to the individual level.
DeVoe, Tillotson, and Wallace (2008) found that, compared with insured
children who had at least one insured parent, children with uninsured
parents were more likely to have never received preventive counseling
services, to have insurance coverage gaps, and to have unmet health-care
needs. Research findings such as these undergird the ACA’s goal of
expanding health insurance coverage to low-income adults, many of whom
are parents.
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Concept of a “Medical Home”
Although public insurance programs such as Medicaid, CHIP, and
provisions of the ACA provide an important health insurance safety net for
children and youth, insurance coverage alone is not sufficient for ensuring
access to health services (Newacheck et al., 2003). A usual source of care
and coordinated systems of care (Starfield, 2008) also need to be in place
to respond to the health-care needs of children and youth. Federal
policymakers have addressed systems issues primarily through programs
funded by Title V of the Social Security Act. For example, one of the
hallmarks of coordinated care is to ensure that children have continuous
access to routine health care and that medical services are integrated with
other child and youth services. The American Academy of Pediatrics and
other advocacy groups have worked closely with the MCHB to implement
the “medical home” concept for all children, especially children with
special health care needs (American Academy of Pediatrics, 2012).
Although the term medical home was originally defined as a physical
location, it has evolved to define a partnership with families to ensure that
children and youth are receiving care that is “accessible, family centered,
coordinated, comprehensive, continuous, compassionate, and culturally
effective” (Sia, Tonniges, Osterhus, & Taba, 2004, p. 1473). Examining
data from the National Survey of Children with Special Health Care
Needs, investigators found that when children have a medical home, they
experience significantly less delay in seeking care and have fewer unmet
health-care needs and fewer unmet needs for family support services
(Strickland et al., 2004). One of the child health objectives in Healthy
People 2020 is to “increase the proportion of children with special health
care needs who have access to a medical home” (U.S. DHHS, n.d.). The
Head Start program and the Maternal and Child Health Bureau Services V
Block Grant program require that states report on how and to what extent
they are achieving this objective.
One of the goals of the ACA is to improve the quality and efficiency of
health-care delivery. To meet this goal, the ACA has incorporated the
medical home concept as one of its initiatives; the ACA uses the term
patient-centered medical home (PCMH). The Agency for Healthcare
Research and Quality (AHRQ) defines PCMH as a “model for organizing
primary care that is comprehensive, patient-centered, coordinated,
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accessible, and high quality and safe” (AHRQ, n.d.).
Another systems-change approach to increasing access to health care for
children and youth is to deliver health care in settings where the majority
of children spend a large portion of their day. This approach is reflected in
policy initiatives to support the development and ongoing operation of
school-based and school-linked health centers. Delivering integrated
services through school-based health centers will be discussed in the next
section on service integration.
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The Case of “Abstinence Only” Versus More
Comprehensive Programs
One area of controversy regarding how well federal health policy has been
informed by risk and protective factors is that of adolescent sexual health.
Comprehensive sexual health education can serve as a protective factor by
providing youth with the knowledge and skills necessary to make healthy
decisions about sexual behavior (Chin et al., 2012). In fiscal year 2008, the
federal government allocated $176 million for abstinence-only education.
At that time, there was no federal program that supported comprehensive
sex education to teach young people about both abstinence and
contraception (Boonstra, 2009). Federal law required that abstinence-only
sexuality education teach that sexual activity outside of marriage is wrong
and harmful for everyone, irrespective of age (Boonstra, 2009). This
mandate prohibited educators from providing information on contraceptive
methods, with the exception of emphasizing their ineffectiveness
(Boonstra, 2009). Perhaps most disturbing is that, after years of evaluation
of abstinence-only programs, no credible evidence has shown that such
restrictive education delays adolescent sexual activity (Boonstra, 2009).
However, empirical evidence did suggest that abstinence-only models may
reduce contraceptive use among sexually active young people, thereby
increasing their risk for STIs and unplanned pregnancies (Boonstra, 2009;
Rosenbaum, 2009).
Furthermore, research has demonstrated that the most effective sexuality
education programs are comprehensive in nature, incorporating both
abstinence promotion and discussion of safer sex options (Kohler,
Manhart, & Lafferty, 2008). In 2009, the Obama administration created the
Office of Adolescent Health (OAH) and introduced a new initiative that
replaced the Community Based Abstinence Program. This initiative, called
the Teen Pregnancy Prevention Initiative, focused on replicating programs
that have proven effectiveness, allocated funds to develop and test
innovative models and new strategies for preventing teen pregnancy, and
developed a collaboration with the CDC to develop community-wide,
multicomponent interventions (National Campaign to Prevent Teen and
Unplanned Pregnancy, 2010; Sexuality Information and Education Council
of the United States [SIECUS], 2012). More recently, the Affordable Care
Act of 2010 created the Personal Responsibility Education Program
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(PREP), which is administered by the Administration for Children &
Families. This program provides grants to states to fund evidence-based
programs to educate adolescents about abstinence and contraception to
prevent HIV, STIs, and pregnancy (SIECUS, 2012). PREP specifically
targets adolescents who are in foster care or homeless, live in rural areas or
areas with a high teen birth rate, or are from a racial or ethnic minority
group. During the Obama administration, there has been a clear move
toward funding evidence-based interventions that target risk and protective
factors related to adolescent sexual health.
348

Using Knowledge of Risk, Protection, and
Resilience to Achieve Service Integration
in Health Policy
349

Service Integration in Health Policy: School-Based
Health Centers
Meeting the health and social needs of children and adolescents, especially
those involved in multiple service systems, requires policies that promote
integration and collaboration among service systems. School-based health
centers (SBHCs) are a prime example of effective service integration in
the area of health and social policy. We will provide an overview of the
history and funding of SBHCs, followed by a discussion of the services
provided and evidence regarding their impact. This section is followed by
a case study of an adolescent with multiple problems to illustrate how
integrated service systems can best meet the needs of children and youth.
Historical Overview
In the United States, the first school-based health initiative began in New
York City in 1894 to assess and contain children with contagious diseases,
such as measles, scarlet fever, whooping cough, and tuberculosis (Keeton,
Soleimanpour, & Brindis, 2012). In 1902, the first school nurse began
providing treatment and care to students and also making home visits to
provide health education to families regarding hygiene and other methods
of disease control. The first SBHCs were opened in the late 1960s and
early 1970s in Cambridge, Massachusetts, Dallas, Texas, and Saint Paul,
Minnesota, to provide accessible and affordable health care to poor
children. In 1978, the Robert Wood Johnson Foundation sponsored the
expansion of SBHCs throughout the United States in an effort to increase
access to community-based health care for children and adolescents in
underserved communities. Through these efforts, policymakers became
more aware of SBHCs and their value. In 1995, the Health Resource and
Service Administration began providing grant funding for SBHCs
(Gustafson, 2005). Since the 1990s, the number of SBHCs has increased
with the help of multiple funding streams. As part of the Affordable Care
Act, $200 million was appropriated to SBHCs between 2010 and 2013 to
improve and expand services to an estimated 875,000 youth per year, a
50% increase compared with youth served in 2009 (U.S. Department of
Health and Human Services, 2011). A national SBHC advocacy
organization, the School-Based Health Alliance, in a position statement,
noted that the SBHC model has the components of a Patient Centered
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Medical Home (PCMH) as outlined in the ACA and that SBHCs across the
country should strive to meet PCMH goals and standards (School-Based
Health Alliance, n.d.).
There are nearly 2,000 school-based health centers located on elementary,
middle, and high school campuses across the country (Keeton et al., 2012).
These centers provide a range of services, including primary medical care,
mental and behavioral health care, reproductive health services, dental/oral
health care, and health education and promotion. Once primarily located in
inner cities, SBHCs have expanded to rural, suburban, and urban areas
(Lofink et al., 2013). SBHCs typically operate via a partnership between a
school district and a local health organization such as a community health
center, hospital, or health department. Most SBHCs are open five days a
week before, during, and after school. SBHC staff include a mix of
professionals: physicians, nurse practitioners, physician assistants, nurses,
dieticians, dental hygienists, psychologists, counselors, social workers, and
health educators (Brown & Bolen, 2012).
SBHCs rely on various funding and billing sources. Over 80% of SBHCs
bill a state Medicaid agency, 71% bill Medicaid managed care
organizations, 64% bill private insurance, and 40% bill Tri-Care (i.e., the
health insurance program for military families). In addition to billing,
SBHCs receive funds from state governments (75%), the federal
government (53%), private foundations (40%), school districts (33%),
hospitals (33%), local governments (32%), private health insurance
organizations (27%), businesses (18%), and professional associations (7%)
(Lofink et al., 2013).
Primary Care
SBHCs provide a range of primary care services including physical exams,
immunizations, treatment for acute illnesses and injuries, treatment for
common chronic diseases (e.g., asthma and diabetes), and routine health
screening (Brown & Bolen, 2012). Researchers found overall significantly
higher completion rates for immunization series among adolescents at
SBHCs compared to those at community health centers despite serving an
adolescent population with lower health insurance coverage (Federico,
Abrams, Everhart, Melinkovich, & Hambidge, 2010). In a study of
children with asthma, those with SBHCs showed less activity restriction
due to asthma and fewer emergency department visits compared with the
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non-SBHC group (Mansour, Rose, Toole, Luzader, & Atherton, 2008).
Mental and Behavioral Health Care
In order to meet both the physical and mental health needs of youth, 78%
of SBHCs provide some form of mental/behavioral health care (Lofink et
al., 2013). These services include crisis intervention (78%), individual
psychosocial assessment and treatment (73%), case management (69%),
classroom behavior support (62%), substance abuse counseling (53%),
assessment and treatment of learning problems (50%), peer mediation
(43%), and prescription and management of psychoactive medication
(39%). A longitudinal study showed that adolescents who were enrolled in
a school with a SBHC were more likely to access mental health services
(Guo, Wade, & Keller, 2008). The authors of another study concluded that
“on-site mental health services and their immediate availability for crisis
intervention allow teenagers to engage in individual, family, and group
treatment before problems become so severe that they interfere with their
education” (Pastore & Techow, 2004, p. 194).
Health Education and Prevention
Most SBHCs are also involved in health education and prevention
activities in the areas of violence, substance use, nutrition, and physical
activity. SBHC engagement in prevention activities varies by the type of
preventive intervention (i.e., individual, small group, classroom, and
school-wide interventions). Depending on the intervention format, 35% to
83% of SBHCs were involved in bullying and violence prevention, 30% to
76% were involved in school safety planning, 20% to 76% were involved
in sexual assault and rape prevention and counseling, and 23% to 76%
were involved in intimate partner and dating violence prevention and
counseling. In terms of substance use, 36% to 82% of SBHCs were
involved in some form of tobacco preventive intervention, 34% to 78%
were involved in alcohol preventive interventions, and 33% to 78% were
involved in drug preventive interventions. Finally, 37% to 90% of SBHCs
were involved in health promotion activities regarding healthy eating,
active living, and weight management (Lofink et al., 2013).
Reproductive Health Care
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Many SBHCs in middle and high schools provide reproductive health
services in the form of abstinence counseling (82%), pregnancy testing
(81%), STD diagnosis and treatment (69%), testicular examinations
(69%), contraceptive counseling (65%), and gynecological examinations
(59%) (Lofink et al., 2013). Half of SBHCs were prohibited from
dispensing contraceptives, most often due to school, district, and state
policies. In centers that were allowed to provide contraceptive services,
SBHCs were more likely to provide condoms as opposed to other methods
of birth control such as the pill (Fothergill & Feijoo, 2000). Although
prenatal care is not available in most SBHCs, a study comparing
adolescents receiving prenatal care in SBHCs had babies with higher birth
weight compared with those receiving prenatal care in hospitals (Barnet,
Duggan, & Devoe, 2003). Further, studies show that receiving prenatal
care in SBHCs is associated with lower rates of absenteeism and dropout
(Barnet, Arroyo, Devoe, & Duggan, 2004; Barnet et al., 2003).
Oral and Dental Health Care
Dental and oral health services are becoming more available at SBHCs and
are provided on-site and through mobile units. Over 70% of SBHCs
reported conducting dental screenings, which may be conducted by a
dental/oral health or primary care provider. In addition, almost 40% of
SBHCs provide dental examinations by either a dentist or dental hygienist
and over 30% of SBHCs provide dental cleanings. Barriers to providing
these services include cost, equipment needs, provider availability, space,
and reimbursement (Lofink et al., 2013).
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Evaluations of School-Based Health Centers:
Acceptability and Accessibility
Evaluation findings of the acceptability of SBHCs among students have
been promising. One study found that 86% of students rated the quality of
care from their SBHC as satisfactory to excellent and 79% rated privacy in
their SBHC as satisfactory to excellent (Santelli, Kouzis, & Newcomer,
1996). Similarly, another study found that 92% of students were satisfied
with the services received at their SBHC, 79% felt comfortable receiving
care at their SBHC, and 74% felt that their visits were confidential
(Pastore, Juszczak, Fisher, & Friedman, 1998).
SBHCs provide developmentally appropriate and comprehensive care to
children and adolescents in a familiar and accessible setting. The SBHC
model links schools, communities, and health systems to provide an array
of primary and preventive health-care services. SBHCs were designed to
address barriers in access to care and help meet the needs of underserved
children. The convenient location allows youth to access care in a timely
manner, which might otherwise be delayed. Parents do not have to take
time off from work to take their child to a provider, which may be
particularly challenging for low-income and single-parent families.
Furthermore, children do not have to miss school to receive care
(Gustafson, 2005). In addition, despite recent improvements to expand
health insurance coverage among children, millions of children remain
uninsured or underinsured. Low-income and racial/ethnic minority
children are less likely to have a regular source of health care and therefore
may benefit from the SBHC model (Brown & Bolen, 2012). In some rural
areas, SBHCs are the only source of primary care for children and youth
(Hossain, Coughlin, & Zickafoose, 2014). SBHCs are also beneficial for
youth with multiple health needs as well as high-risk youth, who benefit
from immediate access to care (Jepson, Juszczak, & Fisher, 1998). Youth
are more likely to use health-care services on a “spontaneous basis”
(Pastore & Techow, 2004, p. 195); therefore, SBHCs offer location,
convenience, confidentiality, and trust—all factors associated with the
utilization of health and psychosocial services by youth (Brindis et al.,
2003).
The following case study illustrates how a school-based health center
serves as a protective factor by providing access to care to a youth with
354

several risk factors for poor health and mental health outcomes. Because of
their location in school settings and the collaborative philosophy and
interdisciplinary approach to providing services, school-based health
centers are well positioned to integrate services for children and youth.
355

Case Study
James, a 14-year-old African American male, lives with his 31-year-old single
mother and 8-year-old sister in a public housing project on the outskirts of town.
James’s mother works in a local fast-food restaurant and has no health insurance.
As a freshman in high school, James is experiencing a great deal of anxiety about
fitting in with his classmates, often feels sad, is not sleeping well, and is falling
behind in his course work because of his lack of motivation and problems
concentrating. Like many of his friends, James is experimenting with alcohol,
marijuana, and other drugs and has recently become sexually active. He had
unprotected vaginal sex at a party the previous week, and for the past 2 days, he
has been experiencing a fire-like burning during urination. James is worried that
he might have gonorrhea, but he has no idea of where to go for help. He is very
uncomfortable and does not want to go to school, yet he feels that there is no way
he can let his mom find out about his condition.
James is fortunate in that he attends a school with a school-based health center
that offers comprehensive services. On the urging of his best friend, who has had
several good experiences at the center, James drops by the center for a visit during
lunch. Because his mother signed an enrollment form for the health center when
James entered high school, he is able to receive confidential services without the
center contacting her. A nurse practitioner sees him initially for assessment and
medical treatment of his STI. The social worker also conducts an initial
psychosocial assessment and schedules a time to meet with James the next day.
She plans to follow-up with his concerns about school and his feelings of sadness
and to learn more about his recent drug and alcohol use and sexual behavior.
James has given the social worker permission to access his school records and
talk with his teachers and school counselor. The social worker will be able to
contact other staff at the health center for assistance in evaluating James and
providing him with needed services. A psychiatrist provides consultation services
to the school-based health center staff. The psychiatrist also conducts psychiatric
evaluations and prescribes and monitors psychiatric medications. In addition, the
health center staff provides counseling and conducts groups on a number of health
and mental health topics, such as substance abuse, sexual health, and coping with
relationships. The health center has recently begun participating in an innovative
CHIP outreach initiative to increase the enrollment of eligible youth. The social
worker thinks that James probably meets the eligibility criteria and, with James’s
permission, she will contact his mother to assist her in enrolling both of her
children. James’s enrollment in the CHIP program will allow the center to be
reimbursed for services and will help the social worker access additional health
and mental health services for James if he needs them.
356

Case Study Questions for Discussion
What would most likely happen to James if a school-based health center did
not exist in his school?
How would he find out how to get care?
Where would he receive care and when?
Who would pay for his care?
How comprehensive would his care likely be?
What is the likelihood that James would be assessed and treated for any
other conditions or problems than his presenting symptoms (i.e., burning on
urination)?
357

Summary
In this chapter, we have reviewed risk factors for several major health
problems (LBW, asthma, overweight and obesity, and STIs) experienced
by children and youth. Although there are risk factors that are unique to
each of these health problems, two major risk factors are common across
health problems: poverty and living in socially and physically unhealthy
environments (Fraser, 2004; Moniz & Gorin, 2014). Access to care, which
includes both access to health insurance and availability of coordinated
and integrated systems of care, plays a major role in decreasing the risk for
poor health outcomes and protecting children and youth from developing
health problems.
U.S. health-care policy has increased children’s access to health services
through the creation of public health insurance programs such as Medicaid
and CHIP and now through the Affordable Care Act (ACA). Through Title
V of the Social Security Act and provisions of the ACA, the federal
government has supported the development of a more coordinated and
comprehensive service system. The medical home and school-based health
centers are examples of efforts at coordination and integration. School-
based health centers are a promising example of integration of primary
care, behavioral health, and prevention services provided in a location that
is accessible to children and youth enrolled in schools. However, attempts
to fully integrate services for children and youth across major service
systems (health, mental health, education, child welfare, and juvenile
justice) are still in their infancy, and much remains to be accomplished.
Furthermore, federal policy has had very limited success in reducing the
number of children living in poverty or near poverty or ensuring that
children and youth live in healthy environments. To truly make a
significant difference in the health of children and youth, federal policy
cannot be constrained to the creation of coordinated and integrated systems
of care, although this would be a substantial achievement. National policy
must also address the poverty and social inequities that contribute to poor
health and well-being.
358

Questions for Discussion
1. How do socioeconomic inequalities and physical and social environments
contribute to health outcomes of children and youth? Given the existence of
these inequalities, what effect will the full implementation of the Affordable
Care Act, which expands insurance coverage to the uninsured and thereby
increases access to medical care, have on the existing health disparities
among children and youth?
2. Given the success of school-based health clinics in integrating service
systems for children and youth, why has their establishment not been more
widespread?
3. What other models are you aware of that integrate service systems,
including health care for children and youth? What policies and
environmental factors need to be in place for these service delivery models
to be developed, implemented and sustained?
359

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Additional Reading
Center for Leadership Education in Maternal and Child Public Health.
(2013). The Affordable Care Act: Goals and mechanisms/Implications of
the Affordable Care Act on MCH populations and public health services.
Healthy Generations, 2013(Fall), 1–40. Available from
http://www.epi.umn.edu/mch/wp-
content/uploads/2012/05/HG_Fall20132
Sparks, P. J. (2009). Do biological, sociodemographic, and behavioral
characteristics explain racial/ethnic disparities in preterm births? Social
Science & Medicine, 68, 1667–1675. doi:10.1016/j.socscimed.2009.02.026
Strolin-Goltzman, J. (2010). The relationship between school-based health
centers and the learning environment. Journal of School Health, 80, 153–
159. doi:10.1111/j.1746–1561.2009.00480.x
379

http://www.epi.umn.edu/mch/wp-content/uploads/2012/05/HG_Fall20132

Web-Based Resources
Association of Maternal and Child Health Programs (AMCHP),
http://www.amchp.org/
Center for Health and Health Care in Schools,
http://www.healthinschools.org
Centers for Disease Control and Prevention, http://www.cdc.gov/
Child Trends DataBank, http://www.childtrendsdatabank.org
Children’s Defense Fund (CDF), http://www.childrensdefense.org/policy-
priorities/childrens-health/
Families USA, http://www.familiesusa.org
The Future of Children, http://www.futureofchildren.org
Henry J. Kaiser Family Foundation, http://kff.org/health-reform/
March of Dimes, http://www.modimes.org/
Maternal and Child Health Bureau, http://mchb.hrsa.gov/
Maternal and Child Health Information Resource Center, Maternal and
Child Health Bureau, http://www.mchb.hrsa.gov/mchirc/
The National Assembly on School Based Health Care,
http://www.nasbhc.org/
The Robert Wood Johnson Foundation, http://www.rwjf.org/
380

http://www.amchp.org/

http://www.healthinschools.org

http://www.cdc.gov/

http://www.childtrendsdatabank.org

http://www.childrensdefense.org/policy-priorities/childrens-health/

Home

http://www.futureofchildren.org

http://kff.org/health-reform/

http://www.modimes.org/

http://mchb.hrsa.gov/

http://www.mchb.hrsa.gov/mchirc/

http://www.nasbhc.org/

http://www.rwjf.org/

Chapter 7 Policies and Programs for
Children and Youth With Disabilities
Susan L. Parish
Alison W. Saville
Jamie G. Swaine
Leah Igdalsky
Children with disabilities (i.e., conditions producing functional limitations
in mobility, self-care, communication, or learning) make up about 13% of
the U.S. population between the ages of 5 and 17 years old (U.S.
Department of Education, 2013). In addition, many more children younger
than 5 years old have impairments of this level of severity. Although the
increasing prevalence of childhood disability is well documented (Boyle et
al., 2011), the reasons for this increase are not fully understood. Medical
and technological advances have enabled more children with disabilities to
survive, which has increased the prevalence of these conditions. However,
increased public awareness has led to a greater identification of
impairments, also contributing to the increased prevalence. The prevalence
of disability is higher among African Americans than Whites. Studies
attribute racial disparities in disability prevalence to the increased
likelihood of African American children living in poverty (e.g.,
Newacheck, Hung, Park, Brindis, & Irwin, 2003); however, these findings
must be substantiated with further research. The prevalence of disability
also varies by gender and disability condition. For example, autism is more
common among males (Jacquemont et al., 2014), whereas Rett Syndrome
is found almost exclusively among females.
Most programs for children with disabilities determine eligibility based on
a child’s diagnosis or disability category, which may vary over the life
course. In addition, how a policy or program defines disability can
significantly affect the number of children who are deemed eligible to
receive services. In the absence of a uniform definition of disability,
children who are eligible for one program based on their diagnosis may not
be eligible for another program, even if its mission is to serve children
with the same disabilities (Beers, Kemeny, Sherritt, & Palfrey, 2003).
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Differential eligibility is more noticeable in state-run programs such as
maternal and child health services because these services are administered
under Title V of the Social Security Act, which gives states substantial
latitude in determining program structures and processes (Beers et al.,
2003).
Terminology.
When a child does not reach expected benchmarks or developmental
milestones such as turning over, crawling, walking, or talking, this is
referred to as a developmental delay. Developmental delays are frequently
found in young children before a specific condition is formally diagnosed.
These delays may be a temporary or a lifelong condition. Developmental
disabilities are lifelong impairments that manifest during childhood and
result in substantial functional limitations, including intellectual
disabilities, autism, cerebral palsy, Down syndrome, and other related
disorders. Young adults with one or more of these disorders who are
transitioning out of high school are often described as having a
developmental disability, which is used as a general diagnostic category.
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Increasing Prevalence of Disability
Medical and technological advances during the latter half of the 20th
century substantially improved prenatal and perinatal care and brought
about dramatic changes in the survival rates of children born with
impairments. For example, between 1990 and 2010, there was a 50%
reduction in maternal mortality worldwide (World Health Organization,
UNICEF, UNFPA, & The World Bank, 2012). These advances have
translated into increased numbers of children with disabilities living into
adolescence and adulthood and explain, at least in part, the increasing
prevalence of disability among children worldwide.
Children with developmental disabilities often need a lifetime of
assistance, including a developmentally appropriate sequence of special
services and individualized supports (Developmental Disabilities
Assistance and Bill of Rights Act of 2000). Conditions such as autism,
sickle cell anemia, cystic fibrosis, and cerebral palsy result in elevated
needs for both primary medical care and specialized therapeutic care. To
maximize their cognitive, emotional, academic, and physical development,
these children may need rehabilitation therapies, environmental
adaptations, assistive devices, personal assistance, and mental health,
home health, or respite care (Perrin, 2002). Ongoing therapies, specialized
interventions, and ancillary and supportive services play a pivotal role in
allowing children to maximize their capacity for independence and fully
participate in daily activities and community life. Furthermore, ancillary
and supportive services such as respite care and other family support
services enable parents to care for their children at home rather than seek
expensive out-of-home care, which is usually publicly financed (Abelson,
1999; Bruns & Burchard, 2000; Curran, Sharples, White, & Knapp, 2001).
A wide array of policies governs the services that children with disabilities
and their families receive. Some policies are designed for children with
disabilities (e.g., special education, disability income transfers), and others
are designed for a broader population of children (e.g., provision of health-
related services to children eligible for Medicaid). Policies directed at
families often provide supports intended to reduce out-of-home placements
and mitigate the physical, emotional, and financial burdens associated with
caring for children with disabilities.
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Although the overarching goal of these policies is to enhance development
and adaptation, the service system for children with disabilities can best be
characterized as fragmented. Numerous organizations control the delivery
of services (e.g., local school districts, state disability offices, state or
county social service agencies), and revenues typically come from two or
more levels of government (i.e., federal, state, county, and/or local). Poor
coordination and collaboration across agencies complicate the challenges
families face in seeking assistance, and the barriers often seem
insurmountable.
In the subsequent sections of this chapter, we review risk and protective
factors related to childhood disability and outline the major social policies
that have been directed toward children with disabilities and their families.
The conceptualization of risk and protection within these policies is
examined. Finally, recommendations to promote greater service
integration are presented. However, before plunging into these tasks, we
briefly describe the theoretical models that guide our analysis.
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Three Theoretical Frameworks
Three theoretical frameworks underpin this chapter: the ecological model,
models of risk and protective factors, and the social or minority model of
disability. The ecological model espoused by Bronfenbrenner (1979, 1986)
posited that individual development occurs and can be understood only
within a larger family and social-environmental context. In this model,
understanding the interplay of factors at the level of the individual, the
family, and the environment is necessary to comprehend what appear to be
individual behavior and individual outcomes. Child developmental
outcomes arise from the complex interplay of these interwoven elements.
Conceptually, risk and protective factors are those elements that influence
the chances of adverse outcomes and optimal development, respectively
(Fraser, Kirby, & Smokowski, 2004). We build our analysis from the
elaboration of the risk and resilience framework presented by Fraser and
his colleagues (2004) and the introductory chapter of this volume. The
ecological perspective requires identifying and analyzing risk and
protective factors at the levels of the child, the child’s family, and the
broader society. This analytic scheme is also consistent with recent
disability studies that have identified a social model of disability, which
distinguishes between individual impairment and disability. Impairment is
an individual’s biological condition, whereas disability is what accrues to
an individual when society’s attitudes, expectations, and built
environments do not accommodate a full range of human difference. Davis
(2000) succinctly described the relationship between disability and
impairment:
Disability is not so much the lack of a sense or the presence of a
physical or mental impairment as it is the reception and construction
of that difference. . . . An impairment is a physical fact, but a
disability is a social construction. For example, lack of mobility is an
impairment, but an environment without ramps turns that impairment
into a disability. (p. 56)
This social model of disability is entirely consistent with an emancipatory
and empowerment perspective. The goal of this chapter, then, is not to
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understand how individual impairments place children at risk but to
evaluate how the larger environment—and especially society’s response to
impairment, as codified in public policy—increases the risk of adverse
development or, alternatively, promotes the optimal development of
children with disabilities. We turn first to the risk and protective factors
associated with childhood disabilities.
386

Risk and Protective Factors for Problems
Experienced by Children with Disabilities
387

Risk Factors
In addition to living in poverty, a number of important risk factors are
associated with childhood disability, including likelihood of experiencing
abuse, social isolation, and ostracism from peers and the larger society,
difficulty accessing needed supportive services, and problems obtaining
medical care when it is needed.
Poverty and childhood disability status are compellingly related. About
38% of special needs children live in households with incomes below the
federal poverty level (Parish, Shattuck, & Rose, 2009), which is a
dramatically higher rate than the 22% of all US children who live in
poverty (DeNavas-Walt, Proctor, & Smith, 2013). In general, child poverty
rates tend to be highest among African American and Hispanic children,
and households of any race or ethnicity that are headed by a single parent
are much more likely to live in poverty than households headed by married
parents (DeNavas-Walt et al., 2013).
The elevated risk of living in poverty for children with disabilities is a
phenomenon that has been widely described by researchers and policy
analysts, but it is not well understood. Even more disturbing, the
prevalence of disability increased between the early 1980s and the mid-
1990s among families living in poverty or those headed by a single mother
(Fujiura & Yamaki, 2000). Furthermore, family income below the federal
poverty level is associated with a higher prevalence of developmental
disabilities (Boyle et al., 2011). Causal ambiguity precludes understanding
the direction of effects, and further research is needed to determine the
nature of the causal relationship between poverty and disability. A case for
effects in both directions can be made. Low-income families are less likely
to have access to sufficient food, adequate prenatal and other medical care,
and decent safe housing, all of which are factors that can be implicated in
increasing the risk of childhood disability. However, the extensive care
needs of children with disabilities are likely to prohibit their parents from
obtaining or maintaining sufficient employment necessary to bring the
household out of poverty (Emerson, 2007).
Regardless of the direction of the relationship between poverty and
disability, the fact that so many children with disabilities live in poverty
has serious implications for their well-being. For children generally, living
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in poverty is associated with a host of negative consequences, including
poor physical health, increased emotional and behavioral problems,
diminished cognitive abilities, and reduced educational attainment
(Brooks-Gunn & Duncan, 1997; Magnuson & Votruba-Drzal, 2009).
However, concern is mounting that poverty is likely to have more
deleterious effects for children with disabilities than it does for typically
developing children (Park, Turnbull, & Turnbull, 2002). This is because
children with disabilities require greater care and stimulation to achieve
proper development, prevent regression, and avert the development of
secondary conditions.
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Costs of Disability
Research into how poverty influences child development is still in its
infancy, and it will likely take some time before risk-inducing
relationships and their applicability to children with disabilities are clear.
We do know that the disability-related costs of raising a child are
extremely high in the United States (Stabile & Allin, 2012; Parish, Seltzer,
Greenberg, & Floyd, 2004). Families of children with disabilities face
unique financial burdens, such as increased therapy costs and home
adaptations (Newacheck & Kim, 2005; Parish & Cloud, 2006). These
increased costs are particularly burdensome for lower-income families
(Lukemeyer, Meyers, & Smeeding, 2000; Parish et al., 2009). Mothers of
children with disabilities often have to reduce the number of hours they
work or quit work outside the home completely to provide adequate care
for their children with special needs (Parish et al., 2004). This
phenomenon is subsequently associated with reduced income and lower
asset accumulation over time (Parish et al., 2004).
Public income transfer and insurance programs do not cover most
disability-related expenses (General Accounting Office, 1999).
Impoverished families of children with disabilities have few choices or
resources for meeting their child’s impairment-related needs (Scorgie,
Wilgosh, & McDonald, 1998). Inadequate financial resources are
associated with diminished parental ability to cope with the extra health
and daily care needs of children with disabilities (Yau & Li-Tsang, 1999).
Moreover, evidence suggests that families raising children with disabilities
often experience significant hardships (e.g., food insecurity, housing
instability, foregone medical care). These hardships and deprivation extend
well into the middle-class stratum of families raising children with
disabilities; this finding is important because this pattern of hardship is not
found among families of nondisabled children (Parish, Rose, Andrews,
Grinstein-Weiss, & Richman, 2008).
Generally, poverty has a direct negative influence on maternal behavior
and on the quality of parenting (Brooks-Gunn, Klebanov, & Liaw, 1995).
We would expect to find similar relationships in the behavior of low-
income mothers of children with disabilities; however, this issue has not
been studied directly. High rates of abuse and neglect also place children
with disabilities at risk. Child abuse is widely recognized as placing
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victimized children at considerable risk for adverse social, developmental,
educational, and behavioral outcomes. Although it is difficult to determine
the rates of abuse for the general population (see Chapter 3; Pagelow,
1984), it is even more problematic to ascertain abuse rates for children
with disabilities because their impairments in cognitive and language skills
make detection of abuse substantially more difficult (Sobsey, 1994). Rates
of physical, sexual, and emotional abuse for children with disabilities are
significantly higher than those for nondisabled children (Child Welfare
Information Gateway, 2012). However, many in the field have argued that
this estimate is quite low (Sobsey, 2004), and the U.S. Department of
Health and Human Services reports that 11% of child maltreatment victims
have a disability (U.S. Department of Health and Human Services, 2010).
Serious risks to emotional well-being are associated with the social
isolation of children with disabilities as well as their encounters with
ostracism from peers and the larger society. The history of discriminatory
and prejudicial treatment of people with disabilities of all ages is a dismal
and pervasive aspect of Western history (Braddock & Parish, 2001).
Unfortunately, contemporary reports of children with disabilities have
indicated that these attitudes have not materially diminished. There is
long-standing evidence that children interact differently with rejected and
ignored classmates (Chazan, Laing, Jones, Harper, & Bolton, 1983;
Dodge, 1983) and even the youngest children with disabilities experience
bullying (Son, Parish & Peterson, 2012). Given these different patterns of
interactions, children with disabilities, and particularly those with severe
impairments, often have limited opportunities for friendships and
integration with their peers.
Social isolation—having few friendships, limited reciprocal relationships,
and minimal peer interactions—follows children with disabilities from
early childhood into adolescence and adulthood (Keogh & Bernheimer,
1987; Keogh, Bernheimer, & Guthrie, 2004; Matheson, Olsen, Weisner, &
Dykens, 2007). Although the long-term effects of this isolation have not
been widely studied in children with disabilities, in general, children’s
social skills, networks, and relationships predict later adjustment
(Kupersmidt, Coie, & Dodge, 1990; Meyer, Cole, McQuarter, & Reichle,
1990). In addition, childhood disability is associated with negative
personal and employment outcomes (Edgar & Levine, 1987; Sitlington,
Frank, & Carson, 1992; Whitney-Thomas & Moloney, 2001). Moreover,
adolescents and children with disabilities express great dissatisfaction
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related to their lack of friends and social integration (Keogh et al., 2004).
Evidence has converged to indicate that parents encounter ongoing stress
and family disruption over the life course of caring for their children with
disabilities (e.g., Farber, 1960; Turnbull, Brotherson, & Summers, 1986;
Williamson & Perkins, 2014). These stresses may result from the child’s
behavior problems, nighttime disturbance caused by the child’s care needs,
social isolation, family chaos, multiple child impairments, chronic ill
health, and financial concerns (Singer & Irvin, 1989). However,
compelling evidence also exists that parents who cope well with their
child’s needs enhance the child’s cognitive and social adjustment and
minimize further family disruption and distress (Bourke-Taylor, Pallant,
Law, & Howie, 2012; Crnic, Friedrich, & Greenberg, 1983; Landesman,
Jaccard, & Gunderson, 1989; Summers, Behr, & Turnbull, 1989).
Successful parental adaptation and coping contributes to what is arguably
the most critical protective factor related to childhood disability: strong
parental support.
Parental support for children with disabilities takes a number of forms
across childhood and often into adulthood. Because of the nature and
organization of disability policy in the United States, parents are
compelled to serve both as their child’s advocate and as the child’s case
manager. When parents aggressively champion their child’s needs, the
child is much more likely to receive the services and supports to which he
or she is entitled. Parental support also bolsters the child’s self-esteem,
creating resilience to the rejection that most children with disabilities
encounter from peers and society.
A closely related protective factor is the competence and mastery that
parents develop as their child ages; these capacities are gained through
surmounting the adversity that they face in securing services for their child
and in coming to terms with their child’s impairment. For parents of young
children with disabilities, a common developmental trajectory begins at the
point of diagnosis with mourning for the nondisabled child they had
anticipated. After this mourning period, most parents report increasing
levels of satisfaction with their caregiving abilities and identify their
caregiving role as a positive part of their self-identity. However, over the
course of their child’s development, parents might revisit grief and
depression during transition periods (e.g., entry into kindergarten, high
school graduation). For some parents, these transition points represent
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jarring reminders that the child’s impairment has altered his or her
developmental trajectory. Even so, parents also overwhelmingly report that
their children with disabilities contribute emotionally, socially, and
intellectually to the richness of family life (Summers et al., 1989; Trute &
Hiebert-Murphy, 2002).
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Protective Factors
Research on protective and promotive factors associated with childhood
disability is far more limited. The most likely explanation for this deficit is
that the medical model of disability that prevailed for much of the 20th
century still informs policy and services for children with disabilities. The
most important protective factors associated with childhood disability are
those that emerge from the family and community context: parental
competence as advocates, case managers, and caregivers for their children;
supportive networks of peers, extended families, and communities;
inclusion in activities of daily life and community life; and adequate and
available medical, educational, and financial resources to enable parents to
provide appropriate care for their children.
Extrafamilial protective factors include supportive schools, faith-based
organizations such as churches or synagogues, and communities, as well as
adequate levels of family support services, including support from
disability and advocacy organizations that address the needs of children
with disabilities and their families. Having sufficient and appropriate
supports available is a critical factor in helping parents positively adapt to
their child’s disability (Ha, Greenberg, & Seltzer, 2011; Singer & Irvin,
1989). The policies that structure such supports are discussed in the next
section. However, little research has been conducted investigating the
mechanisms by which these risk and protective factors directly affect
children with disabilities and their families. Although limited, some
evidence supports our hypothesis that these protective factors (parental and
other supports, responsive public policies, nurturing communities) are
directly involved in building resilience among children with disabilities
(McConnell, Savage, & Breitkreuz, 2014).
In summary, the life circumstances and development of children with
disabilities are shaped by risk and protective factors that emerge from the
environments in which these children live. These environmental factors
emerge from within the family, the community, and the larger society and
are manifested in the public policies that contribute to different facets of
child and family life. Table 7.1 summarizes these significant factors.
394

395

Risk, Resilience, and Protection in Policies
for Children With Disabilities
Over the course of the last century, extraordinary changes occurred in
policies for children with disabilities. At the outset of the 20th century,
policy was organized at the state level and provided limited custodial care
in segregated institutions to the exclusion of nearly all other services.
Beginning in the 1930s, small-scale experimental programs in extra-
institutional long-term care were implemented in New York and Ohio, but
this approach did not take hold nationally. In response to the lack of
services for children with disabilities, parents began organizing their own
educational systems for their special-needs children, and by the early
1940s, fledgling parent advocacy groups had been established. Parent
advocacy had a lasting impact on the service system and ultimately exerted
greater influence than any other force over the shape of services for
children with disabilities (Braddock & Parish, 2001).
Over the past four decades, assertive and effective advocacy by parents of
children with disabilities has precipitated the development of policies that
support services tailored to the individual needs of the child with
disabilities and meet the needs of the entire family (Braddock & Parish,
2001). In addition, in the decades since the 1970s, parent advocacy
culminated in the closure of hundreds of custodial institutions across the
United States and led to the 1975 passage of legislation mandating
education for children with disabilities. As parents emerged as champions
for their children with disabilities, adult activists with disabilities also
began to demand their civil rights, following the trail blazed by African
American leaders in the civil rights movement.
These enormous changes resulted in two significant transformations. First,
the service system, particularly in education and long-term care, began to
reject the prevailing medical model, which held that individuals with
disabilities were inherently defective and in need of professional cures. As
noted previously, supporters of the social model of disability argued for
the thorough inclusion of people with disabilities in all aspects of society,
one that accommodates the full range of human differences. Advocacy by
those with disabilities and their allies ultimately contributed to the
successful passage of the Americans with Disabilities Act of 1990, which
396

prohibits discrimination in public settings and requires employers to
accommodate people with disabilities (Braddock & Parish, 2001).
A second major transformation was the federal government’s entry into the
service and policy arena for children with disabilities, which began on a
large scale in the 1970s. Even when the Social Security Act of 1935 was
passed, the federal government’s role was minimal and limited to funding
supports or services for people with disabilities (i.e., money allocated
through Title X of the act provided limited income transfers to the blind).
The only exceptions to federal noninvolvement were income transfer and
vocational rehabilitation provisions for veterans. For children with
disabilities, the federal government continued its role of noninvolvement
through much of the 20th century. However, the federal role changed in
the 1970s when Medicaid was amended to allow federal reimbursement
for medical and long-term care services for children and adults with
mental retardation; federal law mandated education of children with
disabilities, and the disability income transfer program (Supplemental
Security Income [SSI]) was expanded to cover children.
These policy transformations evolved concurrently with practice changes.
Consistent with the medical model of disability, which was strongly
followed at the beginning of the 20th century, people with disabilities were
considered deviants, and social policy responded with segregation and
sterilization to prevent a perceived group of undesirables from procreating.
Through most of that century, negative attitudes toward people with
disabilities prevailed, and practice models encouraged parents to
institutionalize young children with disabilities, surrendering them to
warehouse-like facilities that provided rudimentary care (Braddock &
Parish, 2001). As attitudes toward people with disabilities shifted, a civil
and human rights perspective emerged, and practices began shifting to
focus on supporting parents in providing at home care for their children
with disabilities (Braddock & Parish, 2001).
At the outset of the 21st century, a number of disparate public policies
influenced children with disabilities and their families. We describe key
federal policies that address income support, education and early
intervention, maternal and child health services, and family support.
Medical care, which is also critically important for children with
disabilities, is discussed in Chapter 6 of this volume.
397

Income Transfers
Children with disabilities and their families can receive income transfer
payments through several different programs: initiatives designed
specifically for people with disabilities and initiatives designed for low-
income people in general. The two major disability income transfer
programs in the United States are Social Security Disability Insurance and
Supplemental Security Income (SSI). The disability insurance program
targets workers who become disabled (and their dependents), and the
program is not a major source of income for children with disabilities. In
contrast, SSI stipulates provision of assistance specifically for children
with disabilities. Generally, the largest cash assistance program for low-
income families is the Temporary Assistance to Needy Families (TANF)
program, the nation’s welfare program, which states administer and jointly
fund with the federal government.
SSI is a means-tested, monthly income program for the elderly and people
with disabilities. The program is federally financed and administered,
although some states supplement federal payments and a few states
administer their own programs directly. Children with disabilities have
received SSI since the program’s inception in 1972 (Social Security
Administration [SSA], 2000). Eligibility is based on the child’s functional
limitations and on parental income and assets relative to family size. For
example, in 2014, a single child with disabilities living in a two-parent
home could receive SSI payments if parental household income did not
exceed $4,092 per month.
A total of 1.3 million children with disabilities younger than 18 years of
age received SSI benefits in October 2012 (Ruffing & Pavetti, 2012). For
2012, the average monthly SSI benefit payment for children was $615
(Ruffing & Pavetti, 2012), which translates to an annual rate of $7,380. In
2014, the federal poverty threshold was $11,670 for one person (U.S.
Department of Health and Human Services, 2014). Therefore, the SSI
payment level for one individual was 37% below the federal poverty level.
Although nearly 26% of children receiving SSI still live below the federal
poverty level (Grad, 2000), the SSI program plays a vital role in reducing
the extent of poverty experienced by these children. Two thirds of SSI
beneficiaries receive at least half of their total income from SSI; Social
Security benefits are responsible for reducing the poverty gap for SSI
398

recipients by an average of 60% (Grad, 2000). Although the level of
support provided by SSI is limited, reduced poverty for many children
with disabilities and their families is an important protective factor.
However, the protective benefits of SSI have been eroded by the Personal
Responsibility and Work Opportunity Reconciliation Act (PRWORA) of
1996. PRWORA catalyzed important changes in SSI for children with
disabilities by constricting child SSI eligibility rules. Following new
guidelines for eligibility, SSI retrenchment associated with PRWORA had
dire consequences for children with disabilities and their families. Between
1996 and 2000, the number of child SSI beneficiaries with mental
retardation declined by nearly 22% (or 76,000 individuals) and declined by
12% for children with all other disabilities (Parish, 2003). To compensate
for the loss of their children’s SSI income, some parents entered the
workforce or increased their work hours (Inkelas, Rowe, Karoly, &
Rogowski, 1999). However, increased work activity did not prevent total
income from declining for most families, some of whom had to seek other
forms of public assistance to compensate for the loss of SSI benefits
(Davies, Iams, & Rupp, 2000; Inkelas et al., 1999).
Low-income families of children with disabilities can also receive income
transfers through TANF, which was reauthorized by the Deficit Reduction
Act of 2005. TANF, which replaced the earlier welfare program, Aid to
Families with Dependent Children (AFDC), represented a major policy
shift in public assistance. Under AFDC, parents raising children with
disabilities were generally exempted from work requirements, whereas
TANF requires participants to be involved in either work or job training;
TANF also limits receipt of cash benefits to a lifetime maximum of 60
months (Thompson, Holcomb, Loprest, & Brennan, 1998). When
Congress was debating the PRWORA legislation, the National
Commission on Childhood Disability (1995) recommended exempting one
parent of a child with disabilities from mandatory work requirements,
excluding parents from being removed from welfare for 2 years following
a child’s termination from SSI, and prohibiting states from counting
children’s SSI benefits when assessing families’ welfare eligibility.
However, these recommendations were rejected in the final version of
PRWORA. Current TANF policies allow states to exempt a parent caring
for a family member with a disability from working if the person with a
disability is living at home and is not a full-time student; however, states
also have the discretion to establish more strict work participation rules
399

than those set by the federal legislation (Parrott et al., 2007). Recent
analyses have found that TANF has had a limited effect on low-income
mothers of children with disabilities. Although TANF’s stated purposes
included increasing marriage and employment to reduce welfare reliance,
evaluation of the program’s effects show limited employment gains, no
marriage increases, and no reduction in overall welfare use among low-
income mothers of children with disabilities (Parish, Rose, & Andrews,
2010).
A real and urgent need exists for policies that accommodate the
responsibilities of parents caring for children with disabilities. First, these
parents face many barriers to maintaining employment, including
children’s ongoing and episodic needs for affordable and appropriate care
(Rosman, McCarthy, & Woolverton, 2001; Shearn & Todd, 2000). In
addition, low-income families, which are overrepresented among those
raising children with disabilities, pay for most child care out-of-pocket;
child care for children with disabilities is more expensive than routine
child care, and the burden of these costs contributes substantially to the
poverty of these families (Lukemeyer et al., 2000; Meyers, Han,
Waldfogel, & Garfinkel, 2001; Meyers & Heintze, 1999). The elevated
care needs of children with disabilities and the extraordinary caregiving
responsibilities assumed by their parents place these parents at elevated
risk of unemployment and underemployment, both of which are directly
associated with family poverty (Parish et al., 2004; Lichter & Eggebeen,
1994).
The system of income transfers in the United States provides critical
support to children with disabilities and their families. These programs
directly address the increased risk of living in poverty for children with
disabilities and attempt, albeit in a limited way, to ameliorate the high
costs of raising children with disabilities. Although SSI alone does not
provide sufficient resources to raise family income above the federal
poverty level, its provisions are important protective factors for the
thousands of families who receive it.
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Education and Early Intervention
The Individuals with Disabilities Education Act (IDEA) began as the
Education for All Handicapped Children Act of 1975 (PL 94-142) and
gave all children with disabilities the right to a free and appropriate public
education. This watershed civil rights law resulted from sustained
advocacy by parents of children with disabilities. IDEA was reauthorized
in 2004 under the Individuals with Disabilities Education Improvement
Act (IDEIA).
Special education has been shaped by the six core principles that formed
the nucleus of the Education for All Handicapped Children Act:
1. Zero reject means schools cannot exclude any children with
disabilities from instruction.
2. Nondiscriminatory evaluation guarantees every child an
individualized, culturally and linguistically appropriate evaluation
before being placed in special education.
3. Individualized Education Plans (IEPs) delineate current performance,
progress on past objectives, goals and services for the school year,
and evaluation of outcomes.
4. Least restrictive environment describes the goal that children with
disabilities are educated to the extent possible in settings with
children without disabilities.
5. Due process codifies the legal steps to ensure school fairness and
accountability in meeting a child’s needs and how parents can obtain
relief via a hearing or second opinions.
6. Parental participation gives parents the right to access their child’s
education records and participate in IEP planning. (Adapted from
Kirk, Gallagher, & Anastasiow, 1993, pp. 51–52.)
These principles have remained fixtures of the act since its initial passage
in 1975. However, the act has also changed over the years in response to
litigation and reauthorizing statutes. We will describe least restrictive
environment, IEPs, and some of the issues that have emerged, including
school district responsibility to fund and provide needed services,
procedures to plan for a child’s transition out of school, and reliance on
parents to serve as advocates for their children.
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Least Restrictive Environment
The notion of least restrictive environment exists to ensure that children
are served in inclusive and integrated settings and are not segregated from
typically developing peers. However, because this is a recommendation
and not a requirement of IDEA, there is great variability among school
districts in the proportion of children with disabilities who are educated in
inclusive settings. Furthermore, parents and teachers have reported mixed
feelings about mainstreaming children with disabilities into least restrictive
environments. Although regular education teachers generally support
mainstreaming, their endorsement appears to deteriorate when they
address their own willingness to include children with disabilities in their
classrooms (Scruggs & Mastropieri, 1996). Moreover, teachers often are ill
equipped or unwilling to adequately include children with special needs in
classroom activities. Concerns about mainstreaming are common to
parents whether raising children with or without disabilities. Some parents
of typically developing children fear mainstreaming will mean that time
will be taken away from their children’s learning experiences, and some
parents of children with disabilities fear their children will not receive the
level of attention available in segregated classes (Rallis & Anderson,
1994). Despite this controversy, many agree that mainstreaming is critical
for children with disabilities because it allows them to develop
interpersonal and life skills and concurrently allows children without
disabilities to learn to accept those with disabilities (Osborne & Dimattia,
1994).
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Individualized Education Plans
The IEP is a legal document developed for each student with a disability.
The IEP is developed by a multidisciplinary team, including the student,
his or her parents, teachers, social workers, speech and physical therapists,
psychologists, and other support people as necessary given the child’s
needs. The IEP is intended to ensure that the child receives an appropriate
education in the least restrictive environment. It is a malleable document
that is supposed to be revised annually, or more often if the child’s needs
change. IEPs address current educational performance levels, goals,
services to support mainstreaming, and other considerations warranted by
the child’s particular abilities and needs (Sopko, 2003). Although IEPs
were mandated by IDEIA and its IDEA forerunner, parents and teachers
recognize numerous barriers in developing appropriate IEPs for children
with disabilities. For example, IEPs take considerable time and skill to
develop and involve varying perceptions and attitudes about interpretations
of inclusion and the responsibilities of educators (Sopko, 2003).
Since 1997, IEPs have been required to include plans for the transition
from school to adult life. This mandate was passed in response to
overwhelming evidence of negative outcomes for children with disabilities
who left high school. The goal of transition planning is to enable children
with disabilities to become active and productive citizens by helping them
bridge the distance between closely supervised, sheltered educational
settings and the less-structured adult world. School districts can begin
including transition planning in a child’s IEP as early as age 14 years.
Transition plans should address instruction, community involvement,
employment, and other adult life objectives and should incorporate the
child’s individual interests and preferences (Sopko, 2003).
Although IDEIA guarantees children with disabilities the right to a free
appropriate public education, there is frequent disagreement between
parents and professionals regarding what constitutes an appropriate
education. Schools often contest the education and support services
requested by parents, and challenges are more common when school
districts are asked to provide related services such as transportation,
assistive technology, and medical services to assist children in obtaining
an education (Katsiyannis & Yell, 2000).
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Expensive health services for students with chronic health problems are
often among the most controversial issues. The U.S. Supreme Court ruling
in Cedar Rapids Community School District v. Garret F. (1999) required
the school district to provide a specially trained nurse as part of a child’s
special education plan when having the nurse available was necessary for
the child’s participation in school (Katsiyannis & Yell, 2000). This ruling
was an important victory for children whose impairments necessitate
ongoing medical care. For all children with disabilities, this ruling
represents a clear statement from the Supreme Court that schools are
responsible for the provision of needed ancillary and supportive services.
Extensive litigation surrounding IDEIA and ongoing challenges by schools
to the rights of children with disabilities has created a system in which
parents must be assertive advocates. The burden parents undertake in
being their child’s advocates and the level of sophistication and resources
they must bring to bear to secure their child’s education are considerable.
Part of the parental role in IEP planning is to safeguard their child’s
educational rights, which engenders an inherently adversarial relationship
between parents and schools. Parents are expected to be active members of
their child’s IEP team (NICHCY, 2010). Although this expectation that
parents will be vigorous advocate for their children has produced
important outcomes such as the Garret F. decision, it is unrealistic and
unreasonable to expect all parents to be effective advocates. Many parents,
and particularly low-income parents, lack the educational and financial
resources to effectively champion their children’s needs. Children with
disabilities who lack a resourceful parent-advocate may be denied their
right to an education.
The second part of IDEIA that is critically important for children with
disabilities is early intervention, which aims to provide prevention and
treatment services to improve cognitive, social, and emotional
development of children younger than 3 years old. Children may receive
early intervention services if they are considered either at risk for delayed
development or have been identified as having a developmental disability
(NICHCY, 2014). Early intervention services have long been recognized
as important for helping children with disabilities achieve their
developmental potential. Best practices for early intervention programs
involve a range of family-centered services that focus on meeting the
needs of the child within the context of his or her family and larger
environment. For example, in the course of early intervention, parents may
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be referred to job assistance or adult education and may receive assistance
in obtaining housing and health care.
The philosophy undergirding early intervention is grounded in the
concepts of protective and promotive factors. Ideally, early intervention
services promote well-being and optimal development by providing
comprehensive community-based support services to help improve
developmental outcomes. Even young children with disabilities are at risk
of developing further complications that may exacerbate their impairments
or cause secondary conditions (Zipper & Simeonsson, 2004). Early
intervention in the United States has been structured by a federal mandate
since 1986, when Part H (now Part C) was added to the Education for All
Handicapped Children Act, mandating the provision of early intervention
services (PL 99-457). The act’s early intervention mandate is to provide
comprehensive services to families of children from birth to age 3
(Richmond & Ayoub, 1993).
When possible, early intervention services should be provided in the most
appropriate natural setting, which includes the home or other community
setting. The emphasis on community-based intervention is intended to
promote children’s integration and inclusion in their home communities
(Graham & Bryant, 1993). Between 2003 and 2004, about 80% of early
intervention programs were provided in children’s homes (U.S.
Department of Education, 2009). Broad-based early intervention services
are essential for the cognitive, social, and emotional development of young
children (e.g., NECTAC, 2011).
Multidisciplinary supports and programs scaffold the early intervention
system, including audiology services, nutrition, family training and
counseling, social work, physical and occupational therapy, and services
providing assistive technology devices. At a minimum, states must identify
infants and toddlers who are deemed to be at risk for or who already have
identified developmental delays. Among other requirements, states are
required to obtain Individualized Family Service Plans and provide data
collection methods and evaluation procedures. When a child enters early
intervention, assessments are conducted of child and family strengths and
risk factors (Ramey & Ramey, 1998). Parents and professionals
collaboratively develop the Individualized Family Service Plan, which
addresses the child and family as a unit (Ramey & Ramey, 1998). This
collaborative effort is important for adequately assessing risk and
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protective factors within the family structure and larger social
environment.
Despite higher rates of disability and poverty among African American
and Hispanic children, non-Hispanic White children are more likely to
receive early intervention services than their peers (U.S. Department of
Education, 2009). The disparity represents problems minority families face
in accessing early intervention services and are not indicative of decreased
need. After age 6, the likelihood that an African American child is enrolled
in services increases as the child moves from early intervention into
special education. However, Hispanic children remain less likely to
receive needed services than children from other racial/ethnic groups (U.S.
Department of Education, 2009). The reasons for this trend are not fully
understood and warrant further investigation.
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Title V of the Social Security Act:
Maternal and Child Health
Title V of the Social Security Act, also known as the Maternal and Child
Health Services Block Grant, is a federal–state partnership program that is
aimed at improving the health of all mothers and children. Title V is not an
entitlement program, and eligibility criteria and how and what programs
are funded vary widely across states (Beers et al., 2003; Maternal and
Child Health Bureau, n.d.; Rosenbaum, Proser, Schneder, & Sonosky,
2002). Title V provides funds to states as block grants that allow the states
autonomy to determine how to spend funds within general guidelines and
goals. For every $4 in federal funds for the program, states are expected to
spend $3 in matching funds. In general, states allocate funds to four levels
of services:
direct health-care services, such as health services for children with
special health-care needs;
enabling services, such as transportation, respite care, and health
education;
population-based services, such as newborn screening and
immunization; and
infrastructure building services, such as policy development, training,
and applied research. (U.S. Department of Health and Human
Services, 2008)
In fiscal year 2009, the total budget for the Federal–State Partnership
Block Grant exceeded $5 billion. Of that money, almost 50% was
earmarked for children with special health-care needs, which includes
children with disabilities. However, there was a great deal of variation
among states in spending their Title V budgets on children with special
health-care needs, ranging from 6% in Illinois to 83% in California. States
also varied in what level of service they chose to fund. For example,
Tennessee allocated more than 72% of its total budget to direct health
services, whereas Missouri allocated only 4% of its budget for such
services (Maternal and Child Health Bureau, n.d.).
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Family Support
Families bear the greatest responsibility for caring for children with
disabilities, and parents constitute the largest group of care providers
(Hogan & Msall, 2002). Family support services are often provided over a
child’s life course and include respite care, environmental adaptations,
assistive devices, personal assistance, mental health, and crisis
intervention. These supports enable families to care for their children with
disabilities at home rather than seek out-of-home care (Bruns & Burchard,
2000; Curran et al., 2001). In addition, these supports play a significant
role in reducing the burden and stress associated with caring for children
with disabilities at home (Floyd & Gallagher, 1997; Freedman & Boyer,
2000; Haveman, van Berkum, Reijinder, & Heller, 1997), and they help
families obtain services for unmet needs (Heller, Miller, & Hsieh, 1999).
Despite the extent of care that families provide for their children with
disabilities, none of the states provide any more than a meager level of
family support. For example, spending for family support services to serve
both children and adults with developmental disabilities and their families
totaled just less than $2 billion in 2004; this was far short of the $39 billion
spent for the entire developmental disabilities service system in all the
states (Rizzolo, Hemp, & Braddock, 2006). Family support services across
the United States are usually jointly financed by the federal and state
governments, often using Medicaid resources that are typically
administered by state or county governments. Levels of funding dedicated
for family support and the types of services available vary greatly between
the states (Parish, Pomeranz, & Braddock, 2003).
Even families who receive support services encounter difficulty in
obtaining all the services they need to care for children with disabilities.
Freedman and Boyer (2000) found that supports, such as respite care,
demonstrably enhanced family well-being and were critically important to
families. However, barriers to securing needed support services include a
lack of flexibility in the types and frequency of services families received,
and critical access difficulties, such as services being unavailable when
they were most needed (Freedman & Boyer, 2000).
We have reviewed the major public policies that influence the lives of
408

children with disabilities and their families in the United States: income
transfers, education, early intervention, and family supports. Considerable
variation exists in the extent to which knowledge of risk and resilience has
informed the development of these policies. However, despite contention
about their effectiveness, these policies are significant in the lives of
children with disabilities and their families. The policies are contributing
—although not yet optimally—to promoting child development and the
successful adjustment of children with disabilities. Table 7.2 provides an
overview of these policies and their features.
409

Using Knowledge of Risk, Protection, and
Resilience to Achieve Service Integration
in Disabilities Policy
Two features define policies related to children with disabilities: (1) the
reliance on parents to be advocates, case managers, and caregivers for their
children; and (2) the fragmentation of policy across service domains.
Parents are expected to have a central role in providing care for their
children from the point of diagnosis to entry into early intervention, to
obtaining support services, to enrolling in the education system, and
through transition planning and beyond. In some policies, this parental role
is explicit: early intervention programs have for decades embraced
collaboration between parents and professionals, and the partnership has
long been regarded as a best practice for infants, toddlers, and preschoolers
with disabilities (Blue-Banning, Summers, Frankland, Nelson, & Beegle,
2004).
However, many parents lack the time, knowledge, and financial and
emotional resources required to be full or effective partners in this
endeavor. Within the formal education system, IDEIA has established
410

ground rules through which parents can enter an adversarial role with their
children’s schools to obtain needed services. Parents speak poignantly of
their advocacy at every step of their child’s development to ensure that
needed services are secured. Although over time sustained advocacy often
helps parents become masters in navigating bureaucracies and securing
services, such efforts are by no means the optimal way for children with
disabilities to obtain what they need. Parents face enough stress in meeting
their children’s physical and emotional care needs and should not also
have to fulfill roles as advocates and case managers.
Fragmentation of services remains an ongoing challenge for children with
disabilities. Often, to obtain the services their children need, parents must
navigate numerous different bureaucracies, with separate institutions
governing income transfers, early intervention and education, family
support, and medical care. All of these programs have different eligibility
criteria, paperwork requirements, definitions of disability, revenue sources,
and administrative entities. Despite considerable redundancy requiring
parents to “prove” that their child has an impairment, streamlined
applications or coordination across providers typically does not exist.
411

Juanita: A Case Example
To further illustrate the fragmentation and parental advocacy that are
hallmarks of disability policy, we considered the experiences of a young
girl, Juanita, who has cerebral palsy and intellectual disabilities. Cerebral
palsy is a nonprogressive group of chronic conditions that results from a
brain injury, which affects muscle coordination and motor development.
Cerebral palsy was formerly included in the category of mental
retardation, although cerebral palsy does not always include intellectual
disabilities. Intellectual disabilities are characterized as below-average
intelligence.
412

Juanita
Juanita is a 9-year-old who lives with her mother. Juanita’s father has not
had contact with the family since the girl’s diagnosis with cerebral palsy at
20 months of age. Their extended family lives out of state. Juanita was
slower than other young children to reach developmental milestones, and her
pediatrician’s referral to a neurologist established the diagnosis for cerebral
palsy. Juanita was in a center-based early intervention program until she
entered public school. Juanita is in a self-contained classroom with other
children with disabilities, but her mother would prefer for her to be
mainstreamed into a regular education classroom. Juanita walks with
crutches, has difficulty grasping objects, and has limited speech that is
difficult to understand. She is incontinent. She is very friendly and outgoing
and is well liked by her teacher, classmates, and other children in her
neighborhood. She has a great sense of humor and likes to tell jokes.
Juanita’s mother has a close relationship with one neighbor, but this
neighbor is not comfortable providing child care for Juanita. Juanita’s
mother has had to limit her work to part-time employment because she
cannot find afterschool care for Juanita, and she must drive and accompany
Juanita to frequent medical appointments. Juanita’s father does not pay child
support, and because her mother’s income is low, Juanita qualifies for
monthly SSI payments and Medicaid. Over the past few years, when her
mother’s income temporarily increased because of work bonuses, Juanita’s
SSI benefits were reevaluated and terminated. Although her mother appealed
those termination decisions, the appeals process took several weeks in each
case. The appeals process is confusing, and Juanita’s mother was not aware
that she could ask for aid pending the outcome of the appeals.
Juanita’s current IEP recommends only one specialized service, which is
speech therapy that she receives in a group setting with several other
classmates. Juanita’s earlier IEP had also recommended physical therapy,
but those services were discontinued 2 years ago when her IEP team, with
the exception of her mother, decided the therapy was no longer necessary
because she had made limited progress. Since that time, Juanita’s physical
functioning has deteriorated, but the IEP team rejected her mother’s initial
appeal to have the physical therapy put back into her IEP. Her mother wants
to pursue this appeal further but needs to learn how to initiate further
appeals.
During her early childhood, Juanita had a number of orthopedic surgeries to
increase her physical functioning. Although she has Medicaid, the only
health-care providers in the region who accept Medicaid are in a county
clinic. Because of the practice structure of the county clinic, Juanita and her
mother always have lengthy waits for care, and she usually sees different
413

providers at each visit. Juanita needs adaptive devices to help her manipulate
tools and independently complete activities of daily living (e.g., feeding,
personal hygiene). To give Juanita greater independence in self-care, her
mother has applied through the clinic’s pediatrician for a number of these
devices. Medicaid has denied these applications, but her mother is appealing
those decisions. Medicaid does not cover the cost of Juanita’s diapers, which
are expensive. The mother has also applied for a cash subsidy to cover the
cost of purchasing the adaptive devices Juanita needs, but she was told that
she is ineligible because the household income is too high.
Juanita’s mother contacted the regional office of the state’s developmental
disabilities department to request respite services. She would like to use the
respite services for Juanita’s afterschool care so she could work more hours.
Although she has completed the application, it cannot be submitted until the
clinic pediatrician finalizes the paperwork certifying Juanita’s disability.
Even if the application is approved, Juanita will be placed on the waiting list.
The regional office told the mother the wait for respite services averages 18
months, and once services are available, she will be eligible to receive a
maximum of 10 hours respite care a month. After receiving respite services
for 1 year, she will again be wait-listed so that other families can receive the
respite service. Given the long wait, Juanita’s mother is anxious to get the
application submitted. However, over the past 2 months, she has called the
clinic weekly to check on the pediatrician’s progress with this paperwork,
but it has not yet been completed. No one has given her a reason for the
delay.
Juanita and her mother’s situation, like so many others, illustrates the
complexity involved in navigating a fragmented and unresponsive service
delivery system.
414

Policy Recommendations
Children with disabilities and their families are protected by policies that
are designed to enhance family functioning and to provide services and
therapies that maximize independence and inclusion in society. At present,
family support and early intervention are based on principles of risk and
protective factors. Special education was developed within a civil rights
framework: Children with disabilities were entitled to the same
educational opportunities as their nondisabled peers. Like SSI payments
for children, special education offers some protective benefits, but such
benefits are limited in scope. On balance, the accrued benefits do not
mitigate the risks associated with childhood disability.
The limited availability of family support services across the United States
translates into few benefits for most families. The model of early
intervention, in which service provision is driven by collaborative parent–
professional partnerships, has much to offer the broader arena of disability
policy for children. In this model, the focus is the whole family rather than
just the child with disabilities, and the goal is to meet the needs of the
whole family across a spectrum of domains. Compelled by a single
Individualized Family Support Plan (IFSP), care and services are typically
coordinated to meet the full constellation of family needs. Our central
policy recommendation is related to using an IFSP model to integrate and
coordinate services across all service and support domains. Expanding the
rubric of the IFSP to include family support services from all funding
sources, including income transfers and Medicaid, would minimize the
avenues and channels parents must navigate to obtain the services a child
needs and to which he or she may be entitled. A “one-stop shopping”
approach would also reduce the fragmentation in services and create a
cohesive service structure. If the IFSP model were incorporated in
children’s education plans, a holistic framework of serving children with
disabilities within the context of their families would replace the current
fractured focus on child deficits and skills.
415

Summary
We have described five of the major policies that influence the well-being
of children with disabilities and their families: (1) income transfers, (2)
education, (3) early intervention, (4) Title V Maternal and Child Health
Services, and (5) family support services. We have shown that these
policies place a burden on parents to function as advocates and case
managers, and, more broadly, that the services produced by these policies
function in similar ways but have inherent differences.
Understanding and accessing programs is difficult because of the lack of
communication between systems, different eligibility criteria, and an array
of separate (and competing) revenue sources. Although concepts of risk
and protective factors are fundamental in early intervention and family
support policies, they are applied in very limited ways to education and
income transfer policies. In addition, family support is so inadequately
funded that it has little meaning or impact for most families raising
children with disabilities. Therefore, our final recommendations stem from
a desire to enable families to meet the care needs of their children, at a
minimum. To accomplish this objective, early intervention must be fully
funded, and funding for family support and income transfers should be
increased to meet the true needs of low-income families.
416

Questions for Discussion
1. What are the implications of categorically based eligibility criteria for
efforts to integrate policies for children with developmental disabilities with
other child and family policies?
2. What policy changes would you recommend to better provide an integrated
service delivery system for children and youth with developmental
disabilities and their families?
3. How will the transition away from a medical model of disability to a social
model of disability influence the delivery of services for children and youth
with developmental disabilities and their families in the coming decades?
417

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(2001). “Who I am and what I want”: Adolescents’ self-definition and struggles. Exceptional Children, 67, 375–389. Williamson, H. J., & Perkins, E. A. (2014). Family caregivers of adults with intellectual and developmental disabilities: outcomes associated with U.S. services and supports. Intellectual and Developmental Disabilities, 52(2), 147–159. doi:10.1352/1934-9556-52.2.147 World Health Organization, UNICEF, UNFPA, & The World Bank. (2012). Trends in maternal mortality: 1990 to 2010. Geneva, Switzerland: Author. Yau, M. K., & Li-Tsang, C. W. (1999). Adjustment and adaptation in parents of children with developmental disabilities in two-parent families: A review of the characteristics ancillary attributes. British Journal of Developmental Disability, 45, 38–51. Zipper, I., & Simeonsson, R. J. (2004). Promoting the development and well-being of young children with disabilities. In M. Fraser (Ed.), Risk and resilience in childhood: An ecological perspective (pp. 244–264). Washington, DC: NASW Press. 430 https://federalregister.gov/a/2014-01303 http://archive.acf.hhs.gov/programs/cb/pubs/cm09/cm09 Additional Reading Davis, L. (2013). The disability studies reader (4th ed.). New York: Routledge. Hogan, D. (2012). The family consequences of children’s disability. New York: Russell Sage Foundation. Naseef, R.A. (2013). Autism in the family: Caring and coping together. Baltimore: Brookes. 431 Web-Based Resources The Arc, http://www.thearc.org/ Bazelon Center for Mental Health Law, http://www.bazelon.org/ Children’s Defense Fund, http://www.childrensdefense.org/ Family Voices, http://www.familyvoices.org/ Institute for Community Inclusion, http://www.communityinclusion.org/ Kids Together, Inc., http://www.kidstogether.org/ Tash, Equal Opportunity and Inclusion for People with Disabilities, http://www.tash.org/ 432 http://www.thearc.org/ http://www.bazelon.org/ http://www.childrensdefense.org/ http://www.familyvoices.org/ http://www.communityinclusion.org/ http://www.kidstogether.org/ http://www.tash.org/ Chapter 8 Policies and Programs for Adolescent Substance Abuse Elizabeth K. Anthony Jeffrey M. Jenson Jeffrey M. Jenson Adolescent substance abuse has been the subject of frequent discussion in local, state, and federal policy circles since the 1960s. Substance abuse among children and youth has also attracted the attention of the American public. A recent opinion poll conducted by the Gallup Organization revealed that 68% of Americans viewed drug use as one of the most serious problems facing teenagers (Gallup Organization, 2009). About 53% of respondents believe that the federal government has made little or no progress in preventing drug use in the past several years. The visible and often devastating effects of substance use on individuals— coupled with the societal and economic costs associated with abuse—have been the targets of repeated social intervention in the past century. Demands for policy and program reform have come from a range of constituents and organizations. A report published at the beginning of the past decade by Physician Leadership on National Drug Policy (2002) outlined the need for more policy directives aimed at preventing adolescent substance abuse in the United States. Recent reports from the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) place considerable emphasis on informing practitioners about efficacious ways to prevent and treat adolescent substance abuse (NIDA, 2009; SAMHSA, 2010). It is significant that researchers and policy officials are working together to apply knowledge about the risk and protective factors associated with the onset and use of alcohol and illicit drugs to social interventions and policies for children and families (Hawkins, 2006; Liddle & Rowe, 2006; Scheier, 2010; Woolf, 2008). In this chapter, we describe risk and protective factors related to substance use and abuse. In addition, we review past and current policy and program 433 responses to treating and preventing substance abuse in adolescence. The utility of a public health framework that emphasizes risk, protection, and resilience for the development of innovative policy and programs is examined. We begin with a brief discussion of recent trends in adolescent substance use. 434 Trends in Adolescent Substance Use Adolescent substance use exists on a continuum that includes no use, nonproblematic use, abuse, and dependence. Substance abuse and dependence represent the most serious concerns to practitioners and policymakers. However, even low levels of drug use by children and youth can be problematic, given the many developmental tasks they encounter at school and in the community. Our review of trends in substance use, therefore, includes reports of experimental and regular use. The nation’s most accurate prevalence estimates for adolescent substance use come from the Monitoring the Future (MTF) study (Johnston, O’Malley, Bachman, & Schulenberg, 2013), sponsored by NIDA and the University of Michigan. MTF is an annual assessment of alcohol and drug use in a random sample of about 16,000 public and private high school students. In-school surveys with nationally representative samples of high school seniors have been conducted since 1975. Eighth- and 10th-grade students have been surveyed since 1991. There have been several notable trends in adolescent substance use since the 1970s. Lifetime illicit drug use—including the use of marijuana, hallucinogens, cocaine, heroin, and other opiates as well as stimulants, barbiturates, or tranquilizers that are not under a doctor’s order—peaked among seniors in 1981. About 66% of 12th graders in 1981 used an illicit drug at least once in their lives; 43% used an illicit drug other than marijuana. Lifetime use of illicit drugs reached its lowest point in 1992; only 41% of seniors used any illicit drug, and 25% used an illicit drug other than marijuana. In 1993, seniors reversed a decade-long pattern of declining illicit drug use. Rates of illicit drug use rose for 6 consecutive years, and by 1999, 55% of seniors reported using illicit drugs. A 10-year trend of declining rates of illicit drug use among high school seniors began in 2000. By 2009, only 47% of seniors reported illicit drug use in their lifetime. This rate rose slightly to 50% by 2013. Lifetime alcohol and tobacco use by seniors reached their highest levels in the late 1970s and early 1980s. About 93% of seniors reported lifetime 435 alcohol use between 1977 and 1985. In 2013, 68% of seniors reported lifetime alcohol use. Interestingly, lifetime cigarette smoking among young people peaked in 1977. About 76% of seniors smoked cigarettes in 1977, compared with 38% in 2013. Substance use among younger adolescents is of particular concern to policymakers and practitioners because early initiation is positively related to later problem use. The number of 8th-grade students reporting lifetime use of any illicit drug decreased from a high of 31% in 1996 to 20% in 2013. About 39% of 10th grade students used illicit drugs in 2013. Adolescent males continue to use most drugs at higher rates than females. There are a few exceptions, with girls in eighth grade having slightly higher rates of use of some substances, such as inhalants and amphetamines. Gender differences in use, with males using at a higher rate for most substances, tend to appear and stabilize as students grow older. Historically, MTF results have indicated that alcohol and drug use are more prevalent among White students than among African American or Hispanic students (Johnston et al., 2013a). However, in 2012, the annual prevalence of illicit drug use among 12th graders was 41% for Hispanic students, 40% for White students, and 35% for African American students. In addition to this shift for Hispanic students, the more recent narrowing of the difference among African American students is driven largely by an increase in marijuana use. Overall, African American students still maintain lower levels of use for the majority of licit and illicit drugs in 8th, 10th, and 12th grades (Johnston et al., 2013a). MTF results provide a fairly accurate picture of substance use among American youth. However, it is important to acknowledge that the MTF study may underestimate the magnitude of substance use among youth in the United States because it does not include school dropouts (an estimated 15% to 20% of students in this age group), a group at high risk for alcohol and drug use. Estimates of drug and alcohol use among minority groups may be particularly affected because more American Indian and Hispanic high school seniors drop out of school than African American, Asian American, or White seniors (Johnston et al., 2013a). Trends in adolescent substance use point to the need for a continuum of policy and practice responses. Prevention strategies are needed to delay initiation and to interrupt the progression of substance use that often begins with alcohol or tobacco and culminates with more serious drug use. 436 Conversely, treatment options are necessary for individuals exhibiting symptoms of abuse or dependence. In recent years, policy and program approaches aimed at preventing and treating adolescent substance abuse have been based on etiological models that emphasize principles of risk, protection, and resilience. 437 The Etiology of Adolescent Substance Abuse: Principles of Risk, Protection, and Resilience Knowledge generated by investigations examining the relationship among risk and protective factors and adolescent substance use has led to significant advancements in the etiology, assessment, and prevention of drug abuse (for a review of such investigations, see Belcher & Shinitzky, 1998; Brook, Brook, & Pahl, 2006; Hawkins, Catalano, & Miller, 1992; Jenson, 2004; Kim, 2009; Schinke, Fang, & Cole, 2008). Yet, definitions and policy applications underlying concepts of risk and protection are clouded with controversy. Most researchers, practitioners, and public health specialists agree that risk factors for adolescent substance use can be empirically identified. As noted in Chapter 1, there is considerably less agreement about the concept and definition of protection. Some authors (Luthar, 2003) have asserted that risk and protective factors act as polar opposites of one another. Other investigators (Fraser, 2004; Rossa, 2002; Rutter, 2000) have argued that protective factors are characteristics and conditions that moderate or mediate levels of risk for problem behaviors like substance abuse. The following discussion of protective factors, consistent with the interpretation presented in Chapter 1, is based on the view that protective factors are traits, conditions, and characteristics that influence or modify the risk of substance abuse. 438 Risk Factors Risk factors for adolescent substance abuse occur at environmental, interpersonal, social, and individual levels. These factors are summarized next and in Table 8.1. Source: Table adapted from Jenson (2004). Environmental Risk Factors Community laws and norms favorable to drug use, such as low legal drinking ages and low taxes on alcoholic beverages, increase the risk of substance use during adolescence (Joksch, 1988). Studies examining the relationship between legal drinking age and adolescent drinking and driving have shown that lowering the drinking age increases underage drinking and teen traffic fatalities (Saffer & Grossman, 1987). Laws and 439 norms that express intolerance for use of alcohol and illicit drugs by adolescents are associated with a lower prevalence of alcohol and drug use (Johnston, 1991). Child poverty rates have increased in the last few years; 23% of children under the age of 18 lived in conditions of poverty in 2012 (Annie E. Casey Foundation, 2013). Poverty is associated with many adverse adolescent outcomes, including conduct problems, delinquency, and unwanted pregnancy (Cauce, Stewart, Rodriguez, Cochran, & Ginzler, 2003; Hannon, 2003). Poverty may also have an indirect effect on adolescent substance use. Family income is associated with many other risk factors for drug use (e.g., parenting practices and academic difficulties); low family income may affect drug use indirectly through such risk factors. Low neighborhood attachment, school transitions, and residential mobility are associated with drug and alcohol abuse (Murray, 1983). Neighborhoods with high population density and high rates of adult crime also have high rates of adolescent crime and drug use (Simcha-Fagan & Schwartz, 1986). Neighborhood disorganization may also indirectly affect risk for drug abuse by eroding the ability of parents to supervise and control their children. Interpersonal and Social Risk Factors Interpersonal and social risk factors for adolescent substance abuse occur in family, school, and peer settings. Children whose parents or siblings engage in serious alcohol or illicit drug use are themselves at greater risk for these behaviors (Biederman, Faraone, Monuteaux, & Feighner, 2000). Children raised in families with lax supervision, excessively severe or inconsistent disciplinary practices, and little communication and involvement between parents and children are also at high risk for later substance abuse (Hill, Shen, Lowers, & Locke, 2000). Similarly, studies have shown that parental conflict is related to subsequent alcohol or drug use by adolescent family members (Brook, Whiteman, Gordon, & Brook, 1988). School failure, low degree of commitment to education, and lack of attachment to school are school-related factors that increase the risk of substance abuse during adolescence (Holmberg, 1985). Adolescent drug users are more likely to skip classes, be absent from school, and perform 440 poorly than non-drug users (Gottfredson, 1981). Association with friends who use drugs is among the strongest predictors of adolescent substance abuse (Fergusson & Horwood, 1999; Reinherz, Giaconia, Hauf, Wasserman, & Paradis, 2000). Peer rejection in elementary grades is associated with school problems and delinquency (Coie, 1990; Kupersmidt, Coie, & Dodge, 1990), which are also risk factors for drug abuse. Some investigators have hypothesized that rejected children form friendships with other rejected children and that such groups become delinquent or engage in drug use during adolescence (Patterson, 2002; Patterson, Reid, & Eddy, 2002). Individual Risk Factors Psychosocial and biological factors are related to drug and alcohol abuse during adolescence. For example, evidence from adoption, twin, and half- sibling studies supports the notion that alcoholism is an inherited disorder (Cadoret, Cain, & Grove, 1980). Several studies have found that a sensation-seeking orientation predicts initiation and continued use of alcohol and other drugs (Cicchetti & Rogosch, 1999; Cloninger, Sigvardsson, & Bohman, 1988). Research also indicates that attention deficit disorders, hyperactivity, and poor impulse control before the age of 12 predict the age of onset of drinking and drug use (Shedler & Block, 1990). Jenson and Potter (2003) found three distinct patterns of co-occurring mental health and substance use patterns in a longitudinal investigation of 154 detained youths. Adolescents who were most likely to abuse alcohol and other drugs also had high levels of self-reported depression, paranoia, hostility, and suicidal ideation. This and other investigations (Loeber, Farrington, Stouthamer-Loeber, & van Kammen, 1998; Vaughn, Freedenthal, Jenson, & Howard, 2007; Vaughn, Wallace, Davis, Fernandes, & Howard, 2008) suggest that mental health problems may play an important role in a youth’s decision to experiment with and to persistently use alcohol or other drugs. 441 Protective Factors Many adolescents develop healthy relationships and succeed in school and the community despite being exposed to multiple risk factors. Empirical research devoted to identifying individual and environmental characteristics that protect youth from substance abuse has lagged behind similar efforts aimed at identifying risk factors for drug use. However, an increasing number of investigators have begun to examine the relationship between protective factors and substance use in recent years (Brook et al., 2006; Jenson, 2004). When identified in children and adolescents, protective factors can be established or enhanced to reduce risks for substance abuse. Protective factors for alcohol and other drug use are summarized next and in Table 8.2. Source: Table adapted from Jenson (2004). Environmental, Interpersonal, and Social Protective Factors Environmental, interpersonal, and social protective factors are attributes that buffer community, neighborhood, family, school, and peer risk factors. The most comprehensive study of protective factors among 442 children was conducted by Werner and colleagues. Werner and Smith (1989) began following a cohort of high-risk children in Kauai, Hawaii, in 1955. Analysis of the children’s outcomes as adolescents and adults has contributed to knowledge about factors that prevent youth from abusing alcohol and other drugs. Werner (1994) found that being raised in a family with four or fewer children, experiencing low parental conflict, and being a firstborn child reduce the effects of poverty and other risk factors for substance abuse. Children who abstained from drug use during adolescence and early adulthood had positive parent–child relationships in early childhood and caring relationships with siblings and grandparents. Children who abstained from alcohol and other drugs also received social support and frequent counsel from teachers, ministers, and neighbors (Werner, 1994). A positive family milieu and community supports are protective factors for drug abuse among children exposed to multiple risk factors. Garmezy (1985) found low childhood stress among high-risk children living in supportive family environments and among adolescents who had strong external support systems. Because stress increases the risk of drug use in later adolescence and early adulthood (Rutter, 2000), such findings have implications for preventing childhood and early adolescent drug abuse. Strong social bonds to parents, teachers, and prosocial peers are significant factors in children’s resistance to drug use (Berrueta-Clement, Schweinhart, Barnett, Epstein, & Weikhard, 1984). Four elements of the social bond have been found to be inversely related to adolescent drug abuse: (1) strong attachments to parents (Brook et al., 2006), (2) commitment to school (Friedman, 1983), (3) involvement in prosocial activities such as church or community organizations (Miller, Davies, & Grenwald, 2000), and (4) belief in the generalized norms and values of society (Jenson & Howard, 1999). Understanding the processes by which strong social bonds develop is necessary to develop strategies that increase healthy bonding in high-risk youth. Social learning (Bandura, 1989) and social development (Catalano & Hawkins, 1996) theorists have suggested that three conditions are critical to the formation of strong social bonds: (1) opportunities for involvement in prosocial activities, (2) possession of the requisite behavioral and cognitive skills necessary to achieve success in such activities, and (3) rewards or recognition for positive behaviors. To 443 promote healthy bonds, policies should support intervention strategies that provide opportunities, enhance skills, and offer rewards to high-risk youth. Individual Protective Factors Individual protective factors are psychosocial and biomedical characteristics that inhibit drug use. Competence in social and problem- solving situations is associated with abstinence and reductions in teenage drug use and delinquency. In a sample of high-risk urban children, Rutter (2000) found that problem-solving skills and strong self-efficacy were associated with successful adolescent outcomes. Youth who possessed adequate problem-solving skills and the ability to use skills were less likely to engage in drug use and delinquency. Jenson, Wells, Plotnick, Hawkins, and Catalano (1993) found that strong self-efficacy decreased the likelihood of drug use 6 months following drug treatment among adjudicated delinquents. These findings suggest that social and problem- solving skills moderate the effects of multiple risk factors for drug abuse and other adolescent outcomes. Attitude and temperament are protective factors for substance abuse. Positive social orientation and positive temperament reduce the likelihood of adolescent drug abuse in several studies of high-risk youth (e.g., Jenson & Howard, 1999). Low intelligence (Werner, 1994) is also related to drug use. 444 Resilience In Chapter 1 of this volume, Jenson and Fraser note the importance of resilience—an individual’s ability to succeed in the face of adverse life circumstances—in the prevention of adolescent problem behaviors such as substance abuse. Anecdotal accounts detailing a person’s ability to overcome substance abuse and addiction are common in American popular literature (Burroughs, 2003; Hamill, 1994; Knapp, 1996). However, the concept of resilience as an empirical construct in the explanation, prevention, or treatment of adolescent substance use remains a relatively new area of investigation (Luthar, 2003; Meschke & Patterson, 2003). Studies indicate that some children and adolescents display high levels of functioning despite being surrounded by adverse familial or environmental influences (Fergusson & Horwood, 2003; Zucker, Wong, Puttler, & Fitzgerald, 2003). Zucker et al. (2003) examined the relationship between levels of resilience and subsequent childhood and adolescent outcomes among sons of alcoholic fathers and found that resilient youth were significantly more likely than nonresilient youth to resist substance use and other antisocial behaviors. Other studies have focused on the role of resilience in overcoming conditions of poverty (Cauce et al., 2003) and exposure to violence (Gorman-Smith & Tolan, 2003). Additional research is needed to better understand the direct and indirect effects of resilience on substance use. 445 Summary Risk factors for substance use have been shown to be relatively stable over the past several decades. The factors summarized earlier consistently predict alcohol and drug use even though social norms about the acceptability of substance use have changed several times during this period. This suggests that policies and programs should encourage the development of strategies that target risk factors at multiple levels, including differential vulnerability, poor child-rearing practices, school achievement, social influences, social learning, and broad social norms. Protection and resilience hold great promise in understanding, preventing, and treating substance abuse. Knowledge gained from studies examining the complex relationships among risk, protection, and resilience should be considered in policy and program design. 446 Risk, Protection, and Resilience in Substance Abuse Policy 447 The Evolution of Drug Policy: A Brief Overview Drug policy in the United States reflects cultural beliefs about the risks associated with substance use and the role of governmental regulation in people’s personal and social lives. Cultural beliefs about substance use and opinions about the best way to prevent or treat substance abuse are in turn affected by a host of social, political, and economic conditions (DuPont & Voth, 1995). The evolving nature of these beliefs may best be seen in the underlying tension that is evident between policy approaches favoring control and regulation and those favoring prevention and treatment. The relative emphasis placed on control strategies versus prevention and treatment alternatives has a significant impact on the nature of policies, programs, and services for children and adolescents available at any given point in time (McBride, VanderWaal, & Terry-McElrath, 2001; Musto, 1996). The good news for prevention and treatment advocates may be that increases in federal funding for adolescent health have led to a greater array of substance abuse prevention and treatment alternatives for children and youth (Dougherty, 1993; Irwin, Burg, & Cart, 2002). Of particular note, beginning in 2010, the Obama administration’s approach to reducing drug use and the consequences of drug use has shifted the historical enforcement approach (“war on drugs”) to the use of science and evidence-based public health and safety, focusing on prevention, treatment, and recovery (Office of National Drug Control Policy [ONDCP], 2014). In the current economic climate, however, there is considerable competition for funds, and efforts to reduce substance abuse among youth must demonstrate evidence of effectiveness. Major American drug policies of the past century are reviewed next and are shown in Table 8.3. Early Drug Policy American drug policy emerged at the turn of the century with the passage of several important acts. The Pure Food and Drug Act of 1906 required labeling of all drugs sold in the country. The Harrison Narcotics Act of 1914 and the 1919 Volstead Act prohibited the sale of narcotics and alcohol (DuPont & Voth, 1995). Prohibition against illicit drugs was used as a public policy approach well into the 1950s, when the federal government implemented drug trafficking laws and enacted strict penalties 448 for drug violations. 1960–1980 The “drug revolution” of the 1960s and 1970s created an increase in demand for illicit drugs that was unparalleled in prior years. Changing social norms reflecting greater tolerance for experimental drug use led to a shift from the predominantly punitive stance that was common before 1960 to an interest in decriminalizing marijuana and other less serious drugs. As “recreational” and experimental drug use became more common, increased public awareness of the health risks associated with substance use coincided with the development of prevention and treatment strategies for illicit drug abuse (McBride et al., 2001). Passage of the Narcotic Addict Rehabilitation Act of 1966 reflected society’s desire to help individuals suffering from addiction. And, in 1967, the American Medical Association endorsed the disease theory as the predominant explanation of alcohol addiction, a change that was to have a profound effect on American social policy (Freeman, 2001). 449 The 1970s witnessed several key pieces of drug-related legislation. Predating President Richard Nixon’s declaration calling for a “war on drugs” by just 1 year, Congress passed the Comprehensive Drug Abuse Prevention and Control Act in 1970. The act consolidated several previous federal laws and categorized addictive drugs for purposes of control and regulation. While reducing the penalties for certain types of possession offenses, the act also strengthened law enforcement efforts. The emphasis on rehabilitation, however, remained an important part of the 1970 legislation. 1980–Present An increase in drug use among the nation’s youth at the end of the 1970s marked a reversal in public opinion about the nature of substance use policy. “Get-tough” approaches began to replace policies favoring 450 community-based treatment, and the subsequent passage of the Anti-Drug Abuse Acts of 1986 and 1988 reinforced a return to policies favoring law enforcement and control (McBride et al., 2001). The federal Office of National Drug Control Policy (ONDCP) was created in 1988 to better coordinate drug policy across states and international borders. By the late 1980s, all states raised the legal drinking age to 21 in response to growing concerns about the dangers and consequences of adolescent alcohol abuse. Arrest, conviction, and incarceration rates for drug-related offenses— particularly among poor youth and youth of color—increased following tougher policy provisions passed in the 1980s (Snyder, 1990). Some policy experts noted a return to drug policies favoring prevention and rehabilitation in the past decade (Physician Leadership on National Drug Policy, 2002). As one important example, treatment parity with other health conditions from an insurance perspective has long been sought by mental health and substance-related disorder advocates. When the Mental Health Parity Act was first introduced in 1996, it provided parity for mental health benefits, in terms of aggregate lifetime and annual dollar limits, when compared with medical/surgical benefits. Substance abuse or chemical dependency was excluded, however. When the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008, it required equity for mental health and substance use-disorder benefits when these services are provided. Specifically, the financial requirements such as copays or deductibles and limitations set on treatment must be “no more restrictive” than the limitations set for all medical/surgical benefits (U.S. Department of Labor, 2010). Building on the MHPAEA and beginning in 2014, the implementation of the Patient Protection and Affordable Care Act (2010) requires coverage of mental health and substance use-disorder services and requires that these services be provided at parity with medical and surgical benefits by insurers and group health plans (Beronio, Po, Skopec, & Glied, 2013). This change coincides with a newfound interest in viewing adolescent substance abuse as a public health problem and applying principles of risk and protection to substance policy and programs. The Obama Administration’s reform of drug policy that began in 2010 emphasizes the prevention of drug abuse as a public health issue in addition to a criminal justice issue. As a consequence, federal drug-control spending has decreased funds for supply reduction while increasing funds for demand reduction in recent years (ONDCP, 2014). Next, we discuss specific 451 federal policies across the domains of law enforcement, prevention, and treatment. These selected policies highlight major trends in policy approaches aimed at adolescent substance abuse. 452 Law Enforcement Law enforcement has always been a critical component of American drug policy (Morin & Collins, 2000; Physician Leadership on National Drug Policy, 2002). Funding for law enforcement efforts aimed at combating adolescent substance abuse has increased substantially nearly every year since 1980. Federal spending for the control of illicit drugs alone increased from $1.5 billion in 1981 to $17.9 billion in 1999 (Robert Wood Johnson Foundation, 2001). Historically, more than 75% of federal funds distributed to state and local communities for the control of illicit drug use were devoted to law enforcement activities (Kleiman, 1998). The 2014 National Drug Control Strategy earmarked approximately 60% of the $25 billion drug control budget for the supply-reduction strategies of international, interdiction, and domestic law enforcement. The remaining 40% of the overall budget was allocated to prevention and treatment (ONDCP, 2014). As Figure 8.1 demonstrates, despite recent shifts, federal spending for supply reduction remains disproportionate to spending levels for prevention and treatment (ONDCP, 2014). However, federal funding for prevention and treatment has increased under the Obama administration from 2013 to the proposed budget for 2015. Domestic and international law enforcement and interdiction policies constitute what is known as a supply-reduction strategy. Intended to disrupt the drug trade market and to limit access to drugs, supply reduction relies on practices such as taxation and law enforcement to control alcohol and illicit drug use. Initiatives to dismantle illicit drug trafficking networks are also included in supply-reduction strategies. The federal drug-control budget provides funding through various initiatives to increase the capacity of organizations such as the Drug Enforcement Administration, Federal Bureau of Investigation, U.S. Customs Service, Border Patrol, and Coast Guard to implement these approaches. Federal initiatives to disrupt international illegal markets, particularly through partnerships with Colombian and Mexican governments, were major goals of the Bush administration (ONDCP, 2009). Figure 8.1 Federal Drug Control Resources by Function 453 Source: This figure is adapted from the National Drug Control Budget, FY 2015 Funding Highlights, by ONDCP, 2014, Washington, DC: The White House. The effectiveness of law enforcement and drug interdiction can be evaluated by assessing the cost of illicit drugs and by monitoring rates of adolescent substance use. Based on these outcome measures, the results of law enforcement and drug interdiction efforts have achieved limited success. Although the United States has spent more than $18 billion a year on international law enforcement and interdiction, evidence suggests that the relative price of many “hard drugs” has actually decreased in recent years (Bach & Lantos, 1999; Kleiman, 1998) and that access to illicit drugs has not diminished (Robert Wood Johnson Foundation, 2001). In 2013, about 50% of adolescents had tried an illicit substance by the time they graduated from 12th grade (Johnston et al., 2013b), a finding that offers at least cursory evidence to suggest that law enforcement and interdiction efforts alone are not effective in reducing adolescent substance use. Supply-reduction strategies restricting access and increasing taxes for alcohol and other drugs appear to have produced greater success in 454 reducing substance abuse. For example, an increase in the minimum drinking age is associated with a decline in alcohol consumption and in alcohol-related auto fatalities (Cook & Tauchen, 1984). Furthermore, federal taxes on alcohol and tobacco have generated government revenue that has been used to fund efficacious prevention and treatment services in many states (Robert Wood Johnson Foundation, 2001). Many experts assert that policy debates about the merits of supply reduction strategies do not lie in the specific findings regarding the effectiveness of law enforcement, interdiction, taxation, and restrictive access strategies (Caulkins, Reuter, Iguchi, & Chiesa, 2005; Kleiman, 1998; Morin & Collins, 2000). Rather, the primary concern of many policy officials is the disproportionate allocation of federal funding, which has historically relegated prevention and treatment alternatives to a secondary priority. Continuing to increase funding for law enforcement and interdiction during periods of limited funding for prevention and treatment illustrates this source of major policy contention. Given the enormous cost of interdiction and enforcement and the ongoing increases necessary to reduce the illicit drug trade, many public-health officials continue to advocate for higher levels of funding for prevention and treatment. 455 Prevention The history of adolescent substance abuse prevention efforts dates to at least the 1960s (Jenson & Bender, 2014). Early prevention efforts educated children and youth about different types of drugs and informed young people about the physical effects of using alcohol and other substances. These “information-only” programs fell short of providing interactive experiences to young people and relied on didactic learning approaches to educate them about substance abuse. Other programs employed “scared- straight” tactics to warn adolescents about the adverse individual and social consequences of alcohol and illicit drugs. Perhaps not surprisingly, programs relaying only information about alcohol and other drugs or exposing youth to the risks of drug use produced few positive results (Hawkins, 2006; Jenson, 2010). The evolution of substance abuse prevention advanced slowly following the early 1970s. It was not until the mid-1980s that an emerging group of prevention researchers began to introduce and test school-based curricula as a new approach to prevent substance abuse (Botvin, 2004; Catalano, 2007). These curricula were based on known correlates of substance abuse and relied on interactive and structured activities that involved children in the concept of prevention. Subsequent longitudinal studies of these interventions revealed that well-designed prevention curricula could effectively prevent the initiation of drug use among young people (e.g., Hansen, 1992). The common thread among the programs was the use of a risk and protective factor framework as a guiding source of program design. Policies and programs supporting substance abuse prevention have increased significantly since the initial program evaluations of the mid- 1980s. The FY 2015 national drug-control budget proposes a 4.5% increase ($58.1 million) over the FY 2014 budget for prevention efforts (ONDCP, 2014). It is widely agreed that the adoption of the risk-based prevention paradigm is largely responsible for the increased attention to prevention policy and prevention research (Robertson, David, & Rao, 2003). NIDA, SAMHSA, and governmental entities such as the Office of Juvenile Justice and Delinquency Prevention (OJJDP) all recognize the utility of a public health framework for prevention and have taken efforts to implement principles of risk, protection, and resilience in their program 456 and policy initiatives (Howell, 2003; Robertson et al., 2003; Schinke, Brounstein, & Gardner, 2002). Programs targeting factors that increase and guard against the risk of substance abuse now represent the most commonly used prevention strategy in the United States (American Academy of Pediatrics, 2001; Centers for Disease Control and Prevention, 2008; Jenson, 2010). The results from a number of longitudinal investigations of risk-based prevention programs implemented in school, family, and community settings reveal positive outcomes with regard to substance use (for reviews, see Biglan & Smolkowski, 2002; Foxcroft, Ireland, Lister-Sharp, Lowe, & Breen, 2003; Pentz, 2010). 457 Federal Policy Initiatives Several important federal policy directives support the use of a public health framework for substance abuse prevention. The Drug-Free Communities Program, initiated in 1997, supports community and anti- drug coalitions that create collaborative efforts among prevention agencies and organizations (ONDCP, 2010). The Department of Education and SAMHSA provide funds for school- and community-based prevention programs under this initiative. Changing social norms about substance use is a primary objective of several media campaigns and education programs that have received generous federal support. In 1998, the National Youth Anti-Drug Media Campaign received $195 million in federal funding and $2 billion in public and private funds to combat media images promoting substance use (Kelder, Maiback, Worden, Biglan, & Levitt, 2000). The National Youth Anti-Drug Media Campaign has been one of the most visible and widespread prevention strategies in the country. Partnership for Drug-Free Kids (formerly known as Partnership for a Drug-Free America) was founded in 1987 as a collaboration with the Ad Council. The program’s primary objective was to educate children, youth, and parents about drug use and to promote young people’s ability to reject illegal drugs through personal and social skill development (ONDCP, 1997). The campaign aimed to change social norms about drug use by communicating messages about youth who do not use substances, discussing the negative effects of drugs, and portraying the positive aspects of a drug-free lifestyle (ONDCP, 1997). An evaluation of the campaign revealed that nearly 80% of youth and 70% of parents who were polled about the campaign recalled seeing at least one message delivered through media sources each week (Westat & the Annenberg School for Communication, 2003). However, like the information-only effort before it, the media campaign in this format produced little direct evidence of reducing substance use. Some modifications have been made to the overall strategy since 2005 through the “Above the Influence” (ATI) (http://www.abovetheinfluence.com/) teen-targeted campaign, which is based on commercial advertising and marketing principles (ONDCP, 2012). The ad and campaign messages were developed and tracked through research and testing phases. The 2010 relaunch increased the scope of the ATI brand with national television, 458 http://www.abovetheinfluence.com/ print, and Internet exposure in addition to local advertising. The results of several evaluations suggested that exposure to ATI predicted a reduction in the initiation of marijuana use (Slater, Kelly, Lawrence, Stanley, & Cornello, 2011); a reduction in marijuana use among eighth-grade girls (Carpenter and Pechmann, 2011; Farrelly, Davis, Haviland, Messeri, & Healton, 2005); and improvements in anti-drug beliefs, drug use intentions, and marijuana use for the target audience of the ATI campaign (Scheier, Grenard, & Holtz, 2011). Public schools have been a primary location of substance abuse prevention activities. Funding for school-based drug education formally began in the 1980s, when Congress allocated about $500 million a year for prevention activities (Burke, 2002; Wyrick, Wyrick, Bibeau, & Fearnow-Kenney, 2001). Federal government involvement in substance abuse prevention, however, has had an uneven history. In the late 1980s and early 1990s, significant amounts of government dollars were devoted to a drug abuse resistance education program called Project D.A.R.E. The popular program brought police officers and law enforcement officials to school classrooms. Officers warned children about the dangers of alcohol and other drugs and worked to reduce negative stereotypes of law enforcement. Evaluations of Project D.A.R.E. revealed that the program was no more effective than routine prevention approaches being used in the nation’s schools and classrooms to prevent substance use (Lynam et al., 1999). To their credit, the developers of D.A.R.E. used these findings to retool the program to include more interactive and skills-based teaching strategies in the curriculum. Still, the enormous sum of money allocated to an ineffective program has been a stark lesson to policymakers about the risk of funding untested prevention approaches. In 1997, the U.S. Department of Education’s Safe and Drug-Free School and Communities Program took an important step in prevention policy by requiring all programs that receive federal funds to select and implement interventions that had demonstrated some degree of effectiveness in preventing substance use. Efforts to increase the number of empirically supported interventions in prevention settings have positively affected the quality and outcomes of school-based prevention programs since 1997 (Burke, 2002). NIDA supports considerable substance abuse prevention research and has developed specific action steps for school and community-based programs that are based on principles of risk and protection (Robertson et al., 2003). 459 Prevention research continues to advance what is known about effective ways to delay or prevent substance use initiation. Efforts are now underway to implement efficacious programs on a larger scale across school districts and communities. No matter how effective such efforts become, the need for treatment services for children and youth experiencing more serious substance use problems must also be an important part of a policy and program continuum. 460 Treatment As the Affordable Care Act is fully implemented, more adolescents should become eligible for substance use disorder services as an identified “essential health benefit” via expansion of dependent coverage, Medicaid and Children’s Health Insurance Program (CHIP), and the health insurance marketplace (Pilkey et al., 2013). Health insurance eligibility is an important part of substance abuse treatment services; however, several other treatment barriers still exist. Several public health organizations, including Physician Leadership on Drug Policy and the American Academy of Pediatrics (2000), were at the forefront of advocacy efforts aimed at increasing funding for substance abuse treatment. A position paper on adolescent drug policy that was published by Physician Leadership on National Drug Policy (2002) called for the use of evidence- based interventions in drug treatment. The group also suggested that levels of substance abuse funding should be similar to funds provided for diseases such as diabetes and heart disease. Physician Leadership on National Drug Policy continues to argue that the long-standing federal emphasis on law enforcement policy has mitigated the potential of treatment as a means of reducing substance abuse problems. Importantly for prevention and treatment efforts, the Obama Administration’s approach to drug control acknowledges drug addiction as a preventable and treatable disease rather than a moral failing (ONDCP, 2014). There is currently no national standard of care for treating adolescent substance abusers in the United States. Substance abuse treatment varies by region, state, and locality and is generally considered to be poorly funded and difficult to access. Recent estimates from SAMHSA’s National Survey on Drug Use and Health reveal that about 1.6 million young people require treatment for an illicit drug or alcohol use problem annually but only 157,000 received treatment in a specialty facility (SAMHSA, 2013). Other reports have indicated that as few as one in every 10 adolescents who need substance abuse treatment actually receive it and that only 25% of those participating in treatment receive the appropriate type and level of assistance (Center for Substance Abuse Treatment, 2002; NIDA, 2009). Historically, access to care appears to be strongly related to inadequate health insurance coverage and to complicated managed-care regulations that limit time allotted for treatment (American Academy of Pediatrics, 2001). While the Patient Protection and Affordable Care Act (2010) 461 expands health insurance coverage for uninsured adolescents and School- Based Health Centers under the Act show promise for access to treatment, there are many barriers to providing treatment that is tailored to the needs of adolescents. A major concern affecting access to care for many children and adolescents is the fragmented nature of substance abuse treatment. Policies and programs supporting adolescent substance abuse treatment come from such disparate domains as education, juvenile justice, child welfare, labor, and health. Each system has its own eligibility criteria, and each operates independently from the other. The result is a fragmented system of care in which many youth may be shuffled from program to program with little coordination across service sectors. Youth with substance abuse problems are also more likely to experience other mental health problems. In many cases, treatment facilities in one system are not equipped to handle multiple problems. For example, estimates indicate that 60% to 80% of youth involved in the juvenile justice system also have a substance use disorder (Washburn et al., 2008). Few resources currently exist to treat youth who have multiple problems. Public sources provide funding for alcohol and drug treatment through a combination of Medicaid and state and local funds. Funds for public substance abuse treatment are limited, and restrictions placed on the type of eligible service often prevent integration across systems of care (Physician Leadership on National Drug Policy, 2002). The Medicaid program provides health insurance coverage for more than 16.4 million children. However, Medicaid programs display considerable variation in the services they fund, ranging from comprehensive treatment benefits in some states to only inpatient detoxification in other states (Gehshan, 1999). Medicaid reimbursement rates are also typically quite low, which has led to less incentive to provide treatment services (American Academy of Pediatrics, 2001). Expansion of health-care coverage for low-income children was included as a provision in a 1997 bill that created the State Children’s Health Insurance Program (SCHIP), now simply referred to as Children’s Health Insurance Program (CHIP). This program allows states to access federal funds for children who are not eligible for other coverage. Funds are provided via the Medicaid program or through a separate program established specifically for CHIP participants. Although coverage still 462 varies considerably by state, all states using CHIP have generally paid for detoxification and for some types of outpatient substance abuse treatment (Gehshan, 1999). Medicaid and CHIP are required to implement the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT). Many experts believe that EPSDT could be an effective way to increase substance abuse treatment services for troubled youth (Rosenbaum, Johnson, Snonsky, Markus, & DeGraw, 1998). However, a general lack of awareness about EPSDT in the professional community has led to underutilization. Weak coordination between Medicaid and SCHIP has also limited use of EPSDT as a referral source for substance abuse treatment. Federal block grants provide resources that seek to improve access to substance abuse treatment services. These grants typically provide funds that are channeled through federal and state agencies. For example, prevention services funded by the Substance Abuse Prevention and Treatment Block Grant are administered by the Center for Substance Abuse Prevention. Corresponding treatment services are funded and administered by the Center for Substance Abuse Treatment, SAMHSA, and the U.S. Department of Health and Human Services. With many states rolling block-grant money into specialty “carve-out” arrangements, one policy concern is that substance abuse services may be inappropriately offered by mental health providers rather than by trained substance abuse treatment specialists. Finally, financial barriers to substance abuse treatment exist. The Affordable Care Act of 2010 now requires parity for mental health and substance use disorder services; however, access to services and availability of developmentally appropriate services is still a concern. Several public health organizations have recently made policy recommendations calling for a more thoughtful and integrated continuum of care in adolescent substance abuse prevention and treatment (American Academy of Pediatrics, 2010; Robert Wood Johnson Foundation, 2010). We explore these and other ideas more fully in the next section. 463 Using Knowledge of Risk, Protection, and Resilience to Achieve Service Integration Principles of risk, protection, and resilience are key components of effective substance abuse intervention. The potential of these principles for public policy has yet to be fully realized. To be effective, knowledge of risk, protection, and resilience should undergird policy and programs in all systems of care for children and youth. 464 A Continuum of Substance Abuse Policy Substance use disorders are prevalent among children and youth in nearly all public sectors of care in the United States. Aarons, Brown, Hough, Garland, and Wood (2001) examined prevalence rates for substance use disorders among adolescents who were receiving care in five service systems in San Diego County. Prevalence estimates ranged from 19% for youth in the child welfare system to 41% and 62% for adolescents in the mental health and juvenile justice systems, respectively. More recent estimates reveal that as many as 49% of children in foster care (Vaughn, Ollie, McMillen, Scott, & Munson, 2007), 80% of youth in the juvenile justice system (Washburn et al., 2008), and 50% of youth with serious mental health problems use alcohol and illicit drugs (James, 2007). The high prevalence of substance abuse across systems of care points to the need for better integration and coordination of prevention and treatment policy and programs. Policies aimed at adolescent substance abuse, like policies targeting other childhood and adolescent problems, have largely been incremental and fragmented. That is, programs and interventions tend to develop as a result of localized conditions that fail to consider national trends vis-à-vis substance abuse or empirical evidence regarding the relative effectiveness of prevention and treatment approaches. To confound matters, service sectors for high-risk youth develop responses to problems that tend to be very similar to one another. Creating an integrated continuum of care must begin with assessment and screening policies and practices. 465 Assessment and Screening Policies An integrated system of care for children and youth must first acknowledge the need to assess and screen youth for a variety of problem behaviors, including substance abuse. Once appropriate assessment data are collected, appropriate placements and sanctions can be more easily determined. Policies are needed to create centralized assessment centers that serve diagnostic and referral needs across major service systems for children and adolescents. Provisions of these policies should include standardized diagnostic tools that offer interpretative guidelines for juvenile justice, mental health, child welfare, and substance abuse practitioners. Standardized assessment procedures might also lead to more systematic placement criteria and decision-making and would allow cross- system comparisons of risk and protective factors found to be prevalent among youth and their family members. Knowledge of these factors, in turn, could be used to inform the direction of prevention and treatment programs. 466 Prevention Policies Perhaps the single greatest policy need in substance abuse prevention lies in funding. Prevention has historically been underfunded when compared with competing demands made by treatment providers and law enforcement (Catalano, 2007; Jenson & Bender, 2014). In recent years, longitudinal studies have indicated that some prevention programs are effective in preventing and reducing substance abuse and are more cost- effective than treatment and law enforcement approaches (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004). The availability of effective programs through the dissemination efforts of entities such as SAMHSA’s National Registry of Effective Programs, the Center for the Study and Prevention of Violence, and interdisciplinary groups dedicated to advancing evidence-based practice such as the Cochrane Collaboration and the Campbell Collaboration is further argument for the adoption of prevention policy as a national priority for children and families. To reach more children and families, prevention policy must bring effective programs to scale at the school, neighborhood, and community levels. One method of increasing the use of effective programs in community settings is found in the Communities That Care (CTC) intervention (Hawkins, Catalano, & Associates, 1992). In the CTC model, coalitions are formed to engage in systematic prevention planning that requires communities to identify prevalent risk and protective factors for adolescent problems in their localities. Following the assessment of such factors, communities are encouraged to select, implement, and evaluate prevention strategies on the basis of available empirical evidence. Recent findings from a longitudinal study called the Community Youth Development Study, a randomized trial that uses principles of CTC, have revealed significantly lower rates of delinquency and drug use among students in experimental communities compared with control communities (Hawkins et al., 2008). These promising results have led the Center for Substance Abuse Prevention (2010) to recommend CTC as a key component in its overall prevention strategy. 467 A Prevention Case Example Bishopville, a (fictitious) suburban community on the East Coast, has recently become alarmed about increases in adolescent substance abuse. Anecdotal reports about all-night drug parties (i.e., raves) involving alcohol, marijuana, and hallucinogens have surfaced in local schools and neighborhoods. A recent party led to the arrest of six teenagers and alerted officials that action steps were necessary. Officials chose the Communities That Care (CTC) model (Hawkins et al., 1992) as a means of better understanding and addressing the problem of adolescent substance abuse in Bishopville. Using the model, Bishopville employed the following action steps that led to the creation of a citywide prevention policy: Step 1: Organizing and mobilizing. Leaders of Bishopville selected key individuals to guide the prevention planning process. These included the mayor, educators, business representatives, and other elected officials. The group subsequently formed a community prevention board that was charged with organizing and mobilizing other community advocates and constituency groups. Step 2: Developing a community profile of strengths, resources, and challenges. Risk and protective factors for adolescent substance use were assessed using a CTC survey with a random sample of children and adolescents in Grades 6 to 12. Survey results were used to rank the most common risk and protective factors found among children and youth in Bishopville. A community-needs assessment aimed at identifying existing and needed services for children and youth was also conducted in this phase. Step 3: Creating a strategic prevention plan. In this phase, the Bishopville Community Prevention Board reviewed and selected several efficacious prevention strategies that will be implemented in their local schools and neighborhoods. A school-based curriculum that targets the early onset of substance use and a community-level media campaign were among the strategies selected for implementation. Step 4: Evaluating and monitoring the plan. Steps were identified to monitor and evaluate the prevention strategies selected by the board. Outcome measures and other methodological decisions were made in consultation with local and national experts to ensure a rigorous evaluation process. Please see Hawkins, Catalano, and Associates (1992) and Hawkins et al. (2008) for a more detailed description of using the CTC model in a community setting. 468 Treatment Policies Historically, treatment for young people has mirrored that for adults; 12- step and self-help interventions based on a disease model of addiction have dominated the field (Liddle & Rowe, 2006). Reviews of adolescent substance abuse treatment have identified relatively few controlled trials in the past two decades (Deas & Thomas, 2001; Jenson, Howard, & Vaughn, 2004; Vaughn & Howard, 2004). Meta-analytic studies assessing treatment outcomes for young drug abusers have suggested that cognitive-behavioral interventions promoting skill development and family-based therapeutic approaches are among the most effective treatment strategies for adolescents (Vaughn & Howard, 2004). Additional controlled studies of adolescent substance use treatment are needed to create the knowledge base necessary to recommend and disseminate efficacious programs to the practice community. Only limited empirical evidence is available to form the basis of a policy continuum reflecting different levels of treatment for adolescent substance abuse. Standards of care for treatment connected to evidence-based interventions also need to be made available to professionals in the treatment community. Years of anecdotal evidence suggest that a lack of communication between drug treatment agencies and poor coordination across service systems have interacted to create a mix of programs that have not adequately met the needs of adolescent substance abusers like the case shown here. Several treatment initiatives have shown promise with regard to improving the disjointed treatment system. Drug courts, an initiative funded by the federal government under the National Drug Control Strategy (ONDCP, 2009) are one alternative for juvenile offenders with substance abuse problems. As part of the program, youth may be referred to treatment and receive mandatory drug sanctions in lieu of traditional case-processing. The Tribal Youth program administered by OJJDP (2000) emerged in response to the problem of violent crime and co-occurring substance use disorders among American Indian youth. The departments of Health and Human Services, Education, Interior, and Justice collaborated to design the program. Program objectives include providing a range of assessment and treatment strategies aimed at addressing the unique needs of substance- abusing American Indian youth. The Tribal Youth initiative represents the type of cross-system coordination needed to implement integrated policies and services for troubled youth. 469 These initiatives represent only the surface of adolescent substance abuse treatment needs in the United States. Efficacy trials of treatment approaches, community advocacy efforts, and standards of care are needed to inform the direction of substance abuse treatment. Coordination across agencies and the development of systems of care should be a top priority in treatment policy discussions. 470 Summary Principles of risk, protection, and resilience hold great promise for substance abuse programs and policies. A prevention-and-treatment continuum based on risk and protective factors offers a cogent solution to legislators and policy officials charged with developing effective ways to prevent and reduce adolescent substance abuse. A public health model that incorporates risk and protection as guiding principles is also consistent with the current evidence-based practice movement. Efforts toward integrating substance abuse policy might benefit by examining overlapping initiatives in juvenile justice and mental health. Co-occurring drug use and mental health problems are well documented among young people. Many youth with concomitant problems are subsequently placed in the nation’s juvenile justice and mental health systems. Efforts to improve coordination must also include the array of treatment providers who contract for services with public agencies. Community-based programs that offer outpatient care, day treatment, and residential care must be added to policy discussions across the multiple service systems for children, youth, and families. A public health approach emphasizing risk, protection, and resilience may provide a common language and effective organizing framework for adolescent substance programs and policies. 471 A Treatment Case Example A case history. Johnny is a 16-year-old boy who is currently under the jurisdiction and supervision of the juvenile justice system. He has a history of property offending dating back some 6 years to when he was arrested for stealing. In recent years, Johnny’s behavior escalated to more serious offenses, including assault. He first experimented with alcohol and marijuana at age 12 and now admits to using marijuana, cocaine, and hallucinogens “whenever and wherever” they are available. Johnny was placed in the juvenile justice system for assaulting a boy in his neighborhood. He reports that he had been drinking and was high on cocaine at the time of the incident. Johnny’s family life had been unstable. His father left home when Johnny was 5 years old; the family has had relatively little contact with him since that time. Johnny has heard from other relatives that his father frequently uses alcohol and that he has been incarcerated on several occasions. Johnny’s mother has worked a series of low-paying jobs but has no history of substance abuse. Two years ago, his mother invited her boyfriend into the family home. Johnny was initially resentful of this decision and has adapted to the situation by largely ignoring the boyfriend. Johnny has two sisters, both of whom are younger. Johnny’s mother reports that Johnny tends to be withdrawn and sad much of the time. He spends long periods of time alone in his room and has recently stopped seeing many of his friends. System response. Johnny’s case represents a profile that is common among youth in the juvenile justice system. Perhaps what is most typical is the presence of multiple and overlapping behavior problems. Johnny’s problems include antisocial conduct, substance abuse, and undiagnosed symptoms of depression. Theoretically, the presence of these problems could logically lead to placement in the juvenile justice system for antisocial conduct, the substance abuse treatment network for drug-using behaviors, or the mental health system for symptoms of depression. The challenge for treating Johnny—and the thousands of young people like him—lies in integrating system responses and treatments in a manner that addresses Johnny’s multiple problems. In Johnny’s case, policies that create and support a centralized assessment process might best lead to a coordinated response across multiple service systems. 472 Questions for Discussion 1. What have been the dominant public policy approaches to adolescent substance abuse in the past four decades? Which strategy has received the greatest percentage of funding? 2. What are the financial and organizational implications of a shift to a public health approach to substance abuse prevention and treatment? 3. What are the challenges in integrating service systems for the delivery of adolescent substance abuse treatment and prevention? 4. What policy recommendations would you make to address the disjointed delivery system? 473 References Aarons, G. A., Brown, S. A., Hough, R. L., Garland, A. F., & Wood, P. A. 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489

Additional Reading
Jenson, J. M., & Bender, K. A. (2014). Preventing child and adolescent
problem behavior. Evidence-based strategies in schools, families, and
communities. New York: Oxford University Press.
Liddle, H. A., & Rowe, C. L. (Eds.). (2006). Adolescent substance abuse:
Research and clinical advances. New York: Cambridge University Press.
Scheier, L. (Ed.). (2010). Handbook of drug use etiology: Theory,
methods, and empirical findings. Washington, DC: American
Psychological Association.
Springer, D. W., & Rubin, A. (Eds.). (2009). Substance abuse treatment
for youth and adults. Hoboken, NJ: John Wiley.
Tolan, P., Szapocznik, J., & Sambrano, S. (Eds.). (2007). Preventing youth
substance abuse: Science-based programs for children and adolescents.
Washington, DC: American Psychological Association.
490

Web-Based Resources
The Campbell Collaboration, www.campbellcollaboration.org
The Cochrane Collaboration, www.cochrane.org
Monitoring the Future, www.monitoringthefuture.org
National Institute on Drug Abuse, www.nida.nih.gov
Physician Leadership on National Drug Policy, www.PLNDP.org
Robert Wood Johnson Foundation, www.impacteen.org
Social Development Research Group, www.sdrg.u.washington.edu
Substance Abuse and Mental Health Services Administration,
www.samhsa.gov
491

http://www.campbellcollaboration.org

http://www.cochrane.org

http://www.monitoringthefuture.org

http://www.nida.nih.gov

http://www.PLNDP.org

http://www.impacteen.org

http://www.sdrg.u.washington.edu

http://www.samhsa.gov

Chapter 9 Juvenile Justice Policies and
Programs
William H. Barton
The knowledge, events, and values specific to any given point in time
exert a profound influence on juvenile justice policy and practices. After
decades of “getting tough” with young offenders and flirting with the
treatment model du jour, the juvenile justice system now finds itself at a
policy and programmatic crossroad. Recent advances in theory, research,
and practice based on principles of risk, protection, and resilience hold
promise for a more rational, comprehensive set of juvenile justice policies
and practices. Nevertheless, such optimism must be tempered by the
inevitable role played by societal values, politics, and public perceptions
and by limitations in the knowledge base itself.
This chapter provides an outline of this conceptual advance in juvenile
justice policy, places it in a historical context, and suggests ways it can be
used to improve current and future policies and practices. The first section
presents an overview of the goals and stakeholders involved in juvenile
justice policy. The second section reviews current patterns of delinquency
prevalence and incidence. The third section outlines the risk and protective
factors associated with delinquent behavior. The fourth section traces the
history of juvenile justice policies, noting the extent to which presumed
risk and protective factors have exerted an influence. The final section
applies what we have learned about risk, protection, and resilience to
juvenile justice policies and practices and concludes that this knowledge
base can provide a foundation for more effective and efficient ways to
address delinquency through the promotion of positive youth development.
492

Purpose and Overview of Juvenile Justice
Policy
Prior to the 20th century, the United States did not have a juvenile justice
policy per se. Although age was considered a factor in mitigating
punishment, the adult court had jurisdiction over children who committed
crimes. The first juvenile court was established in Chicago in 1899, and by
1925, all but two states had followed suit (Bernard & Kurlychek, 2010).
The juvenile court was the expression of the first formal juvenile justice
policy, which held that juveniles were distinct from adults and that the
system should act in the best interests of the child. Specialized juvenile
probation services emerged to monitor juveniles who were under the
jurisdiction of the court (National Center for Juvenile Justice, 1991).
This two-tiered court system created a tension between the goals of
rehabilitation and punishment that continues to this day. As described later
in this chapter, the parade of policy reforms since the founding of the
juvenile court has reflected alternating emphases on these two primary
goals. Historically, relatively lenient policies favoring treatment have
alternated with “get tough” policies mandating punishment. Table 9.1
summarizes events that have shaped juvenile justice policy since the
founding of the first juvenile court.
493

494

495

Sources: Bazemore and Umbreit (1995); Bernard and Kurlychek (2010); Latessa
(2004); Lattimore et al. (2004); McNeese (1998); National Research Council
(2013); Skiba et al. (2003); Snyder and Sickmund (1999, 2006); Stanfield (1999);
Weiss (2013); Wilson and Howell (1993).
To whom do juvenile justice policies apply? The juvenile court has
jurisdiction over young people who meet the definition of a juvenile in a
given state and against whom a petition is filed alleging a delinquent act
(behavior that would be a crime if committed by an adult) or a status
offense (behavior that would not be considered criminal if committed by
an adult, e.g., school truancy or running away from home). Once a petition
is filed, the juvenile probation department prepares a predisposition report
summarizing the facts and context of the case and containing
recommendations to the judge for corrective action. Should the judge
adjudicate the child as delinquent, which is analogous to a determination
of guilt in adult criminal court, dispositional options might include
probation supervision, placement in a nonresidential program, or
residential placements of varying restrictiveness.
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The definition of a juvenile, that is, one who comes under the jurisdiction
of the juvenile court, varies from state to state. In most states, the upper
age limit of juvenile court jurisdiction is 17 years, but in New York and
North Carolina, that limit is 15 years; in 10 other states, including Georgia,
Massachusetts, Michigan, and Texas, it is 16 years; and in Connecticut, the
age limit was raised from 15 to 17 years in 2012 (Office of Juvenile Justice
and Delinquency Prevention [OJJDP], 2013a). Further complicating the
definition of a juvenile, policies in some states extend juvenile court
jurisdiction to age 20 years for status offenses, and most states (32) allow
extended juvenile court supervision of placements of delinquents through
age 20 (or even older in a few states, including through age 24 in
California, Montana, Oregon, and Wisconsin) (OJJDP, 2013b).
States have long been able to use judicial waiver to transfer young
offenders to adult court jurisdiction under certain conditions. In the 1990s,
many states modified their juvenile codes to redefine young people who
commit certain crimes as adults, even though their age would otherwise
define them as juveniles. For example, in many states, 14- or 15-year-olds
charged with murder or certain other serious crimes can be processed
automatically in adult court. In addition, most states have other
mechanisms of transferring jurisdiction from juvenile to adult court by
judicial waiver, prosecutorial discretion, or both.
Juvenile justice policies affect many other stakeholders, including the
family members of young offenders, the neighborhoods in which they live,
the broader community, and the public and private service providers who
administer juvenile justice programs. Thus, as juvenile justice policies
shift emphases among the system’s goals, there are ongoing implications
for family stability, neighborhood social capital, and the economy.
Taxpayers pay for the majority of juvenile justice services. In recent years,
the cost of such services has been rapidly increasing, led by treatments that
are more intensive, settings that are most restrictive (i.e., requiring greater
security measures), and services that are of greater duration.
497

Delinquency and Delinquents: Prevalence
and Trends
As noted earlier, the term delinquency technically refers to acts committed
by juveniles that would be crimes if committed by adults. However,
delinquency often colloquially refers to the full range of problem
behaviors exhibited by young people that could result in their appearance
in juvenile court. A complication emerges when we realize that
delinquency is a concept defined through a combination of behavioral
indicators and societal definitions and responses, and these definitions and
responses tend to change over time. Indeed, some behaviors that are
currently not considered as delinquency may have once fit the definition,
whereas some contemporary constructions of delinquent behavior might
not have been labeled as problematic in other times. For example, in
earlier eras, delinquency included simply being seen near an unsavory
establishment or being poor and congregating in public with other poor
children (Bernard & Kurlychek, 2010). More recently, some altercations
among youth that previously would have been ignored or handled
informally by parents, neighbors, or schools now lead to formal charges.
The dynamic nature of the concept of delinquency poses some problems
for a discussion of risk and protective factors because there is at least an
implicit assumption that the outcome being “predicted” is at the individual
level.
Despite the preceding caveat, describing the current prevalence and
distribution of delinquency provides a sense of its scope. There are two
ways to approach this task. First, given the focus of this chapter on
juvenile justice policies and how they apply to those who become involved
with the juvenile justice system, we summarize recent data on juvenile
arrests and court processing. Then, because not all delinquent behavior is
detected or formally processed but is, at least in large part, presumably
related to the same etiological factors, we summarize what is known from
self-report delinquency studies.
In 2011, the most recent year for which data are available, 1.47 million
people younger than 18 years of age were arrested in the United States,
accounting for 20% of all arrests for property crimes and 13% of arrests
for violent crimes (Puzzanchera, 2013). Most U.S. crimes are committed
498

by people between the ages of 10 and 49 years old, 20% of whom are
between 10 and 17 years old, according to the 2010 Census (Howden &
Meyer, 2013). Thus, juveniles are overrepresented in arrests for such
crimes as arson (42%), vandalism (29%), robbery (22%), burglary (21%),
and motor vehicle theft (21%) but are underrepresented in arrests for such
crimes as murder (8%), aggravated assault (10%), drug abuse violations
(10%), and forcible rape (14%) (Puzzanchera, 2013). In 2011, females
were involved in about one third (29%) of juvenile arrests (Puzzanchera,
2013). Although African Americans make up just 17% of the U.S.
population between the ages of 10 and 17 years old, African American
youth accounted for much higher percentages of juvenile arrests for nearly
all offense categories (e.g., violent crimes, 51%; property crimes, 35%;
drug abuse violations, 23%) (Puzzanchera, 2013). Similar arrest data are
not available for Hispanic youth. However, there is evidence that Hispanic
youth are slightly overrepresented at other points in the juvenile justice
system. In 2011, about 21% of the U.S. population between 10 and 17
years old was Hispanic (author calculation, based on data tables in U.S.
Census Bureau, 2013); in a 1-day census in 2011, Hispanic youth
accounted for 25% of those detained and 22% of those in residential
juvenile correctional placement (Sickmund, Sladky, Kang, & Puzzanchera,
2013).
Another way to look at juvenile offense patterns is to consider the
proportion of juvenile arrests accounted for by various crimes. Of the 1.47
million juvenile arrests in 2011, 4.6% were for violent index offenses (e.g.,
murder, non-negligent manslaughter, forcible rape, robbery, aggravated
assault); 23% were for property crime index offenses (e.g., burglary,
larceny-theft, motor vehicle theft, arson); 13% were for other assaults;
10% were for drug offenses; 9% were for disorderly conduct; 7% were for
alcohol offenses; 5% were for vandalism; and the remaining 28% were for
other nonindex offenses (based on Puzzanchera, 2013). Juvenile arrest
rates for nearly all crimes have decreased noticeably since a high point in
the mid-1990s, with an overall decline of 31% from 2002 to 2011, and are
at their lowest levels since 1980 (Puzzanchera, 2013). The decline has
been even more pronounced for African American youth than for White
youth, excluding a brief uptick between 2004 and 2008 (Puzzanchera,
2013).
Of course, police do not refer all arrested youth to juvenile courts. In 2011,
police referred 68% of arrested youth to juvenile courts and 7% directly to
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adult courts, while releasing 22%, with the remaining 3% referred to some
other service (Puzzanchera, 2013). In 2010, juvenile courts processed
about 1.4 million delinquency cases (Puzzanchera & Robson, 2014). In
contrast to juvenile arrest trends, juvenile court delinquency caseloads
increased 17% from 1985 to 2010, although they declined 19% from 2001
to 2010 (Puzzanchera & Robson, 2014). Of the delinquency cases brought
before juvenile courts in 2010, more than half (54%) resulted in formal
petitions, about one-third (31%) were adjudicated delinquent, and about
8% were placed out of the home (Puzzanchera & Robson, 2014). The large
majority of all cases (about 67%), whether formally petitioned or not,
received some form of consequence (or service), including probation,
placement, or some other sanction (Puzzanchera & Robson, 2014).
The official record data described above reflect the volume of delinquency
brought to the attention of law enforcement and the courts. However,
juvenile arrest and court data do not give a good estimate of the overall
incidence or prevalence of delinquent behavior. Much delinquent activity
goes undetected or unprocessed by the system. Moreover, arrests are case-
specific rather than person-specific or crime-specific. That is, the same
juvenile may account for several arrests, a single arrest may result from
several crimes committed by an individual, and a single crime may result
in the arrest of multiple individuals (Puzzanchera, 2013). Therefore,
studies of self-reported delinquency can be a useful supplement to official
data.
Self-report delinquency studies have a long history in criminology
research, with the consensus being that youths’ self-reports of delinquent
activity are reasonably reliable and valid when collected under appropriate
conditions of anonymity or confidentiality (Elliott & Ageton, 1980;
Farrington, Loeber, Stouthamer-Loeber, Van Kammen, & Schmidt, 1996;
Hindelang, Hirschi, & Weis, 1981; O’Malley, Bachman, & Johnston,
1983). Studies based on samples of general school populations have
consistently shown that about 80% of adolescents report having engaged in
behavior that could have gotten them in trouble with the law if detected. A
relatively high number of adolescents report use of alcohol and illegal
substances, truancy, and minor fights (Elliott, Huizinga, & Ageton, 1985;
Farrington et al., 1996). A smaller number of adolescents report
involvement in serious offenses against people or property. Relatively few
adolescents report frequently committing such offenses, and most do not
go on to commit crimes as adults (Elliott et al., 1985; Farrington et al.,
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1996; Moffitt & Caspi, 2001). Thus, although a large majority of youth
engages in some misconduct, relatively few—only 6% to 8%—are the
chronic, serious juvenile offenders who account for most of the serious
juvenile crime (Hamparian, 1978; Wolfgang, Figlio, & Sellin, 1972;
Wolfgang, Thornberry, & Figlio, 1987). Risk and protective factors for
delinquent conduct are described next.
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Risk and Protective Factors for Delinquency
The risk and protection framework for understanding delinquency has
evolved from separate lines of research and theory. Some researchers have
adopted an epidemiological approach to the study of youth problem
behaviors, such as psychopathology, substance abuse (Hawkins, Catalano,
& Miller, 1992), delinquency (Dryfoos, 1990; Elliott, 1994; Thornberry,
Huizinga, & Loeber, 1995; Tremblay & Craig, 1995), school dropout
(Wehlage, Rutter, Smith, Lesko, & Fernandez, 1989), and teenage
pregnancy (Dryfoos, 1990; Franklin, Grant, Corcoran, O’Dell, & Bultman,
1995). From a different perspective, other researchers have attempted to
understand why some individuals achieve positive developmental
outcomes despite resembling those at highest risk for failure (Anthony,
1987; Rutter, 1985; Werner & Smith, 2001). In recent decades, these
streams of research and theory have converged to identify a common set of
risk and protective factors associated with various developmental
outcomes.
Risk factors have been defined by Fraser, Kirby, and Smokowski (2004) as
“any influences that increase the chances for harm or, more specifically,
influences that increase the probability of onset, digression to a more
serious state, or maintenance of a problem condition” (p. 14). Regarding
protective factors, some scholars make a distinction between direct
protective factors that predict low involvement in problem behaviors with
or without the presence of risk and indirect or buffering factors that
operate in the presence of risk to mediate or buffer the effect of risk, thus
enhancing positive adaptation (Garmezy, 1985; Lösel & Farrington, 2012;
Masten, 1994; Rutter, 1985). Others suggest using the term promotive
factors for those influences associated with positive developmental
outcomes for all people, reserving the term protective factors for those that
operate only or more strongly in the presence of risk (Fraser et al., 2004;
Fraser & Terzian, 2005; Sameroff, 1999). Risk, promotive, and protective
factors each may operate in either domain-specific (i.e., related to specific
developmental outcomes) or general ways.
Most research on risk, promotive, and protective factors usually focuses on
linking variation in these potentially predictive factors with variation in
outcomes such as delinquency, other youth problems, and/or positive
developmental trajectories. Also important to an understanding of risk,
502

resilience, and juvenile justice is the growing understanding of what may
be considered a universal risk of adolescence as a developmental stage.
Studies of adolescent brain development since the late 1990s have
produced a growing consensus that “adolescence” is defined less by
chronological age than by a combination of biological markers and social
roles, brain development does not proceed at the same pace for everyone
and may not be complete until one’s mid-20s, the frontal lobe (responsible
for decision-making) develops last, and significant hormonal changes
occur that are linked to emotionality and aggression (Dahl, 2004;
Weinberger, Elvevag, & Giedd, 2005). Accordingly, impulsive behavior is
essentially normal for adolescents, some of this impulsivity may lead to
engagement in delinquent behavior, and, in turn, such behavior may lead
to encounters with law enforcement and the juvenile justice system
(Coalition for Juvenile Justice, 2006). Of course, how these developmental
patterns play out for individual youth depends upon a complex interplay of
the variable ecological influences discussed below.
Several recent reviews summarized the research regarding risk factors,
protective factors, and resilience in general (Durlak, 1998; Fraser et al.,
2004; Werner & Smith, 2001) and for delinquency and violence in
particular (Hawkins et al., 2000; Howell, 2003; Lipsey & Derzon, 1998;
Lösel & Farrington, 2012; Office of the Surgeon General, 2001;
Stouthamer-Loeber, Loeber, Wei, Farrington, & Wikström, 2002;
Williams, Ayers, Van Dorn, & Arthur, 2004). Table 9.2 lists risk,
protective, and promotive factors identified at various ecological levels in
those reviews.
503

Individual Level
Some risk and protective factors are biological or genetic in origin. For
example, males are at higher risk than females for antisocial behavior (e.g.,
Patterson, Reid, & Dishion, 1992). Recent work suggests that the absence
of the genetically controlled monoamine oxidase (MAOA) enzyme is
associated with aggressive behavior (Rowe, 2001) and that its presence
can buffer the risks associated with early child maltreatment (Kim-Cohen
et al., 2006). Several researchers have identified the role of temperament in
resilience, finding that, from an early age, children with an “easy”
temperament fare better than do those with a “difficult” temperament
(Moffitt & Caspi, 2001; Werner & Smith, 2001). Presumably, the child’s
natural temperament elicits responses in kind from parents and others.
Hyperactivity in young children is associated with later behavioral
problems and delinquency (Loeber, Farrington, & Petechuk, 2003).
Intelligence, as measured with IQ tests, can be seen as a protective factor
when high (Masten, 1994) and a risk factor when low (Loeber, Farrington,
Stouthamer-Loeber, & van Kammen, 1998). Hawkins, Catalano, and
Miller (1992) reported a relationship between a mother’s alcohol and drug
use during pregnancy and a child’s later delinquency.
504

505

Fraser, Kirby, and Smokowski (2004).
Hawkins et al. (2000).
Lipsey and Derzon (1998).
Office of the Surgeon General (2001).
Williams et al. (2004).
Lösel & Farrington (2012).
Stouthamer-Loeber et al. (2002).
Werner and Smith (2001).
Durlak (1998).
Other factors at the individual level are psychological or behavioral. Risk
factors include early aggressive behavior (Farrington, 1991; Hawkins et
al., 2000), rebelliousness, and alienation (Williams et al., 2004). Attitudes
506

and beliefs favorable to deviance are a risk factor (Hawkins et al., 2000),
whereas prosocial attitudes act as a protective factor (Lösel & Farrington,
2012; Office of the Surgeon General, 2001; Williams et al., 2004). Other
protective or promotive factors include high levels of internal locus of
control and assertiveness (Werner & Smith, 2001), social problem-solving
skills (Durlak, 1998; Werner & Smith, 2001; Williams et al., 2004), self-
efficacy, self-esteem (Fraser et al., 2004), and having a religious or
spiritual orientation (Lösel & Farrington, 2012).
507

Family Level
The family represents the most salient social context for children;
therefore, it is not surprising that the literature identifies a number of
important risk and protective or promotive factors within the family. A
relatively consistent picture emerges. Through attachment and modeling,
the family exerts a profound effect on children’s behavior. Nearly all
authors of systematic reviews have noted inconsistent or harsh discipline
practices, parental criminality, child maltreatment, lack of parental
involvement, and divorce as risk factors and concurrently mentioned warm
relationships with prosocial parents who are involved in their children’s
lives and who provide consistent monitoring and discipline as perhaps the
strongest protective or promotive factor (Durlak, 1998; Fraser et al., 2004;
Hawkins et al., 2000; Lipsey & Derzon, 1998; Lösel & Farrington, 2012;
Office of the Surgeon General, 2001; Stouthamer-Loeber et al., 2002;
Werner & Smith, 2001; Williams et al., 2004). Werner and Smith (2001)
noted the role of parental education in preventing antisocial conduct and
found that parents with a high school education represented the line
tipping the scale from a risk factor to a protective factor. However, a more
recent study by Theokas and Lerner (2006) suggested that the strongest
family factor protecting against adolescent risk behaviors is not parental
education but rather “collective activity,” such as eating dinner together.
Williams et al. (2004) mentioned several protective factors that appear to
apply specifically to African American families, including a strong
achievement orientation, presence of strong spiritual values, racial pride,
and bonds to extended family members.
From a meta-analysis of 119 studies that examined relationships between
various family characteristics and concurrent or later problem behaviors,
Derzon (2010) concluded that family factors (including family SES,
discord, stability, warmth and relationship, and child-rearing skills, among
others) may play a more complex role. As an example, Derzon (2010)
notes,
…the lack of care-giver warmth may, on its own, modestly increase
the likelihood of youth antisocial behavior. However, in the presence
of other risk factors (e.g., gang membership, drug use, low impulse
control), warm relationships between care-giver and child likely
508

reduces the influence of these factors while the lack of warmth may
significantly amplify the impact of those risk factors in generating
antisocial behavior. (p. 290)
509

Peers
Association with delinquent peers is a frequently cited and relatively
strong correlate of delinquency, which appears to apply more to
adolescents than to younger children (Hawkins et al., 2000; Moffitt, 1993;
Office of the Surgeon General, 2001). It would seem logical that
delinquent peers can both model and reinforce antisocial behavior,
although it may also be the case that delinquent youth select delinquent
friends. Lösel and Farrington (2012), however, cautioned that delinquent
peers may be a marker rather than a cause of delinquency. Interestingly, in
a multisite study, Henry, Tolan, Gorman-Smith, and Schoeny (2012) found
that peer deviance was a significant risk only for White youth and not for
African American or Latino youth. On the other hand, Haggerty, Skinner,
McGlynn-Wright, Catalano, and Crutchfield (2013) found no race
differences in predictors of teen violence. There appears to be a consensus
that association with prosocial peers functions as a protective or promotive
factor regardless of race (Durlak, 1998; Lösel & Farrington, 2012;
Stouthamer-Loeber et al., 2002; Werner & Smith, 2001).
510

Other Adults
A relationship with a caring adult outside of the immediate family is an
important protective factor or asset (Eccles & Gootman, 2002; Fraser et
al., 2004; Scales & Leffert, 1999; Werner & Smith, 2001). Such a
relationship may emerge naturally with an extended family member, a
neighbor, or teacher. Alternatively, this relationship may be arranged in
formal mentoring programs, such as the Big Brothers and Big Sisters
program. This program has been successful in reducing recidivism among
young offenders (Tierney, Grossman, & Resch, 1995).
511

Schools
Next to the family, schools are the most important social arena for children
and adolescents. The literature consistently indicates that school
commitment and academic performance are linked to developmental
outcomes. Low commitment and poor performance are consistently
identified as risk factors, and strong commitment and good performance
are identified as protective factors (Fraser et al., 2004; Hawkins et al.,
2000; Henry et al., 2012; Lipsey & Derzon, 1998; Lösel & Farrington,
2012; Mann & Reynolds, 2006; Office of the Surgeon General, 2001;
Richart, Brooks, & Soler, 2003; Stouthamer-Loeber et al., 2002; Werner &
Smith, 2001; Williams et al., 2004). Moreover, there is evidence that the
quality of the school environment plays an important role in the onset and
prevention of delinquency (Durlak, 1998; Gottfredson, 2000; Lipsey &
Derzon, 1998).
512

Neighborhood and Community
Poverty is one of the most frequently cited correlates of delinquency
(Fraser et al., 2004; Hawkins, Catalano, & Miller, 1992; Hawkins et al.,
2000; Lipsey & Derzon, 1998; Office of the Surgeon General, 2001;
Werner & Smith, 2001). The availability of drugs and weapons, exposure
to violence, and neighborhood disorganization in general (e.g., high
population mobility, physical deterioration, high crime rates, and lack of
social cohesion) are risk factors for delinquency (Aisenberg & Herrenkohl,
2008; Hawkins et al., 2000; Nash & Bowen, 1999; Sampson, Raudenbush,
& Earls, 1997; Williams et al., 2004). On the other hand, communities and
neighborhoods with high collective efficacy are presumed to exert
informal social control that helps protect against delinquency (Fraser et al.,
2004; Lösel & Farrington, 2012; Nash & Bowen, 1999; Sampson et al.,
1997).
Community norms broadly affect delinquency through formal laws and
policies as well as informal means (Durlak, 1998; Hawkins, Catalano, &
Miller, 1992; Williams et al., 2004). For example, a community that
vigorously pursues enforcement of age limits for the purchase of alcohol
might be expected to have lower delinquency rates. Fraser et al. (2004)
noted that limited opportunities for education and employment and the
presence of racial discrimination are risk factors for delinquency, whereas
the presence of opportunities for education and employment provides
protection from delinquency.
513

Race and Ethnicity
When considering risk and resilience, it is challenging to disentangle race
and ethnicity from socioeconomic status. It is clear that African American
and Latino youth in particular show higher rates of involvement in youth
problem behaviors generally (Cauce, Cruz, Corona, & Conger, 2011) and
in delinquency in particular, as described previously in this chapter.
African American and Latino youth are much more likely than White
youth to reside in high-poverty neighborhoods, which in turn exposes them
to much higher levels of the community-level risk factors listed above
(e.g., low social cohesion, exposure to violence, availability of drugs and
weapons, etc.) and places families at higher levels of stress. In addition to
facing the neighborhood conditions just mentioned, many African
American and Latino families are headed by single parents, many parents
struggle to find work (or, if working, struggle to find adequate time to
supervise children), and many families lack other child-care resources, all
of which may negatively affect parenting practices (Cauce et al., 2011).
While research in general indicates that parental warmth, engagement, and
support provide strong protection regardless of race or ethnicity (Fraser et
al., 2004; Li, Nussbaum, & Richards, 2007; Williams et al., 2004) and that
authoritarian parenting styles are less effective, there is evidence that
strong discipline may be effective in buffering many of the low-income
neighborhood risks in African American and Latino households (Cauce et
al., 2011). Finally, as will be argued below, the juvenile justice system
itself may be viewed as a risk factor, and youth of color are clearly
overrepresented throughout the system (a review of the extensive literature
on Disproportionate Minority Contact is beyond the scope of this chapter;
for a quick summary, see Bell & Ridolfi, 2008; National Council on Crime
and Delinquency, 2007).
514

Gender Differences
A recent meta-analysis of predictors of delinquency among girls
documented important gender differences in risk and needs profiles
(Hubbard & Pratt, 2002). The results indicated that even though many of
the strong predictors were the same as those for boys (e.g., history of
antisocial behavior, antisocial peers, antisocial attitudes, and antisocial
personality), the role of other predictors was more pronounced among
girls. These gender-dependent factors included IQ, family dysfunction,
trauma and sexual abuse, mental health and substance abuse problems,
high-risk sexual behaviors, and school problems (Hubbard & Pratt, 2002).
These findings were consistent with those of a recent study of 672 girls in
detention, which determined that most of the girls had experienced trauma
(84%), met criteria for mental health problems (78%), reported having a
parent or close friend with criminal justice system involvement (61%), and
had been sexually active (76%) (Lederman, Dakof, Larrea, & Li, 2004). In
another study, detained girls were significantly more likely than were
detained boys to exhibit risks and needs related to family and parenting,
mental health, traumatic events, physical health, psychopathy,
accountability, and peer relationships (Gavazzi, Yarcheck, & Chesney-
Lind, 2006).
Although these differences suggest the need for gender-specific
programming, the evidence supporting the effectiveness of gender-specific
programming is not yet compelling. Zahn and colleagues, in a recent
systematic review of evaluations of gender-specific and gender-neutral
programs, concluded that (a) there were very few strong studies available,
(b) there was no evidence that gender-specific programs were more
effective than other programs in reducing recidivism, and (c) there was
evidence that programs with a strong history of success with boys also
worked well for girls (Zahn, Day, Mihalic, & Tichavsky, 2009). However,
the investigators noted that gender-specific programs showed positive
results on measures related to empowerment and quality of life, including
education, employment, relationships, self-esteem, and self-efficacy (Zahn
et al., 2009).
515

Summary
In addition to illustrating the ecological nature of risk and protection,
several key themes emerge from this review:
Many risk, promotive, and protective factors are malleable (e.g., the
presence of social support, the development of social skills, parenting
skills); others are not subject to change (e.g., IQ, temperament,
gender).
The effect of risk factors is not necessarily linear; that is, the presence
of multiple risk factors can increase the probability of undesirable
outcomes exponentially (Lösel & Farrington, 2012; Pollard, Hawkins,
& Arthur, 1999; Rutter, 2001).
There is both overlap—among the risk, protective, and promotive
factors—and co-occurrence—among adolescent problem behaviors—
with a set of common risk and protective factors associated with a
range of problems (Dryfoos, 1990; Hawkins, Catalano, & Miller,
1992; Huizinga, Loeber, Thornberry, & Cothern, 2000).
The effect of some risk and protective factors is developmentally
specific (Hawkins et al., 2000; Office of the Surgeon General, 2001).
Risk and protective factors generally appear to operate similarly
across cultural and ethnic groups (Elliott, Huizinga, & Menard, 1989;
Haggerty et al., 2013; Hawkins, Laub, & Lauritsen, 1998; Williams,
Ayers, Abbott, Hawkins, & Catalano, 1999), with some exceptions
(Cauce et al., 2011; Henry et al., 2012); however, there are gender
differences as noted above.
Risk factors can combine either simultaneously or cumulatively over
time and, in either case, increase the probability of undesirable
outcomes.
In general, risk factors and protective factors are inversely distributed
across social strata; that is, those at highest risk generally have fewer
natural protections than those at lower risk (Cauce et al., 2011;
Pollard et al., 1999).
A useful theoretical framework for summarizing knowledge of risk,
protection, resilience, and developmental outcomes comes from the social
development model (Catalano & Hawkins, 1996), which is a synthesis of
social control theory, social learning theory, and differential association
theory. Although developed as an explanation for antisocial behavior, the
516

social developmental model is more broadly applicable to developmental
outcomes. Catalano and Hawkins (1996) outlined the four purported
socialization processes affecting children that constitute the heart of the
model:
(1) perceived opportunities for involvement in activities and
interactions with others, (2) the degree of involvement and
interaction, (3) the skills to participate in these involvements and
interactions, and (4) the reinforcement they perceive as forthcoming
from performance in activities and interactions. (p. 156)
Through these processes, the child develops a social bond with the
socializing unit, with its strength dependent on the consistency of the
socializing processes. Bonding, which consists of attachment,
commitment, and beliefs, then influences the child’s subsequent behavior
as he or she seeks to maintain the connection. Antisocial behavior results
from (a) a weakening of the bond with prosocial socialization agents; (b) a
situation in which, even in the presence of a prosocial bond, the situational
inducements to deviance are sufficiently compelling; or (c) a situation in
which the child develops a strong bond to antisocial socialization agents,
including parents or peers. Finally, the social developmental model
contains developmentally specific submodels that reflect changes in the
child’s salient socialization agents at different ages (e.g., the progression
from family to school). From this model, it can be seen that behavior
emerges from the ecological interplay of individual characteristics, social
interactions, and environmental supports/constraints; the direction of the
developmental trajectory (prosocial or antisocial) is dependent on the array
of risk, protective, and promotive factors.
Notwithstanding the substantial advances in research and theory regarding
risk and resilience, no one should assume that knowledge of risk and
protective profiles can predict long-term developmental outcomes with
pinpoint accuracy. For example, attempts to quantify the effect sizes of
various risk factors have shown that the predictive power of even the most
powerful risk factors is modest (Hawkins et al., 2000; Office of the
Surgeon General, 2001). Evidence from longitudinal studies suggests that
turning points, such as military service and, especially, marriage, can have
a profound effect on positively redirecting developmental trajectories
(Laub & Sampson, 2003; Werner & Smith, 2001). The error variance in
517

predictive models may be due to incomplete specification of the
predictors, or it may indicate that chance, personal agency, and
individuals’ interpretation of the immediate context play major roles in
eliciting behavior. As Lösel and Bender (2003) noted, “errors in prediction
of antisociality in childhood and adolescence should not just be viewed as
a technical deficit. They are also indicators of the general phenomena of
multifinality and equifinality in development” (p. 131). In sum, although
the growing knowledge base of the risk and resilience framework may
have great relevance for policies and practices, that knowledge must be
applied cautiously and with recognition of its limits.
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Risk, Protection, and Resilience in
Juvenile Justice Policy
Until recently, knowledge of risk, protection, and resilience had not
influenced juvenile justice policies and programs in profound ways. This
lack of influence in itself is not surprising because this knowledge base has
emerged only within the last few decades. Instead, policies and practices
appear to have primarily reflected concepts such as deterrence,
incapacitation, and retribution, with an occasional dose of developmental
psychology. Juvenile justice policies and programs have sought to protect
the community and to reform offenders by teaching offenders that
delinquency leads to unpleasant consequences. This lesson has been
implemented by either closely supervising offenders’ behavior or placing
offenders in restrictive settings, keeping them off the streets for some time.
In the century since the founding of the juvenile court, juvenile justice
policies have evolved amid the dialectic between the goals of punishment
and rehabilitation of young offenders. Bernard and Kurlychek (2010) have
captured this fluctuating history well, describing the “cycle of juvenile
justice” as beginning with the observation that delinquency is a serious and
escalating problem, blaming the problem on the current tenor of policies
(either “get tough” or lenient), advocating reforms moving to the other
pole, discovering that the problem remains unsolved, blaming the then-
current tenor of policies, switching to the other pole again, and so on.
Juvenile courts were meant to function in the best interests of the child,
and early juvenile correctional programs were supposed to be treatment
programs rather than prisons. However, when high rates of delinquency
and recidivism continued, the juvenile court and juvenile correctional
practices became tougher. Specifically, the court’s discretionary powers,
which were intended to reduce the punitiveness of the adult courts, became
suspect because juveniles lacked many due process protections. A series of
U.S. Supreme Court challenges gradually brought many of those due
process protections into the juvenile court by the latter part of the 20th
century (Bernard & Kurlychek, 2010; Snyder & Sickmund, 1999).
However, the increasing formality of the juvenile court system has
rendered it more like the adult system and perhaps paved the way for
policies such as “three strikes,” mandatory sentences for some offenses,
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and the increasing use of transfer to the adult system via judicial waiver,
prosecutorial direct file, or statutory exclusion.
520

Juvenile Justice System Involvement and
Incarceration as Risk Factors
Throughout its checkered history, the juvenile justice system has
continually relied on secure, residential placements, both before
adjudication (detention) and after adjudication (training schools and
private secure residential facilities). In recent years, a number of studies
have documented major problems with the use of such facilities (for a
recent vivid qualitative examination, see Bernstein, 2014). Specifically:
1. Secure facilities are overused; many youths in secure residential
facilities are not serious or chronic offenders and could be placed in
less restrictive settings (Snyder & Sickmund, 1999, 2006).
2. Many secure residential facilities house youths in poor conditions
characterized by overcrowding (Livesy, Sickmund, & Sladky, 2009),
sexual abuse (Beck, Harrison, & Guerino, 2010), or otherwise unsafe
environments (Lerner, 1986; Parent et al., 1994).
3. Secure residential facilities are relatively ineffective; that is, gains
made during incarceration, if any, tend to dissipate when youths
return to the community, and recidivism outcomes are often no better
—or even worse—than would be found in less restrictive,
community-based settings (Gatti, Tremblay, & Vitaro, 2009; Holman
& Ziedenberg, 2006; Lipsey, 1992; Loeber & Farrington, 1998;
Loughran et al., 2009).
Treatment programming in juvenile corrections has used behavioral
contingencies and, more recently, cognitive-behavioral approaches to
modify behavior and thinking patterns that are presumed to lead to
offending behavior. Within the field, there has been some recognition of
the importance of peer influences on adolescents, as expressed in treatment
models such as guided group interaction (McCorkle, Elias, & Bixby,
1958) and positive peer culture (Vorath & Brendtro, 1974). However,
whatever the treatment modality, recidivism has remained high, with
studies finding that between 50% and 90% of youths are reincarcerated in
juvenile or adult facilities within 1 to 3 years of their release from juvenile
correctional facilities (Howell, 2003; Minor, Wells, & Angel, 2008;
Trulson, Marquart, Mullings, & Caeti, 2005).
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Considerable evidence has accumulated to suggest that juvenile justice
system involvement is itself a risk factor for poor developmental
outcomes. The iatrogenic effects (i.e., unintentional detrimental or harmful
effects) of involvement with the juvenile justice system include, but are
not limited to, future offending. For example, even after controlling for
offense-related and demographic factors, both the use of secure detention
and the decision to formally process a case have been linked to more
restrictive dispositions and higher levels of recidivism (Feld, 1991; Frazier
& Bishop, 1985; Frazier & Cochran, 1986). Similarly, the research cited
above about the iatrogenic effects of incarceration is compelling (Gatti et
al., 2009; Holman & Ziedenberg, 2006; Lipsey, 1992; Loeber &
Farrington, 1998; Loughran et al., 2009). Social learning theory (Akers,
1985) provides one theoretical explanation for these relationships;
exposure to other delinquent peers occurs in most juvenile justice
interventions, especially incarceration, and it results in peer-deviancy
training (Dishion, McCord, & Poulin, 1999; Dishion, Spracklen, &
Patterson, 1996; Dodge, Dishion, & Lansford, 2006). Alternatively,
labeling theory (Becker, 1963; Bernburg, Krohn, & Rivera, 2006; Lemert,
1951) suggests that others respond to the label of delinquent by expecting
the youth to behave accordingly, and youth who are labeled as delinquent
might also internalize that label. In addition to being a risk factor for
recidivism, juvenile justice system involvement during adolescence is
associated with limited educational, employment, and financial outcomes
as well as adult mental health disorders and substance abuse (Fagan &
Freeman, 1999; Moffitt, Caspi, Harrington, & Milne, 2002). For a recent
review of the evidence regarding the deleterious social, developmental,
and fiscal consequences of incarcerating juveniles, see a recent report from
the Justice Policy Institute (Petteruti, Walsh, & Velázquez, 2009).
522

Risk, Resilience, and Recent Reform
Efforts
Despite the “get tough” climate of juvenile justice policies initiated since
the latter part of the 20th century, some policy officials have recognized
the ineffectiveness and expense of relying on incarceration to reform
offenders. Therefore, some policymakers have advocated for greater use of
community-based programs at all stages of the juvenile justice system. In
many instances, community-based responses have served to divert youths
from formal processing through the system. In other instances,
community-based resources have served as integral parts of the formal
system (e.g., probation) or as complementary components (e.g.,
community-based treatment programs). For a review of community-based
programs in juvenile justice, see Barton (2002).
In an attempt to move beyond the punishment–rehabilitation dialectic,
Maloney, Romig, and Armstrong (1988) provided a major advance in
conceptualizing juvenile justice goals by articulating the “balanced
approach” to probation. According to this approach, juvenile justice
policymakers must consciously balance concern for three system goals: (1)
public safety protection, (2) accountability (of the juvenile and the
system), and (3) competency development. In other words, every decision
point in the system must consider and account for these three goals.
Several states subsequently adopted the balanced approach in their
juvenile codes or agency mission statements.
More recently, advocates of restorative justice (e.g., Bazemore & Terry,
1997; Bazemore & Umbreit, 1995) have sought to replace the traditional
retributive paradigm of juvenile justice, which views crimes as offenses
committed against society, with a new paradigm that views crimes as
upsetting the balance of rights and obligations, with victims and offenders
seeking a mediated restoration of that balance. Although the restorative
justice paradigm has not been adopted fully in most places, elements of
restorative justice have increasingly appeared, usually targeting minor or
first-time offenders, including such practices as family-group conferences
(McGarrell, Olivares, Crawford, & Kroovand, 2000) and teen courts
(Butts, Buck, & Coggeshall, 2002). In many ways, the restorative justice
approach is consistent with the principles of risk, protection, and
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resilience.
Since the mid-1990s, knowledge about risk and protective factors has
found its way into mainstream juvenile justice policy discussions and has
been heavily promoted by the Office of Juvenile Justice and Delinquency
Prevention in its comprehensive strategy (Howell, 1995; Wilson &
Howell, 1993). This strategy combines an emphasis on prevention
strategies, which attempt to reduce community risk factors and enhance
protective factors, with the application of community-based interventions
(and less use of incarceration) and evidence-based treatment models in the
juvenile justice system. Although not limited to jurisdictions adopting the
comprehensive strategy, an increasingly common application of risk
principles (albeit not resilience) to juvenile justice has been the use of
structured risk-assessment instruments (Howell, 2003; Wiebush, Baird,
Krisberg, & Onek, 1995). Many jurisdictions now use such instruments at
various points in the juvenile justice system to guide decisions regarding
placement in secure detention, probation supervision levels, dispositional
placement restrictiveness, and aftercare planning (Wiebush et al., 1995).
Risk, protection, and resilience are explicitly ecological concepts;
however, the tendency is to apply them primarily at the individual level.
Thus, we see the contemporary extension of the typological enterprise,
with an emphasis on developing risk and need profiles of individual youths
and making juvenile justice system decisions (e.g., detention placements,
treatment plans) at least partly based on these assessments. This approach
may or may not be much of an improvement. The evidence suggests that
although risk and protective factors have some explanatory power at the
aggregate level, these factors do not do a very good job of predicting
outcomes at the individual level (Laub & Sampson, 2003; Office of the
Surgeon General, 2001; White, Moffitt, Earls, Robins, & Silva, 1990). The
use of risk profiles represents an improvement over pure chance
predictions, but the rate of false-positive and false-negative predictions is
high. False-positive predictions are characterized by individuals with high-
risk profiles who do not go on to commit more offenses. Conversely, false-
negative predictions involve youths with low-risk profiles who do go on to
commit crimes. In some sense, the advances in risk and protective factor
research may have provided juvenile justice policymakers and
practitioners with an exaggerated sense of confidence that their decisions
are evidence-based decisions.
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Risk, Resilience, and Evidence-Based
Programs
A burgeoning literature on “what works” in juvenile justice has emerged in
recent decades as a counter to the now infamously misinterpreted “nothing
works” mantra of the 1970s (Lipton, Martinson, & Wilks, 1975). Major
reviews and meta-analyses of juvenile correctional treatment programs
have indicated that many approaches, if implemented correctly and
targeted toward the appropriate youths, can reduce recidivism (Andrews et
al., 1990; Lipsey, 1992; Lipsey & Wilson, 1998). Several websites list
prevention and intervention programs with research-based evidence of
effectiveness. For example, The Blueprints for Violence Prevention
(Center for the Study and Prevention of Violence [CSPV], 2014) considers
model programs to be those that meet the following criteria: evidence of a
deterrent effect with a strong research design, sustained effect, and
multiple site replications. Promising programs meet only the first criterion.
As of this writing, the Blueprints website lists nine model programs and 23
promising programs addressing youth risk or protective factors related to
delinquency.
The financial burden of programs is also an important consideration. The
Washington State Institute for Public Policy (WSIPP) has applied a
sophisticated cost–benefit analysis based on meta-analyses of a wide range
of crime-prevention and intervention programs for juveniles and adults
(Drake, Aos, & Miller, 2009). The WSIPP analysis found that many
prevention and intervention programs are cost-effective, whereas others
are not. Table 9.3 presents a listing of several juvenile programs and
indicates whether they are Blueprint model programs and whether the
program has been determined as cost-effective by the WSIPP.
In the WSIPP model, benefits are estimated per participant and reflect the
combined savings to taxpayers from reduced criminal justice processing
costs (if any) and the value of crime victim benefits based on the
program’s estimated effect on preventing future crimes, net of program
costs (Drake et al., 2009). Programs with poor economic returns include
“Scared Straight” programs, wilderness challenge programs, intensive
probation or parole programs, and boot camps, none of which is even
remotely informed by the risk and resilience framework. In contrast,
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prevention programs that strengthen families, provide mentoring, and
foster school success and social skills, along with intervention programs
that are either explicitly ecological or target key risk factors, were found to
be highly cost effective (Drake et al., 2009). Examples of highly cost-
effective programs included Multisystemic Therapy, Functional Family
Therapy, and coordinated services (i.e., comprehensive, coordinated
services also called wraparound services). Drake and colleagues (2009),
with a partial, more recent update (Aos & Drake, 2013), reported that these
programs offered combined benefits per participant, ranging from about
$15,000 to as much as $88,000 (see above for how benefits were
calculated). It is no accident that these cost-effective approaches are either
informed by or consistent with the risk and resilience framework.
Center for the Study and Prevention of Violence (2014)
Aos and Drake (2013); Drake, Aos, and Miller (2009).
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Although much of the research base on risk and protection uses the
presence or absence of delinquency as the primary dependent variable,
merely preventing delinquent or antisocial behavior may not be the only
positive goal of risk- and resilience-based interventions. The resilience
literature and positive youth development literature remind us that being
“problem-free isn’t fully prepared” (Pittman & Irby, 1996, p. 3). The
juvenile justice system is primarily concerned with preventing the
recurrence of delinquency. However, that system might be more successful
if it were to embrace the universal goals of positive youth development,
which focus on promoting competence, character, connections,
confidence, and contribution (Hamilton, Hamilton, & Pittman, 2004). In
this way, communities would have the opportunity not only to prevent
youth problem behaviors but also to promote long-term, healthy
development.
Clearly, formal juvenile justice system involvement, particularly
incarceration, interrupts the normal course of adolescent development. It
disrupts adolescents’ ability to complete developmental tasks by removing
them from the supports and opportunities available in the community to
their nondelinquent peers (Altschuler, 2005; Chung, Little, & Steinberg,
2005). Although the risk and resilience framework has increasingly
informed juvenile justice policies and programs, its full potential has yet to
be realized. It can provide a foundation for more fundamental changes in
juvenile justice policies and practices. These changes would incorporate
the truly ecological nature of risk and resilience, broaden the system goals
from merely controlling delinquent behavior to promoting positive youth
development, and rely on and further promote coordination among the
various service systems that affect the lives of adolescents, as advocated
by Jenson and Fraser (2006). The next section explores what some of those
changes might look like and highlights some efforts that are currently
underway.
527

Using Knowledge of Risk, Protection, and
Resilience to Enhance Juvenile Justice
Policy and Practices
Based on the risk and resilience framework, Fraser and Terzian (2005)
outlined three basic practice principles: (1) strengthen protection and
reduce risk (both must be addressed); (2) understand the effect of the
social and developmental context on protection and risk; and (3) identify
and disrupt risk mechanisms, that is, the “sequencing of events that elevate
risk” (p. 20). The Blueprint model programs and the cost-effective
programs identified by WSIPP, along with the following discussion of
additional ways to incorporate the risk and resilience framework into
juvenile justice, are congruent with these practice principles.
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Changing the Culture of Juvenile Justice
Thorough application of the risk and resilience framework would require a
change in the prevailing juvenile justice culture, and that traditional culture
is deeply entrenched. It is difficult for justice system actors to transcend
long-standing beliefs in the effectiveness of deterrence and punishment,
despite evidence to the contrary. It is also difficult for those working in the
current juvenile justice system to take an ecological view when confronted
with a steady stream of individuals. The culture of many juvenile justice
agencies is “passive-defensive,” with routinized procedures, resistance to
innovation, and “climates characterized by depersonalization, emotional
exhaustion, role overload, and role conflict” (Hemmelgarn, Glisson, &
James, 2006, pp. 76–77). The effects of this culture and climate include
low morale, high rates of staff turnover, and cookie-cutter approaches to
case planning and interventions. The poor outcomes have been
documented previously in this chapter.
In the last few years, interest in incorporating positive youth development
principles into juvenile justice has grown, albeit not without recognition of
the challenges facing such a transformation (Barton, 2004; Butts,
Bazemore, & Meroe, 2010; Butts, Mayer, & Ruth, 2005; Frabutt, Di Luca,
& Graves, 2008; Schwartz, 2001; Torbet & Thomas, 2005). There are
some juvenile justice settings in which the positive youth development
perspective has taken root, and although strong evidence of effectiveness
is not yet available, these settings tend to produce more positive climates,
less staff turnover, and much lower rates of recidivism (Barton & Butts,
2008; Barton & Mackin, 2012; Barton, Mackin, & Fields, 2008; Kurtz &
Linnemann, 2006). The comments of an administrator who shepherded
such a transformation are provided in Box 1.
Several factors appear to promote the successful transformation of an
agency’s culture:
A hospitable community culture—the values in relatively progressive
communities are more likely to be congruent with positive youth
development principles;
The commitment of leadership—establishing and championing a
vision, facilitating and empowering staff to adopt innovation, and
staying the course;
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Adopting the strengths perspective as the practice model;
Encouraging early adopters to serve as role models and peer trainers;
Thorough training, followed by periodic “booster” trainings;
Intentional hiring—bringing on staff already familiar with positive
youth development principles and/or strength-based practice, or at
least those who do not have to “unlearn” the traditional approaches;
Integration into bureaucratic processing—make the paperwork reflect
the goals and practice principles (more details on this point appear
below);
Consistent reinforcement through regular staff supervision;
Collaboration with other agencies in the community—organizational
permeability helps to prevent a return to the isolated correctional
culture;
Using feedback from data on youth outcomes for continuous quality
improvement and to help “sell” the new approach. (Barton & Butts,
2008, pp. 43–45)
The integration of positive youth development principles and the strengths
perspective into the bureaucratic processing of juvenile justice agencies is
especially critical. This integration can be, and should be, completed at
two levels: individual practice and program accountability. Integration at
the level of individual practice requires the adoption of a structured
strengths assessment. Some of the risk assessment instruments mentioned
previously include some coverage of strengths but typically address
strengths as an afterthought, and seldom do the strengths inform case
planning in any meaningful way. There are instruments that staff can use
to assess strengths, including the Behavioral and Emotional Rating Scale
(Epstein & Sharma, 1998), Child and Adolescent Needs and Strengths
(Lyons, Griffin, Fazio, & Lyons, 1999), and the Youth Competency
Assessment (Mackin, Weller, Tarte, & Nissen, 2005; Nissen, Mackin,
Weller, & Tarte, 2005). These instruments encourage staff to create truly
individualized intervention plans, and the process of administering the
assessment also enables staff to develop stronger relationships with the
youths; such relationships are at the heart of producing positive change
(Barton & Butts, 2008).
To promote program accountability congruent with the risk and resilience
and positive youth development frameworks, program design and
evaluation should be based on explicit program theory, which highlights
the role of the positive youth development principles as both intermediate
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and longer term outcomes. An evaluation of an out-of-school-time
program provides an example of the application of such a logic model
(Anthony, Alter, & Jenson, 2009). This model begins with the
identification of risks at multiple ecological levels and then designs
interventions to provide protections intended to build resilience and
produce intermediate outcomes related to positive youth development
(competence, confidence, character, and connection), which, in turn, are
expected to produce long-term outcomes including not only reduced
antisocial behavior but milestones of positive development (educational
achievement and economic self-sufficiency; Anthony et al., 2009, p. 49).
Making explicit the linkages between risk, resilience, positive youth
development, and long-term promotion of positive developmental
outcomes (and reduction of the probability of negative developmental
outcomes), models such as this one encourage program stakeholders to
focus rationally on strategies that risk and resilience theory and research
suggest will be most effective.
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Comments of a County Juvenile Probation
Administrator About Changing the Culture
I would say that, . . . commonly in our field, there are two different mindsets.
One is that these kids are doing things that are harmful to other people, to
society, and that’s true. And so people who have that view of these kids—
harmful to society—they often have a lot of compassion for victims, and
they take a point of view that the only way to approach that is to control that,
to contain that, and that might mean removing kids from the community or
restricting [kids]; this whole restrictive-punitive notion of how you deal with
that. And then there are the other people who [think that] these are kids who
you need to support, develop, and help. And I think that the most significant
realization that we can come to is that they are not mutually exclusive,
incompatible approaches, and that there is another way—which
acknowledges that the kids have hurt society and have created victims and
hurt people—but at the same time acknowledges that they have the
capabilities and strengths and capacities that haven’t been tapped; and that
the approach is that you can do all of these things at one time. . . . Just
because you have identified a kid’s strengths doesn’t mean that you . . . say,
“We accept the things you’ve done.” And I think it’s the same thing for
parents or running any organization. There are certain things that are not
acceptable—and you have to be very clear about what those are—but at the
same time you acknowledge that there are a lot of things in each individual
that are very strong, and you point those to success. So I think that it’s that
bifocal frame of reference that you have to overcome: it’s not either-or.
I think the only way you can overcome it—[because] you don’t go into a big
room of 400 people or your big staff and tell them that, you don’t preach it. I
could probably say better what you don’t do; I know what you don’t do—
What you do is first of all [have] patience and recognize that organizational
change takes years, and that you need to [be] very explicit. . . . I approach
things [with] fairly long-range plans, long-range vision and constantly
communicate that vision. [I am] very clear about what that [vision] is; it’s
not very complicated. It can be very simple, and you pretty much keep
saying the same things over and over again. You can see it here; we are
pretty clear about what our values are. We defined what they are, we make
decisions of hiring based on those values, we incorporate them at every
level. You model them, and then you see change over the course of the
years.
Source: [Name withheld], from interview transcript with this author, October
11, 2006. This county department had adopted a strength-based, positive
youth development approach in 2001. By 2004, its rate of delinquency
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petitions was substantially lower than that of the other large counties in its
state. Its recidivism rate of 25% was lower than the state average and had
fallen faster than that in the rest of the state.
533

Juvenile Justice Interventions
As noted previously, efforts within the core of the juvenile justice system
to incorporate knowledge of risk, protection, and resilience in policy and
practice have been limited. Nevertheless, there are some promising ways
that the risk and resilience perspective can inform juvenile justice policies
and practices. Chief among these is the use of truly individualized,
collaborative case coordination in system of care (SOC) (Duchnowski,
Kutash, & Friedman, 2002; Stroul & Friedman, 1986) or wraparound
service models (Burchard, Bruns, & Burchard, 2002; Goldman, 1999;
VanDenBerg & Grealish, 1996). The wraparound approach explicitly
values culturally competent, strengths-based assessment and practice
(Saleebey, 2013); involves youths, parents, informal sources of support,
and professionals as partners in service planning; and operates through a
formal collaboration among provider agencies that span traditional service
arenas and use blended funding streams (Goldman, 1999). A growing body
of evidence supports the promise of wraparound services (Burchard et al.,
2002) and indicates that this approach is cost-effective (Aos, Phipps,
Barnoski, & Lieb, 2001).
Models of individualized wraparound service can be applied to juvenile
justice (Kendziora & Osher, 2004). Wraparound programs such as
Wraparound Milwaukee (Kamradt, 2000; Wraparound Milwaukee, n.d.)
and the Dawn Project in Indianapolis (Choices, 2010) serve youth with
mental health or substance abuse needs who enter the juvenile justice
system. These programs have reported promising results in terms of
reduced residential placements and lowered recidivism (Kamradt, 2000;
Wisconsin Council on Children and Families, 2010; Wright & Anderson,
2005). Most, if not all, cases currently entering the juvenile justice system
or transitioning from residential placements could benefit from
wraparound services. The intensity of services could vary based on the
assessed needs and strengths of the individuals, their families, and
contexts. Not all would require lengthy and expensive services, and the use
of and length of stay in costly residential placements would likely
decrease.
The Annie E. Casey Foundation’s Juvenile Detention Alternatives
Initiative (JDAI) is another vehicle that has triggered culture shifts in
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several jurisdictions. Using a detailed blueprint to guide detention reform,
JDAI encourages stakeholders to adopt values consistent with the risk and
resilience framework to reshape their understanding of detention and, by
extension, the broader juvenile justice system. Formally launched in five
sites in 1993, JDAI had expanded to more than 250 sites in 39 states by
2013, covering about one-third of the nation’s youths (Mendel, 2014).
Although the initiative has not been successful or sustained in all sites, a
recent evaluation documented dramatic reductions in the use of secure
detention (50% or more) in many sites, with no concomitant increases in
juvenile crime or failures to appear for court hearings (Mendel, 2014).
Moreover, the JDAI approach has been credited with other system
improvements beyond reductions in secure detention use, including
reduced disproportionate minority contact, fewer commitments to state
juvenile correctional institutions, enhancements to community-based
intervention alternatives, and greater collaboration among system
stakeholders (Mendel, 2014). From personal experience with several JDAI
sites, I have been struck by changes in the way JDAI site stakeholders
view and talk about youth, including greater recognition of the
applicability of a strengths-based, positive youth development lens that
focuses as much on enhancing protective factors as on controlling risk
factors.
In the last few years, the cumulative research on risk and resilience,
coupled with advances in developmental science, appears to have reached
a broader audience of policymakers and practitioners, fueling some
promising, holistic proposals for transforming the juvenile justice system.
For example, the National Research Council (2013) and the National
Campaign to Reform State Juvenile Justice Systems (Weiss, 2013) have
offered comprehensive strategies and pointed to several exemplary
programs and jurisdictions. Not only do these approaches rest on
convincing evidence of effectiveness, but they promise to be less costly.
Perhaps some of the impetus for embracing these approaches comes from
jurisdictions’ recent fiscal constraints, but perhaps it also reflects the
eventual translation of research into practice. It remains to be seen whether
these perspectives, what Weiss (2013) has termed the “Fourth Wave” of
juvenile justice reforms, will take root, promote the culture change in
juvenile justice described in the previous section, and be sustained, or turn
out simply to be another pendulum swing in the cycle of juvenile justice
(Bernard & Kurlychek, 2010).
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A more radical way of embracing the risk and resilience framework might
be to divorce the juvenile justice system from treatment programming
altogether. Others have advocated splitting the legal and social welfare
programming aspects of the court (e.g., Feld, 1999), but for slightly
different reasons. Recall the three goals of juvenile justice articulated in
the balanced approach as described earlier (Maloney et al., 1988). Perhaps
the juvenile justice system should concentrate on what it could do best—
public safety protection and accountability enforcement from a just deserts
framework, transferring responsibility for competency development to
community service providers more aligned with the risk and resilience
framework. That is, there would still be juvenile court proceedings,
probation oversight, and enforcement of the terms of accountability.
However, probation would work in partnership with community service
providers and other community stakeholders, who would both participate
in the development of dispositional recommendations to the court and
provide the individualized case management services.
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Prevention
Knowledge of risk, protection, and resilience may be most useful for
juvenile justice at the periphery of the system, where the corrosive
influence of the traditional juvenile justice culture is either absent or
minimal. The best example is prevention, where this knowledge can
inform efforts to lower the risks and increase the protection in entire
communities or focus efforts on targeting risks and strengthening
protection in the more specific contexts of schools or families. The
Communities That Care (CTC) approach of Hawkins, Catalano, and
Associates (1992) is an example of community-wide prevention that is
developed in considerable detail. CTC components include a framework
for community mobilization, local assessment of risk and protective
factors, and a menu of evidence-based programs that can be tailored to
meet specific communities’ needs. An evaluation of CTC in several
Pennsylvania communities showed CTC counties with modestly reduced
delinquency rates even though implementation was inconsistent
(Greenberg & Feinberg, 2002). More recently, a CTC evaluation that used
a randomized, county-level design in several states showed promising
early results in terms of reductions in targeted risk factors and delayed
onset of delinquent behavior among youth in CTC sites (Hawkins et al.,
2008) and CTC appears on the most recent WSIPP list of evidence-based,
general prevention programs (WSIPP, 2014).
There is evidence that school-based prevention programs targeting risk
factors can be effective (CSPV, 2014; Hawkins & Herrenkohl, 2003).
These programs address the major school-based risks, including early
aggressive behavior, academic failure, and low commitment to school. The
promising approaches that Hawkins and Herrenkohl reviewed included
attempts to improve organizational climate and classroom management, to
engage families in supporting academic achievement, to increase
opportunities for school bonding, to teach emotional skills for self-control
and social interaction, and to promote prosocial norms.
Similarly, Tremblay and Japel (2003) reviewed a number of programs that
appeared effective in preventing delinquency by improving parents’ skills
and supports, addressing children’s cognitive skills, and reducing early
disruptive behavior among children. Tremblay and Japel’s review showed
that several perinatal and preschool programs effectively changed
537

parenting behavior in at-risk families (e.g., communication, attitudes,
discipline techniques) in ways that would appear to reduce risks and
strengthen protection. Another group of studies included in Tremblay and
Japel’s review supported the notion that very early interventions with at-
risk families, including parent training, environmental stimulation, and
parent support could improve children’s cognitive functioning and reduce
early disruptive behaviors. Tremblay and Japel (2003) concluded, “The
general impression from the review of the twenty-eight prevention
experiments is that early childhood interventions can have a positive
impact on the three most important risk factors for juvenile delinquency:
disruptive behavior, cognitive skills, and parenting” (p. 237).
More recently, Hall, Simon, Lee, and Mercy (2012) identified several
promising youth violence prevention approaches that emphasize
community collaborations targeting locally specified risk and protective
factors. In addition, the Office of Justice Programs and Centers for Disease
Control and Prevention published a comprehensive approach to gang
prevention (Simon, Ritter, & Mahendra, 2013) that builds upon the
ecological risk and resilience and positive youth development frameworks
discussed in this chapter.
538

Aftercare
Another key opportunity for incorporating the risk and resilience
framework at the periphery of juvenile justice is aftercare, as best
exemplified by the Intensive Aftercare Program model (IAP) developed by
Altschuler and Armstrong (1991, 1998). IAP includes the following key
components:
case management services;
a collaborative network of community services;
services that are “backed in” to the residential facility (i.e., the case
manager meets with the youth, conducts an assessment, develops a
release plan, and arranges for relevant community-based service
providers to visit the youth in the facility prior to release);
a “step-down” process, in which youths move first into a transition
phase, gradually experiencing more community interaction during the
last weeks of incarceration, and then go on to closely supervised
release, and finally to decreased supervision; and
a system of graduated sanctions to help control behavior during
aftercare. (Altschuler & Armstrong, 1998)
The Boys & Girls Clubs of America has recently attempted to blend IAP
and strengths-based principles in juvenile aftercare programs in several
sites (Barton, 2006). A case example illustrating ways to incorporate
strengths into aftercare programming is discussed in Box 2.
Evidence for the effectiveness of juvenile aftercare programs is mixed.
The National Council on Crime and Delinquency (NCCD) evaluated three
IAP pilot sites over a 5-year period, using an experimental design that
included random assignment to IAP and a control group in each site
(Wiebush, Wagner, McNulty, Wang, & Le, 2005). The study concluded
that recidivism rates were high for both the IAP and control groups. These
disappointing results were tempered somewhat by cautions related to small
sample sizes and by the observation that many youths in the control groups
may have received enhanced parole services as well. Finally, there was
some evidence that among the IAP participants, those who received higher
levels of services both prerelease and postrelease showed lower rates of
recidivism (Wiebush et al., 2005). A more recent evaluation of the Boys &
Girls Clubs of America’s juvenile reentry programs, which are also based
539

on the IAP model, produced findings similar to those of the NCCD study
(Barton, Jarjoura, & Rosay, 2014). The authors attributed the lack of
strong evidence for effectiveness to many daunting implementation
challenges faced by the sites. However, Aos (2004) found promising
results in a quasi-experimental evaluation of Washington State’s Family
Integrated Transitions (FIT) program. Although not identical to the IAP
model, the FIT program shares many important elements, including family
involvement, a collaborative team approach to case management, and
continuity between prerelease and postrelease phases.
540

Incorporating Strengths in Juvenile Aftercare
When Raymond was a 12-year-old, he was committed for possession of a
firearm on school property. He was sent to one of two maximum security
facilities for boys in the state. He struggled with the program at the facility
and spent 2 years at the facility before he was released on 6 months parole
and allowed to live with his mother. Just after he completed his parole, while
staying with his father in a nearby county, he was arrested on a battery
charge. He was placed back with his mother and ordered to serve home
detention for 3 months. The day after he was released from home detention,
he left the house without permission. He used drugs he stole from his aunt,
who also lived in the house, and his mother reported him to the police. He
resisted arrest and was committed back to the state, being sent to a second
maximum security facility as a 15-year-old.
This time, he completed the treatment program at the state facility with few
problems. Although he could have been released after 10 months, there were
concerns about him living with either parent. The mother lived in a trailer
with four children and a husband. The father owned a strip club and was at
work every night for the entire night. Consequently, Raymond would have
been without supervision in his father’s home. Raymond preferred to live
with his father; his mother resented this and acted to prevent it. Their
relationship was very strained as a result, and they broke off all contact.
Raymond no longer knows how to get in touch with his mother. Finally,
arrangements were made for Raymond to be released to a group home. He
spent 7 days at the group home before he was arrested for shoplifting. He
was recommitted to the secure care facility. He is now 17 years old and
expects to be released this fall.
He currently has access to an aftercare program that began working with him
in the secure care facility. In addition to many risk factors (early
involvement with the system, aggression, broken home, strained relationship
with his mother, negative peer involvement), his aftercare worker has
identified several strengths in Raymond. He is strong academically; is a
skilled athlete; is competent in using assertiveness to avoid peer pressure; is
eager to please adults and people in authority; is developing skills in
decision-making and problem-solving; and is able to reflect critically on his
own thinking, choices, and behavior. He has demonstrated good insights into
his relationships with his family, has expressed that he wants to work with a
mentor, and has been open to asking for assistance. He enjoys working on
service projects and willingly takes a leadership role, if allowed.
Raymond and his father have a good relationship, and each cares about the
other. His father is planning to remarry soon. A placement with his father
541

may be possible this time, if the father’s new wife is willing and able to help
with evening supervision. Raymond expects to complete his GED while in
the facility and wants to go to college. His aftercare worker will help him
apply to the local technical college. Other components of his reentry plan
include providing Raymond with an opportunity to participate in Youth as
Resources service projects with other prosocial youth and perhaps to work at
a Boys & Girls Club, where he can combine his athletic interests with his
leadership skills. He will be referred for counseling to help him deal with his
feelings about his relationship with his mother. An important aspect of this
aftercare program is the continuity of the mentoring relationship with the
aftercare worker begun in the facility and continuing into the community.
Source: Adapted from Dr. Roger Jarjoura, director, Aftercare for Indiana
Through Mentoring, personal communication, June 10, 2004. Used with
permission.
542

Summary
Juvenile justice policies and practices are society’s way of confronting and
dealing with behavior beyond the social norms, that is, juvenile
delinquency. The United States historically has vacillated between an
emphasis on punishment and treatment of juvenile delinquents, with
neither approach proving very effective. The juvenile court was
established in 1899 to formally recognize that children were distinct from
adults. However, since then, the vacillation between punishment and
treatment emphases has intensified. To illustrate, the juvenile court has
taken on more of the trappings of the adult system, and the end of the 20th
century produced a wave of “get tough” policies such as zero tolerance and
the increased use of transfers to the adult court, despite a decline in
juvenile crime rates since the late 1990s.
An examination of juvenile justice policy and practice trends reveals little
explicit connection to the research and theory that has grown from the risk
and resilience perspective until very recently. Its impact may finally be
growing, as evidenced by several major policy initiatives. The risk and
resilience framework evolved from two initially separate streams of
research: developmental psychopathology, using epidemiological methods
to identify the causes of youth problem behaviors, and longitudinal studies
of resilience seeking to understand why some people attain positive
developmental outcomes in the face of high risk or adversity. A reasonable
consensus has emerged regarding an array of risk and protective or
promotive factors at various ecological levels—the individual, family,
peers, school, neighborhood, community, and society—that influence the
probability of delinquency and other youth problems.
It is logical to assume that this knowledge can help the juvenile justice
system develop policies and practices that, by reducing risk and enhancing
protection, prevent delinquency or its recurrence. At present, the most
common application of this framework has been the proliferation of risk-
assessment instruments to guide placement or treatment decisions at
various points in the juvenile justice process. This chapter has argued that
despite the impressive aggregate claims of the risk and resilience research,
this risk-assessment approach, although perhaps an improvement over
purely discretionary, clinical judgment, has limitations because it primarily
543

presumes a degree of predictive accuracy at the individual level that does
not exist.
This chapter has presented several promising strategies for incorporating
risk and resilience into the juvenile justice system, including community-
wide prevention initiatives, targeted prevention in schools or with families,
and interventions such as individualized wraparound services and aftercare
programs that aim to work across system boundaries. Truly meaningful
change in juvenile justice policies and practices requires a culture shift in
the way system actors view youth and the goals of the system. This shift
should be based on the ecological risk and resilience framework, pursue
positive youth development goals in addition to the prevention and control
of delinquency, and incorporate a strengths-based, collaborative approach
to practice. This chapter highlighted some recent attempts to transform the
juvenile justice culture, including the explicit adoption of a strength-based,
positive youth development approach in some jurisdictions; the Annie E.
Casey Foundation’s JDAI; and recent national proposals to reform juvenile
justice using concepts of risk, resilience, and developmental science. All of
these strategies include making the boundaries of the juvenile justice
system more permeable through formal collaborations with other
community entities. In this way, the partnering agencies and stakeholders
can reinforce the application of the risk and resilience framework, thereby
enhancing the juvenile justice system’s ability to achieve all three of its
goals: public safety protection, accountability, and competency
development.
544

Questions for Discussion
1. What are the main obstacles to incorporating the principles of risk,
protection, and resilience into juvenile justice policies and practices?
2. In what ways is the strengths perspective compatible with the principles of
risk, protection, and resilience?
3. What are the major factors leading to reforms or modifications of juvenile
justice policies and practices? Which, if any, are most apt to lead to
sustained changes? Why?
4. How do risk and protective factors for juvenile delinquency compare with
those identified for other youth problems, such as substance abuse or poor
school adjustment?
5. Do you think the “Fourth Wave” of juvenile justice reforms emerging in
recent years will spread? Why or why not? If such reforms do become
widely adopted, do you think they will be sustained or be overtaken by a
subsequent round of “get tough” policies and practices?
545

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Wright, E. R., & Anderson, J. A. (2005, September). Sixth annual
evaluation briefing of the Dawn Project Evaluation Study. Indianapolis,
IN: Indiana University, Indiana Consortium for Mental Health Services
Research. Retrieved from
http://www.choicesteam.org/documents/reports/DawnProjectEvaluationBriefing .
Zahn, M. A., Day, J. C., Mihalic, S. F., & Tichavsky, L. (2009).
Determining what works for girls in the juvenile justice system: A
summary of evaluation evidence. Crime & Delinquency, 55, 266–293.
doi:10.1177/0011128708330649
569

http://county.milwaukee.gov/ImageLibrary/Groups/cntyHHS/Wraparound/UNDERSTANDINGRECIDIVISM2011

http://wraparoundmke.com/

http://www.choicesteam.org/documents/reports/DawnProjectEvaluationBriefing

Additional Reading
Bazemore, G., & Walgrave, L. (Eds.). (1999). Restorative juvenile justice:
Repairing the harm of youth crime. Monsey, NY: Criminal Justice Press.
Bernard, T. J., & Kurlychek, M. C. (2010). The cycle of juvenile justice
(2nd ed.). New York: Oxford University Press.
Hamilton, S. F., Hamilton, M. A., & Pittman, K. (2004). Principles for
youth development. In S. F. Hamilton & M. A. Hamilton (Eds.), The youth
development handbook: Coming of age in American communities (pp. 3–
22). Thousand Oaks, CA: Sage.
Howell, J. C. (2003). Preventing and reducing juvenile delinquency: A
comprehensive framework. Thousand Oaks, CA: Sage.
National Research Council. (2013). Reforming juvenile justice: A
developmental approach. Committee on Assessing Juvenile Justice
Reform, R. J. Bonnie, R. L. Johnson, B. M. Chemers, & J. A. Schuck
(Eds.), Committee on Law and Justice, Division of Behavioral and Social
Sciences and Education. Washington, DC: The National Academies Press.
Weiss, G. (2013). The fourth wave: Juvenile justice reforms for the twenty-
first century. New York, NY: Public Interest Projects, National Campaign
to Reform State Juvenile Justice Systems. Retrieved from
http://www.publicinterestprojects.org/wp-content/uploads/2013/09/The-
Fourth-Wave-Long
570

http://www.publicinterestprojects.org/wp-content/uploads/2013/09/The-Fourth-Wave-Long

Web-Based Resources
Annie E. Casey Foundation, http://www.aecf.org/
Building Blocks for Youth, http://www.buildingblocksforyouth.org/
Center for the Study and Prevention of Violence (Blueprints),
http://www.blueprintsprograms.com/
Office of Juvenile Justice and Delinquency Prevention (OJJDP),
http://www.ojjdp.gov/
OJJDP: Model Programs Guide, http://www.ojjdp.gov/mpg
OJJDP: Statistical Briefing Book,
http://www.ojjdp.gov/ojstatbb/default.asp
Washington State Institute for Public Policy,
http://www.wsipp.wa.gov/intro.asp
571

http://www.aecf.org/

http://www.buildingblocksforyouth.org/

http://www.blueprintsprograms.com/

http://www.ojjdp.gov/

http://www.ojjdp.gov/mpg

http://www.ojjdp.gov/ojstatbb/default.asp

http://www.wsipp.wa.gov/intro.asp

Chapter 10 Toward the Integration of
Child, Youth, and Family Policy
Applying Principles of Risk, Resilience,
and Ecological Theory
Jeffrey M. Jenson
Mark W. Fraser
The chapters in this book describe policies and programs aimed at pressing
problems facing American children and their families. These policies—
and the services they have generated—represent a complex array of
legislative, administrative, and judicial responses to social and health
problems affecting children. Identifying and analyzing major policy
responses to the challenges confronted by children and their families is a
difficult undertaking for legislators, governmental officials, judges,
scholars, and other experts. Imagine, then, the confusion experienced by a
child, adolescent, or parent receiving assistance in one or more of the
service systems reviewed in this book. Unfortunately, no road map exists
to guide family members through the labyrinth of programs and agencies
that provide services for children and youth. For many families, what we
call the “service system” is not a system. Rather, it is a maze of programs
and procedures with varying eligibility requirements and service
definitions. In their complexity, these systems too often wind up
compromising the good intentions of advocates, policymakers, and
practitioners.
To try to make sense of public policies in terms of their historical
development and current dimensions, chapter authors have applied a risk
and resilience framework that is grounded in ecological theory. In the
following section, we summarize their findings using the constructs of risk
and protection. The second section outlines a developmental process to
guide the creation and implementation of a logical continuum of policies
and programs for children, youth, and families.
572

Policies and Programs Across Service
Systems
This book has traced the origins and evolution of public policies that
define major American service systems for children, youth, and families.
Chapter authors have used the principles of risk and resilience to describe
and assess policy responses to a range of child and adolescent problems
and conditions. Each chapter began with a review of risk and protective
factors that were relevant to problem behaviors or to conditions within
particular policy domains, such as child welfare and mental health.
Services in the areas of income maintenance, child welfare, developmental
disabilities, education, health, juvenile justice, mental health, and
substance abuse are usually developed vertically, with separate funding
streams and administrative structures; however, the reader is likely to have
been struck by the similarity of risk and protective factors across
substantive domains. Prior reviews of risk and protection have also noted
the overlap of risk and protective factors across problem domains (Fraser,
Kirby, & Smokowski, 2004; Hawkins, Catalano, & Miller, 1992; Jenson &
Bender, 2014; O’Connell, Boat, & Warner, 2009). The similarity of factors
related to different service systems is a clue both to the complexity of
public responses to issues confronting children and families and to the
potential for reform. In Chapter 1, we identified common risk and
protective factors for child and adolescent problems at the environmental,
interpersonal, social, and individual levels of influence. These
characteristics and conditions are ubiquitous across all of the policy
domains discussed in the book.
The presence of common risk and protective factors for different child and
adolescent behaviors and conditions affords a special opportunity to think
organically about creating policies that address the root causes of problem
behaviors. For example, the authors in this volume have indicated that a
number of common environmental factors, such as poverty, poor
parenting, and community disorganization, are associated with juvenile
delinquency, substance abuse, and child maltreatment. It follows, then, that
these risk factors should become the targets of coordinated and integrated
policy and program responses in the juvenile justice, substance abuse, and
child welfare systems.
573

A parallel theme that emerged from each chapter concerned the lack of
attention in policy development that has been afforded to the underlying
correlates of child and adolescent problems. On balance, chapters
described an incremental and reactive approach to the creation of policies
that collect over time to form the basis for programs in public service
systems for children, youth, and families. Policies tend to be the product of
reform cycles that stem from changes in the nature and prevalence of
social and health problems. For example, the rubella epidemic of the mid-
1960s increased the number of children with severe auditory and visual
disabilities. The sudden increase in the population with special needs
contributed to the reform of special education policies; through the
Education for All Handicapped Children Act (PL 94-142) in 1975, public
schools were provided with resources to serve children with disabling
conditions that had once been considered so severe that only institutional
care was thought appropriate. When incidence and prevalence rates
increase dramatically, the attention of the public and policymakers is
diverted to particular service systems or programs. When the prevalence of
problems increases, policy reforms tend to be introduced at a fast pace, but
often without adequate consideration of unintended consequences or long-
term effects.
This pattern of hurried, inadequately considered policy formulation is
common. In Chapter 9, Barton noted the cyclical nature of juvenile justice
policy, which is characterized by a shifting emphasis on rehabilitation and
punishment. This revolving cycle of policy has defined a myriad of
reforms, ranging from the creation of probation in the first juvenile courts
of the early 1900s to recent judicial waiver procedures that permit juvenile
offenders to be tried in criminal courts and exposed to adult sanctions.
Barton noted that officials in the juvenile justice system are currently
debating the merits of policy changes made in the mid-1990s, which led to
a greater emphasis on punishing young offenders. Similarly, Fraser and
Lanier (Chapter 5) identified fluctuations in mental health policy based on
evolving beliefs about the appropriate role of institutional and community-
based care for persons with serious mental illnesses. In addition, Pecora
and Harrison-Jackson (Chapter 3) traced the evolution of child welfare
policy through periods that saw dramatic changes in social norms
regarding child abuse and neglect. Examples of the cyclical and reformist
nature of social policy for children and families are numerous.
Only the naive would not recognize the important contribution of social
574

norms and public perceptions to public policy. After all, legislation is
largely a result of the public’s reaction to social conditions and problems.
The discussion of the No Child Left Behind Act (PL 107-110) provided by
Frey, Mandlawitz, Perry, and Walker in Chapter 4 illustrated the power of
public perception in reshaping education. Public outcry for school reform
and accountability in the past decade are reflected in many provisions of
the act. Similar examples can be drawn from the evolution of public
policies in the antipoverty field (as discussed by Williams Shanks and
Danziger in Chapter 2) and the developmental disabilities field (as
discussed by Parish, Saville, Swaine, and Igdalsky in Chapter 7).
The recent passage of the national Patient Protection and Affordable Care
Act (ACA) (PL 11–148) demonstrates clearly the complexities inherent in
balancing incremental change and public perception. Following 18 months
of deliberation, the U.S. Senate and House of Representatives passed
significant health-care legislation in March 2010. Congressional
deliberations highlighted the tension between legislators who favored
comprehensive reform and legislators who favored incremental change in
health-care policy. Sentiment for comprehensive or incremental reform
was also expressed in public actions taken by members of the medical
profession, health insurance companies, and public interest groups. The
ACA was the product of a long and contentious debate that led to a series
of compromises between officials who held competing views on
comprehensive and incremental change. Key provisions of the legislation
are designed to make health care more affordable and accountable. The bill
bans insurance companies from discriminating against individuals with
preexisting health conditions and provides a means for uninsured people to
obtain health care. Specific provisions of the law will be implemented in
defined phases during the next several years. However, the effects of what
many public officials perceive to be an ill-advised and radical change in
health-care policy will likely be debated—and adjudicated—for many
years. Rounds, Hall, and Huitron discuss initial effects of the ACA on
health-care policies and practices in Chapter 6.
Public policy should be based on the confluence of public concern and
research knowledge. However, the urgency created by public perception
and pressure sometimes precipitates changes that produce reforms with
unintended and negative side effects. When pressured to respond to real or
apparent changes in the nature of a child or adolescent problem behavior,
officials frequently turn to convenient policy solutions that address
575

symptoms but fail to address the underlying risk and protective factors
associated with that problem (Jenson & Bender, 2014). The result of this
process is ineffective, fragmented, and short-lived programs that
sometimes do more harm than good. Arguably the greatest and most
damaging effect is that such programs add to bureaucratic inertia, making
systems more complicated, slower to respond with true reform, and less
fertile for creating innovations.
Few service systems for children, youth, and families have developed a
deliberate or effective continuum of care. Nearly all chapter authors noted
that primary care systems tend to offer a patchwork assortment of
programs and services that are seldom delivered to children and families in
a sequential or rational fashion. One exception might be the
comprehensive strategy for the prevention, treatment, and control of
juvenile delinquency, which was adopted by the juvenile justice system in
the late 1990s. This strategy, developed and disseminated by the Office of
Juvenile Justice and Delinquency Prevention (Howell, 2003; Zavlek,
2005), outlines a continuum of care and graduated sanctions (i.e.,
punishments related to the seriousness of offenses) that many states use as
a framework for handling young offenders. The strategy emphasizes a
continuum of service that matches the individual’s needs, which are often
identified through systematic risk assessment, and the individual’s history
of offending to appropriate interventions and sanctions. Recent studies
indicate that a comprehensive approach to reducing recidivism among
juvenile offenders is effective (e.g., Howell & Lipsey, 2012).
Finally, careful historical analysis reveals that untested and ineffective
policies and programs are repeated over time. One example is the recurring
use of media campaigns as a way to increase awareness about the dangers
of substance use. Anthony, Jenson, and Howard note in Chapter 8 that this
strategy had little effect on reducing substance use in the 1970s and early
1980s. However, recent public awareness of increasing drug use among
adolescents has rekindled interest in media and information campaigns that
alert young people and their parents to the dangers of alcohol and other
illicit drug use. As Anthony and colleagues discussed, this interest is
reflected in the large allocation of federal funds to a national media
campaign in recent years.
Perhaps the most salient point in each author’s historical review of public
policy is the absence of a uniform underlying framework to guide policy
576

development. No common model or framework for policy development
could be found across the eight service systems reviewed by authors. We
believe that principles of risk and resilience—grounded in ecological
theory—offer a useful framework for considering the conditions that affect
children and that, by applying a risk- and protective-factor perspective, we
can better design social programs to address these conditions. Next, we
offer some thoughts on how these principles might be used to develop
policy for children, youth, and families.
577

Risk and Resilience: An Ecological
Perspective for Developing Child, Youth,
and Family Policy
Rooted in ecological theory, principles of risk, protection, and resilience
have been successfully applied to prevention and treatment with children
and adolescents in varied settings. In particular, substance abuse- and
delinquency-prevention programs have been based on risk and protective
factors occurring at levels of influence (e.g., environmental, interpersonal
and individual) that are compatible with ecological theory (Germain,
1991). However, the full utility of risk, protection, and ecological theory
for policy development remains untapped.
Using a risk- and protection-based approach to creating policies for
children, youth, and families requires a step-by-step approach. These steps
are outlined next and summarized in the developmental policy process
shown in Figure 10.1.
578

Step 1: Evaluate Risk and Protective Factors
Policymaking begins with developing an understanding of the risk and
protective factors associated with a targeted child or adolescent problem
behavior. Consistent with ecological theory, factors should be assessed or
summarized at environmental, interpersonal, social, and individual levels.
Chapter authors have reviewed risk and protective factors associated with
each of the problem behaviors and conditions discussed in this book.
Because common risk and protective factors have been identified for many
social and health problems, it may not always be necessary for
policymakers to conduct basic risk or protective factor assessments. In
many fields, research studies already specify predominant risk and
protective factors (e.g., Fraser, 2004; Hawkins, 2006; Herrenkohl, Chung,
& Catalano, 2004; Jenson & Bender, 2014; Woolf, 2008). However,
differences in local environmental conditions may necessitate new
assessments in some circumstances. For example, an urban center may be
concerned about the disproportionate nature of poverty or the needs of
racial/ethnic groups in certain geographic areas. The ways in which risk
and protective factors vary by region, gender, and culture are the subject of
much current research. Although some risk and protective factors are
common, risk factors also clearly vary from the tribal lands of the
mountain and plains states to the urban centers of the East and West
coasts. These differences complicate risk assessment and pose a major
challenge for policymakers.
thinking about policy from a risk and protection perspective offers two
advantages. First, the perspective allows for the use of a common language
across policy domains. This gives policymakers, advocates, practitioners,
and researchers a uniform vocabulary to use in describing related
behaviors, setting program objectives, and assessing program outcomes.
Second, because concepts of risk and protection emerged from research in
several related fields—child development, mental health, prevention
science, and public health in particular—we can build on diverse and
cumulative scientific knowledge. This rapidly expanding knowledge base
holds the potential—as demonstrated in many chapters of this book—to
reform service systems across the country.
579

Step 2: Assign Policy Responsibility in Ways That
Promote Service Integration Across Systems
Policies based on empirical evidence about the risk and protective factors
associated with child and youth problems should be developed and
implemented across the policy arenas addressed in this book. Integrating
key programs and services identified or implied by policies across and
within systems of care should be a priority. Critical questions that should
be considered in the policy development and integration processes include
the following:
1. Which service systems have primary responsibility for the programs
and services defined or implied by the policy?
2. Where does fiscal accountability lie for the programs and services
defined or implied by the stated policy?
3. Does the stated policy explicitly develop links between and within the
major service systems for children, youth, and families?
4. Do adequate implementation resources exist within or across the
primary systems to achieve service integration?
5. How can service systems integrate existing or new program
resources, including staff, physical locations, training curricula, and
evaluation tools and methods?
Figure 10.1 A Developmental Process of Child, Youth, and Family Policy
580

Locating and integrating program components defined by social and health
policies within and across service systems are challenging undertakings.
Collaborative partnerships between executive leadership, administrators,
practitioners, and researchers are necessary to achieve the more fluid
delivery and integration of policies aimed at children, youth, and families.
collaboration between service systems to prevent early and unwanted teen
pregnancy illustrates policy and program efforts aimed at integration. See
the accompanying box.1
A similar example illustrating the positive effects that system collaboration
and integration can have on adolescent behavior is found in efforts to treat
co-occurring substance abuse and mental health problems. Jenson and
Potter (2003) tested an experimental intervention created to fill the
mandate of legislation passed by the Colorado State Legislature. A
legislative note mandated the mental health and juvenile justice systems to
find innovative ways to treat co-occurring substance use and mental health
problems among young offenders. The state systems responded by
assessing risk and protective factors for adolescent substance abuse and
mental health problems. An intervention was designed to place mental
health case managers in juvenile justice facilities. Jenson and Potter
conducted a longitudinal investigation of the program and found that the
youth who received the intervention reported significant reductions in their
levels of depression, anxiety, and substance use. This type of cross-system
integration holds promise for reducing child and adolescent problem
581

behaviors. Studies showing positive outcomes resulting from coordinated
interventions involving systems from mental health, health, juvenile
justice, and substance abuse domains illustrate the potential of social
policies supporting programs that cross traditional boundaries (Finkelstein
& Markoff, 2004; Graves, Frabutt, & Shelton, 2007; Kaufman et al.,
2006). These findings are encouraging because they indicate that we are
beginning to recognize the benefits of policies, programs, and services that
use coordinated and collaborative efforts.
582

The Value of Collaboration and Integration:
The Case of Early and Unwanted Teen
Pregnancy
Early and unwanted adolescent pregnancy rates fell by 24% between 1996
and 2001 (Centers for Disease Control and Prevention, 2002). The decline,
although likely influenced by a host of factors, was partially attributed to
improvements in the coordination of policies and programs between the
nation’s health-care and educational systems. This collaborative effort
included:
The systematic dissemination of information by public health
departments, government agencies, and schools aimed at educating and
creating awareness among the public about the high rates of adolescent
pregnancy in the United States.
The implementation of school-based prevention efforts aimed at
delaying the onset of adolescents’ sexual activity and educating
students about the risks associated with unprotected sex.
The creation of school-based health clinics to reach adolescents who
might not have access to medical care and thus were likely to be at
highest risk for early and unwanted pregnancy.
The allocation of targeted federal, state, and local funds to establish
community-based health clinics that educate young men and women at
risk for early, unwanted pregnancy and offer treatment for young
families.
The decline in adolescent pregnancy rates came at a time of increased
collaboration between the nation’s health-care and educational systems. This
successful collaboration demonstrated the potential of policy and program
integration for reducing child and adolescent problems.
583

Step 3: Use Evidence to Create Public Policy
Responses
Empirical evidence gained from studies of risk and protective factors
should be used to create child, youth, and family public policies.
Developing evidence-based policy, or at least evidence-informed policy,
will require the dissemination of aggregate-level information about the
etiology of child and adolescent problems to policymakers during the
deliberation processes that lead to the creation of public policy. A critical
step in dissemination is translating the empirical evidence in a manner that
is immediately useable and practical for legislators and policy experts.
Recent developments in evidence-based practice (EBP) offer an
opportunity to advance the notion of creating policies for children and
families from an empirical framework. In the 1990s, EBP evolved in the
medical profession from a concept to a movement to a professional
imperative aimed at helping physicians select effective treatments for their
patients. Definitions and perceptions of what EBP is—and what it is not—
vary widely. In what is arguably the most accepted definition of EBP,
Sackett and colleagues (Sackett, Straus, Richardson, Rosenberg, &
Haynes, 2000) stated that EBP is “the integration of best research evidence
with clinical expertise and [client] values” (p. 1). This definition implies
that EBP is a process, characterized by specific steps and actions that
require practitioners to locate, select, and implement the best available
interventions for a targeted group or population.
An important parallel exists between the essential steps of EBP and the
policy making process as illustrated in Figure 10.1. In both processes, the
identification of risk and protective factors associated with specific
problems lead to the design, selection, and testing of individual and social
interventions. In an ideal setting, the best available interventions—
meaning those with strong research evidence supporting their effectiveness
—are then translated to broad-based social policies aimed at improving the
lives of children and families.
Unfortunately, relatively few effective interventions manage to navigate
the difficult path from implementation to policy. One recent exception is
the Nurse-Family Partnership Program developed by David Olds and
colleagues (Olds, Henderson, Tatelbaum, & Chamberlin, 1986). Aimed at
584

guiding low-income mothers and their firstborn children toward successful
futures, the program offers intensive home-visitation services during a
woman’s pregnancy and for 2 years after the birth of a first child.
Controlled trials of the intervention have demonstrated positive effects in
preventing child maltreatment and reducing maternal arrests (Olds et al.,
2014). In addition, other evaluation studies have demonstrated reductions
in child and adolescent conduct problems (Olds et al., 2009; Olds et al.,
2010). More important, the program has recently been adopted by
Colorado, among several other states, as part of a required set of
interventions aimed at helping vulnerable young women and their families.
The successful translation of evidence gained from intervention trials of
the Nurse-Family Partnership to specific child and family policy may
provide a template for other systems of care discussed in this book.
585

Step 4: Determine the Course of Specific Individual
and Social Interventions
To determine the course of individual and social interventions, policy
officials should consider evidence that identifies evidence-based programs
and services for children and adolescents. Policy creation that integrates
principles of risk, resilience, and EBP requires a comprehensive review of
empirical evidence about the efficacy of alternative intervention
approaches. In essence, determining the appropriate course of social
intervention begs the old question, “What works best for whom under what
conditions?”
Several outlets have surfaced as sources for obtaining information about
effective interventions for children and youth. In Chapter 1, we noted the
work of the University of Colorado’s Center for the Study and Prevention
of Violence. The center has identified a number of efficacious prevention
programs that can be selected as the basis for a community or state’s
violence-prevention efforts (Center for the Study and Prevention of
Violence, 2014). Similarly, the Substance Abuse and Mental Health
Services Administration (2014) maintains the National Registry of
Evidence-Based Programs and Practice, a comprehensive list of effective
substance abuse and mental health programs. The Coalition for Evidence-
Based Policy (2014) has compiled a compendium of early childhood,
educational, and youth development programs that have been found
effective in preventing violence and other childhood and adolescent
problems. In addition, interdisciplinary groups such as the international
Campbell and Cochrane Collaborations have provided public worldwide
access to systematic reviews of the literature on treatment outcomes across
a range of adolescent problems. These reviews offer a rich source of
information for policy officials who are engaged in the process of
recommending or selecting interventions for public systems of care
(Campbell Collaboration Library, 2014; Cochrane Collaboration, 2014).
Decision makers are beginning to consider both program and cost-
effectiveness when selecting interventions and creating policies for
children and families. Historically, practitioners and policy officials have
had little credible empirical evidence regarding the costs and benefits of
social interventions to guide their decisions about which programs to select
or to fund. Fortunately, this situation is changing through work conducted
586

by numerous research teams, such as Aos and colleagues at the
Washington State Institute for Public Policy (Aos, Lieb, Mayfield, Miller,
& Pennucci, 2004; Lee, Aos, Drake, Pennucci, Miller, & Anderson, 2012).
These researchers reviewed the benefits and costs of a wide range of
prevention programs aimed at problems such as aggression, delinquency,
school failure, and substance abuse. All of the programs included in their
review had been previously tested in research using either an experimental
design or a well-constructed quasi-experimental design. Findings from the
study showed that some prevention programs yielded cost savings and
effectively prevented or delayed the onset of problem behaviors. Equally
important, Aos and associates produced tangible evidence in the form of a
benefit-per-dollar cost figure for early childhood, prenatal and infant home
visitation, youth development, mentoring, substance abuse, teen
pregnancy, and juvenile offender programs. Benefits were greatest for
juvenile offender programs. In these programs, the cost savings ranged
from $1,900 to more than $31,000 per participant. Substantial benefits
were also found among prenatal and infant home visitation programs,
ranging from $6,200 to $17,200 in savings per individual youth. In
addition, early childhood education programs and selected youth
development programs were shown to produce significant benefits. The
cost-saving figures generated by the Aos team point both to the importance
of investing in effective programs and to the danger of funding ineffective
programs. Policymakers and other decision makers are well advised to
consider the findings and to implement the recommendations consistent
with the growing evidence base. To make better use of the research
literature on the effectiveness of interventions for children and adolescents
(for a review, see Allen-Meares & Fraser, 2004) and to implement the kind
of collaborative programs the authors have described in every chapter will
require state and local officials to find ways of breaking down
organizational barriers. In addition, policymakers will need to break
through institutional isomorphism and exert leadership in overcoming the
turf issues that have confounded previous reform efforts (e.g., the
implementation of the Children’s and Community Mental Health Services
Improvement Act of 1992, which attempted to create systems of care
within mental health). Unfortunately, many of the nation’s educational
systems, human services agencies, and state and community organizations
fail to consider, select, or implement tested or effective programs. There
continues to be a significant gap between what we know to be effective in
preventing and treating childhood and family problems and what programs
are actually implemented; this gap must be narrowed (Fixsen, Naoom,
587

Blasé, Friedman, & Wallace, 2005). Policymakers should be encouraged
to pay greater attention to the benefits gained by implementing proven and
tested programs. Perceived barriers associated with replicating and
implementing effective program strategies must be eliminated.
588

Step 5: Implement, Monitor, and Evaluate Policies
and Interventions
The development of collaborative systems of care will also require greater
emphasis on monitoring and evaluating the interventions. The energy and
enthusiasm associated with reforms must be converted into systemic
procedures that monitor the implementation of new programs, provide
feedback, and articulate consequences for failed or inconsistent
implementation. This level of accountability implies using fidelity checks
to ensure that interventions are being implemented as intended, conducting
cost–benefit analyses to assess the economic consequences of programs
and policies, and assessing child, youth, and parent outcomes. Monitoring
and evaluation allow legislators and others to determine the outcomes of
policies and programs; effective efforts can be re-funded, and ineffective
approaches can be redesigned.
589

Summary
In this book, we have suggested that this country needs a new framework
for child, youth, and family policy. Specifically, we have argued that a risk
and resilience model, grounded in principles of ecological theory, offers
potential for creating policies and programs that will lead to effective
interventions for the problems that confront children and families in
America.
The time is ripe for a new paradigm that will focus on the developmental
processes—both risk and protective—related to the social and health
problems that public policies are intended to address. Opinion polls
assessing public willingness to fund early intervention and rehabilitation
programs for children and youth have shown strong support for
collaborative and community-based efforts (Baker, Metcalfe, Berenblum,
Aviv, & Gertz, 2014; National Council on Crime and Delinquency, 2007).
Advances in strengths-based practice, assets-oriented programming, and
positive youth development have emerged, and they complement the risk,
protection, and resilience framework set forth in this volume (Catalano,
2007; Maton, Schellenbach, Leadbeater, & Solarz, 2004). Although more
research is needed to better understand the interactive processes inherent in
these approaches, the potential of the risk and resilience model for policy
development should not be understated. Finally, recent trends in the
acceptance of evidence-based practice have brought researchers and policy
experts together in ways that were unseen in past years.
The principles of risk and resilience arose from research on developmental
psychopathology and prevention science. Major advances have occurred in
these fields in the articulation of the developmental trajectories of children
who drop out of school, become delinquent, use illicit substances,
experience serious emotional disorders, or have other poor developmental
outcomes. At the same time, this knowledge has been used to design
effective prevention programs, many of which have been described in the
previous chapters. These programs attempt to reduce risk, strengthen
protection, and alter developmental trajectories. Findings from these
programs are promising (Dodge, 2009; Jenson & Bender, 2014).
In the glow of promise from these programs, we ask, “Is it adequate to
590

construct policy on the basis of risk factors alone?” We think risk
reduction alone is an insufficient goal for public policy, although
achieving risk reduction would be a significant step forward. It is the hope
incumbent in the concept of resilience—where children at high risk prevail
over adversity—that gives us pause. One driving force behind policy
development must clearly be a moral imperative to reduce risk. However,
from resilient children, we learn that risk reduction is defined, in part, by
strategies that ameliorate or buffer adversities. In studying these protective
processes, we often find that what protects children at risk also serves to
promote positive developmental outcomes for all children (e.g., Fraser,
2004; Jenson, Alter, Nicotera, Anthony, & Forrest-Bank, 2013).
From this perspective, public policy for children and youths should be
guided by attempts toward reducing risk while promoting protection. For
all children (including those at risk), public policy should promote
competence in social and academic settings, confidence in interpersonal
relationship, and a self-efficacy in making life-course decisions. In
addition, child policy should seek to foster connections to others who
provide support and mentoring, the development of character or moral
integrity regarding right and wrong behaviors, and feelings of caring or
compassion for others who may be less fortunate (Catalano, Berglund,
Ryan, Lonczak, & Hawkins, 2004; Catalano, Hawkins, Berglund, Pollard,
& Arthur, 2002; Lerner, Almerigi, Theokas, & Lerner, 2005; Lerner,
Fisher, & Weinberg, 2000). Too often, policy development is influenced
by changes in problem rates or by catalyzing events such as epidemics or
disasters. Of course, it is important to respond when rates rise or events
create great need. However, public policy for children and youth should be
proactive rather than reactive. It should promote protective processes that
nurture developmental outcomes for all children, but especially those at
great risk. In the sense of Healthy People 2020 (U.S. Department of Health
and Human Services, 2010), the intent of public policy for children, youth,
and families should extend beyond the prevention of delinquency,
substance abuse, or other social and health problems. Rather, the intent of
policy should express health-promoting societal goals related to positive
developmental outcomes for all children and the creation of widely
accessible means for achieving those outcomes. Although highly
structured and focused programs may always be needed to help children
who have special needs (e.g., children who are victimized by individual
disadvantage or tragic events), public policy for children should be rooted
in core commitments that strengthen families, improve schools, and
591

reinvigorate neighborhoods.
Much remains to be done to solve the fragmented nature of child, youth,
and family policy in the United States. Individual service systems employ
skilled practitioners, and each system can point to exemplary programs
and innovative service delivery patterns. Despite those examples, child,
youth, and family policies continue to suffer from the lack of an
underlying and unifying framework that integrates services across problem
domains and creates fully articulated systems of care. A risk and resilience
perspective, coupled with ecological theory, holds promise as an
organizing framework for future public policy efforts directed at the
nation’s young people. It is their future and our challenge.
592

NOTE
1. Biglan, Brennan, Foster, and Holder (2004) used a similar format with a
different example to demonstrate the importance of collaboration in
developing strategies for working with high-risk youth.
593

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Index
Abandoned Infants Assistance Act (1988), 75
Above the Influence campaign, 241
Academic failure:
adolescent substance abuse, 231
delinquent behavior, 264t, 267
gender differences, 98, 99t
graduation rates, 98, 99t
promotive factors, 99–100, 101t
protective factors, 99, 101t
racial/ethnic populations, 98, 99t
risk factors, 99, –100
trends, 6, 97–98
See also Education policy
Accountability in education, 105t, 111, 113, 115, 121n1, 299
Achievement gap, 107–108
Adaptation, 13
Adjudication, 259
Adolescent pregnancy, 304
Adolescent substance abuse:
academic impact, 231
assessment policy, 244–245
discussion questions, 248–249
drug courts, 247
early drug policy, 235
environmental protective factors, 232t, 233
environmental risk factors, 230–231
etiology of, 229–234
federal policy initiatives, 240–242
federal policy resources, 238f
gender differences, 228–229
individual protective factors, 232t, 233–234
individual risk factors, 230t, 231–232
Internet resources, 241, 255
interpersonal protective factors, 232t, 233
interpersonal risk factors, 230t, 231
law enforcement role, 237–239
600

legislative history, 235–237
policy continuum, 244
policy development, 235–244
policy development (1960–1980), 235–236
policy development (1980–2000s), 237
poverty impact, 231
prevention case example, 245–246
prevention programs, 14, 239–240, 245–246
protective factors, 232–234
racial/ethnic populations, 229, 247
resilience, 234
risk factors, 230–232
risk-protection-resilience model, 235–244
service integration, 244–247
social protective factors, 232t, 233
social risk factors, 230t, 231
theoretical frameworks, 14
treatment case example, 248
treatment programs, 242–244, 246–247
usage trends, 6–7, 228–229
Adoption and Safe Families Act (1997), 58, 74
Adoption Assistance and Child Welfare Act (1980), 72
Adoption Incentive Program, 74
Adoption Promotion Act (2003), 74
Adoption Reform Act (1978), 73, 75
African Americans:
achievement gap, 107–108
adolescent substance abuse, 229
asthma, 171t, 172
child demographics, 53t
child welfare policy, 79–80
delinquent behavior, 261, 268
education policy, 102t, 107, 116
graduation rates (2010–2012), 98, 99t
low birth weight (LBW), 170, 171t
overweight/obesity, 171t, 173
poverty, 23f, 24–25, 26–27
single-parent households, 53t
with disabilities, 201, 204, 214–215
AIDS, 14, 176
601

Aid to Dependent Children (ADC), 31
Aid to Families with Dependent Children (AFDC), 31, 73, 210
Alcohol, Drug, and Mental Health Administration Appropriations Act
(1984), 141t
Alternative planned living arrangement (APLA), 79
American Academy of Pediatrics, 185, 242
American Medical Association, 236
American Psychiatric Association, 126
American Psychological Association, 145
American Recovery and Reinvestment Act (2009), 32–33, 39, 106t,
114, 181t
America 2000, 104t
A Nation at Risk (1983), 104t, 109–110
Annie E. Casey Foundation, 41, 259t, 280
Anti-Drug Abuse Acts (1986/1988), 236t, 237
Antipoverty programs:
cash assistance, 31, 33, 34t, 36t
child care, 32, 35t
discussion questions, 43
employment assistance, 31, 32–33, 36t
food assistance, 31–32, 34t
global comparison, 37, 42
Great Recession (2007–2009), 38–40
historical development, 31–38
housing assistance, 33, 34t, 35t
Internet resources, 34–36t, 50
program participation (1965–2012), 37f
savings accounts, 33, 37, 41–42
service integration, 40–42
tax credit, 32, 35t
See also Poverty
Anxiety, 127–128
Asian Americans:
child demographics, 53t
overweight/obesity, 173
poverty, 23f
single-parent households, 53t
Assets for Independence Act (1998), 33
Asthma, 171t, 172–173
Attachment theory, 61
602

Attention deficit and hyperactivity (ADHD), 127t, 128–129
Balanced Budget Act (1997), 182
Behavioral Severity Assessment Program (BSAP), 82t
Bell, Terrel, 109
Blueprints for Violence Prevention (Center for the Study and
Prevention of Violence), 274
Boys & Girls Club of America, 282–283
Breed v. Jones (1975), 258t
Brown v. Board of Education of Topeka, Kansas (1954), 102t, 107,
116
Bush, George W., 104t, 239
Campbell Collaboration, 245, 305–306
Carter, Jimmy, 137
Cash assistance:
antipoverty programs, 31, 33, 34t, 36t
income transfer programs, 209–211, 217t
savings accounts, 33, 37, 41–42
Cedar Rapids Community School District v. Garret F. (1999), 213
Center for Substance Abuse Prevention, 243
Center for Substance Abuse Treatment, 243
Center for the Study and Prevention of Violence (University of
Colorado), 245, 274, 305
Centers for Disease Control and Prevention (CDC), 153
Central Provident Fund (Singapore), 42
Chafee Independent Living Program, 73
Child Abuse CAPTA Reauthorization Act (2010), 75
Child abuse/neglect:
child demographics, 53–54t
children with disabilities, 205–206, 208t
Child Welfare Demonstration Projects, 52, 86n3
child well-being outcome, 58, 60t
community protective factors, 64t, 69t
community risk factors, 64t
developmental theories, 61
ecological theory, 61
epigenetic change factors, 61, 87n5
family well-being outcome, 58, 60t
federal outcome standards, 58–60
603

foster care, 52, 56–57
grandparent caregivers, 53–54t, 64, 87n7
individual protective factors, 63t, 69t
individual risk factors, 63t
Internet resources, 59
maltreatment defined, 56
maltreatment risk factors, 62–66
maltreatment trends, 51, 86n1
outcome domains, 57–60
out-of-home placements, 52, 56–60
parental/family protective factors, 63–64t
parental/family risk factors, 63–64t
permanency roundtable (PRT), 52, 86n4
permanent placements, 57–58, 59–60t
poverty impact, 54t, 64, 68, 87n8
protective factors, 63–64t, 67–70
racial/ethnic demographics, 53t
racial/ethnic placements, 56–57
racial/ethnic protective factors, 66–67, 68, 70
relationship protective factors, 69t
resilience factors, 66–67
risk factors, 62–66
risk-protection-resilience model, 61, 62–70
safety outcomes, 57, 59t
service goals, 52, 55–60
social learning theory, 61–62
social support theory, 62
system approach, 55
theoretical frameworks, 60–62
See also Child welfare policy
Child Abuse Prevention and Treatment Act (1974), 71, 73, 75
Child and Adolescent Network, 151
Child And Adolescent Service System program (CASSP), 137–138
Child and Family Services Review, 59
Child care, 32–33, 35t
Child Care and Development Block Grant (CCDBG), 32, 35t
Childhood schizophrenia, 127t, 129
Child-Parent Centers (Chicago), 153
Children’s and Community Mental Health Services Improvement Act
(1992), 138–140, 142t
604

Children’s Bureau (1912), 179, 180t
Children’s Health Insurance (CHIP), 168, 178, 242, 243
Children’s Health Insurance Program Reauthorization Act (2009),
181t, 183
Children’s Mental Health Initiative (1992), 138–139
Children’s Mental Health Services Act (California, 1992), 150
Children with disabilities:
abuse/neglect impact, 205–206, 208t
case example, 218–219
costs of, 205–207
developmental delay, 202
developmental disabilities, 202
discussion questions, 221
early childhood interventions, 211–215, 217t
education policy, 211–215, 217t
education policy (1975), 71–72, 103t, 109, 141t, 211–212, 214,
217t, 298
education policy (1990), 72, 104t, 110, 211, 217t
education policy (1997), 105t, 111, 115
education policy (2004), 105t, 111–112, 211, 213, 214, 216, 218
family support services, 215–216, 217t
gender differences, 201
impairment, 203–204
income transfer programs, 209–211, 217t
individualized education plan (IEP), 211, 212–215, 217t
Internet resources, 226
least restrictive environment placement, 212
maternal and child health, 215, 217t
policy recommendations, 220
poverty impact, 201, 204–205, 208t
prevalence of, 202–203
protective factors, 207–208
racial/ethnic populations, 201, 204, 214–215
risk factors, 204–205, 208t
risk-protection-resilience model, 208–211
service integration, 216, 218–220
social isolation of, 206, 208t
social model of disability, 203–204
supportive services, 206–207, 208t
theoretical frameworks, 203–204
605

Children with special health care needs, 169
Child Trust Fund (United Kingdom), 42
Child Welfare Demonstration Projects, 52, 86n3
Child welfare policy:
case example, 83–85
challenges of, 76–81
discussion questions, 86
Internet resources, 71–76, 77, 96
legislative history, 71–76
policy development (1970s), 71–72
policy development (1980s), 72–73
policy development (1990s), 73
policy development (2000s), 74–76
racial/ethnic populations, 79–80
risk-protection-resilience model, 70–71
service integration, 81–83
See also Child abuse/neglect
Chlamydia, 175, 176
Civil Rights Act (1964), 112
Civil Rights Movement, 108
Clinton, Bill, 31
Coalition for Evidence-Based Policy, 305
Cochrane Collaboration, 245, 305–306
Coleman, J.S., 108
College and career readiness, 113–114
Common Core State Standards (CCSS), 114
Communities That Care (CTC), 14, 245–246, 281
Community Mental Health Center Act Amendments (1965/1975),
141t
Community mental health centers, 136–137
Community protective factors, delinquent behavior, 265t, 267–268
Community risk factors:
academic failure, 100t
delinquent behavior, 265t, 267–268
Comprehensive Community Mental Health Services for Children and
Their Families, 138–139, 143
Comprehensive Drug Abuse Prevention and Control Act (1970), 236
Compulsory School Attendance Act (1852), 102t
Conduct disorder, 127t, 128
606

Dawn Project (Indianapolis), 279–280
Deficit Reduction Act (2005), 142t, 180t, 210
Delinquent behavior:
academic protective factors, 264t, 267
academic risk factors, 264t, 267
community protective factors, 265t, 267–268
community risk factors, 265t, 267–268
court caseloads, 261–262
crime data, 261
family protective factors, 264t, 266
family risk factors, 264t, 266
gender differences, 261, 268–269
individual protective factors, 263, 264t, 265–266
individual risk factors, 263, 264t, 265–266
poverty impact, 267
prevalence and trends, 260–262
promotive factors, 263, 264–265t
protective factors, 262–270
racial/ethnic populations, 261, 268
risk factors, 262–270
social protective factors, 264t, 266–267
social risk factors, 264t, 266–267
See also Juvenile justice policy
Denmark, 37
Dental health care, 189
Depression, 127t, 128
Developmental delay, 202
Developmental disabilities, 202
Dewey, John, 107
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-V), 126
Differential association theory, 14
Disabilities. See Children with disabilities
Dodd, Christopher J., 156
Domenici, Pete, 156
Drug abuse. See Adolescent substance abuse
Drug courts, 247
Drug-Free Communities Program, 240
Dysthymia, 127t, 128
607

Early and Periodic Screening, Diagnosis, and Treatment Program,
181–182, 243
Early childhood interventions:
children with disabilities, 211–215, 217t
education policy, 110–111, 113, 118
mental health policy, 152–153
Early Head Start-Child Care Partnership, 113
Earned Income Tax Credit (EITC), 32, 35t
Eating disorders, 127t, 129
Ecological theory:
child abuse/neglect, 61
common service themes, 298–300
evidence-based practice (EBP), 304–305
intervention evaluation, 307
policy development model, 302f
protective factor evaluation, 301
risk factor evaluation, 301
risk-protection-resilience model, 15–16, 300–307
service cost-benefit analysis, 306
service integration, 301, 303
specific interventions, 305–306
teen pregnancy, 304
Eddings v. Oklahoma (1982), 258t
Education for All Handicapped Children Act (1975), 71–72, 103t,
109, 141t, 211–212, 214, 217t, 298
Education policy:
academic promotive factors, 99–100, 101t
academic protective factors, 99, 101t
academic risk factors, 99–100
accountability, 105t, 111, 113, 115, 121n1, 299
case example, 119
children with disabilities, 211–215, 217t
college and career readiness, 113–114
discussion questions, 120–121
early childhood education, 110–111, 113, 118
early public policy, 101, 107
graduation rates (2010–2012), 98, 99t
grant programs, 114
high-stakes assessment, 114
individualized education plan (IEP), 211, 212–215, 217t
608

Internet resources, 124
least restrictive environment placement, 212
legislative trends, 100–101, 102–106t, 107–114
policy trends (1852–2010), 102–106t
policy trends (1930–1970), 107–109
poverty and, 108–109
promotive interventions, 116–117
racial/ethnic populations, 102t, 106t, 107–108, 112
risk-protection-resilience model, 115–116
role of, 117–120
school choice, 113
school funding, 117–118
school violence, 110
segregation, 102t, 103t, 107, 109, 116
service integration, 116, 119–120
standards, 114
See also Academic failure; Children with disabilities
Education Training Voucher (ETV), 73
Eighteenth Amendment, 236t
Eighth Amendment, 258t, 259t
Electronic benefit transfer (EBT) cards, 31–32
Elementary and Secondary Education Act (1965), 103t, 108–109
Employment assistance, 31, 32–33, 36t
Enculturation, 117
Environmental protective factors:
adolescent substance abuse, 232t, 233
risk-protection-resilience model, 12t
Environmental risk factors:
adolescent substance abuse, 230–231
mental health disorders, 131–134
poverty, 30
risk-protection-resilience model, 10t
Epigenetic change, 61, 87n5
Equality of Educational Opportunity (Coleman), 108
Essentials for Childhood, 153
Evidence-based practice (EBP):
ecological theory, 304–305
juvenile justice policy, 274–276
mental health policy, 145–146
609

Family Educational Rights and Privacy Act (1974), 76
Family protective factors:
delinquent behavior, 264t, 266
mental health disorders, 135t
Family risk factors:
academic failure, 100t
delinquent behavior, 264t, 266
mental health disorders, 131t
Family Violence Prevention and Services Act, 73, 75
Federation of Families for Children’s Mental Health, 151
Female-headed households, 24f
Finland, 37
Food assistance programs, 31–32, 34t
Food insecurity, 28
Fort Bragg, North Carolina, 144–145
Foster care, 52, 56–57, 73
Foster Care Independence Act (1999), 73
Fostering Connections to Success and Increasing Adoptions Act
(2008), 74, 80
Fourteenth Amendment, 112
Fourth Wave, The (National Campaign to Reform State Juvenile
Justice Systems), 259t
Gay, lesbian, bisexual, transgendered youth, 80
Gender differences:
adolescent substance abuse, 228–229
children with disabilities, 201
delinquent behavior, 261, 268–269
graduation rates (2010–2012), 98, 99t
health conditions, 175, 176–177
mental health disorders, 130, 131t, 133–134
Generalized anxiety disorder, 127
Global antipoverty programs, 37, 42
Goals 2000, 104t
Gonorrhea, 175, 176
Good Neighborhoods Initiative (Detroit), 41
Graham v. Florida (2010), 259t
Grandparent caregivers, 53–54t, 64, 87n7
Great Debate, The, 108
Great Recession (2007–2009), 38–40
610

Guided group interaction model, 272
Gun-Free Schools Act (1994), 110
Halbig v. Burwell, 183
Harlem Children’s Zone (New York City), 40–41
Harrison Narcotics Act (1914), 235, 236t
Head Start Act (1965), 103t, 108, 110–111
Health conditions:
asthma, 171t, 172–173
gender differences, 175, 176–177
low birth weight (LBW), 169–172
multiple births, 172
overweight/obesity, 171t, 173–174
poverty impact, 172, 174
prevalence rates, 171t
protective factors, 177–178
racial/ethnic populations, 170, 171t
risk factors, 169–177
sexual behavior, 176–177
sexually transmitted infections (STIs), 174–177
very low birth weight (VLBW), 169–170
Health insurance, 168, 178, 184
Health policy:
accessibility dimensions, 167
behavioral health care, 188
case example, 190
children with special health care needs, 169
current U.S. status, 167–168
dental health care, 189
discussion questions, 191
education and prevention services, 188
health insurance availability, 168, 178, 184
Internet resources, 200
legislative history, 180t
legislative impact, 167–168
mental health care, 188
Patient-Centered Medical Home (PCMH), 168, 184–185, 187
policy development, 179–183
primary care services, 187
reproductive health care, 188
611

School-Based Health Center (SBHC), 186–190
service integration, 186–189
sexual behavior, 185–186
system organization, 168
Healthy People 2020, 185
Healy, William, 136
Herpes simplex virus, 175
Higher Education Act, 79
Higher Education Opportunity Act (2008), 79
High school graduation rates (2010–2012), 98, 99t
High-stakes assessment, 114
Hispanics:
adolescent substance abuse, 229
asthma, 171t, 172
child demographics, 53t
child welfare policy, 79–80
delinquent behavior, 261, 268
graduation rates (2010–2012), 98, 99t
low birth weight (LBW), 170, 171t
overweight/obesity, 171t, 173
poverty, 23f, 24–25, 26–27
single-parent households, 53t
with disabilities, 204, 214–215
HIV, 175, 176
Home and Community Based Alternatives to Psychiatric Residential
Treatment Facilities Medicaid
Demonstration Waiver (2005), 142t, 217t
Home-visiting program, 152
Hope VI, 33, 35t
Housing assistance, 33, 34t, 35t
Hull House Association, 136
Human papillomavirus, 175
Impairment, 203–204
Improving America’s Schools Act (1994), 104–105t, 110
Incarceration system, 271–272
Income-threshold measure, 23
Income transfer programs, 209–211, 217t
Independent Living Initiative, 72–73
Indian Child Welfare Act (1978), 72
612

Individual Development Account (IDA), 33, 37, 41–42
Individual Family Support Plan (IFSP), 220
Individualized education plan (IEP), 211, 212–215, 217t
Individual promotive factors, academic failure, 101t
Individual protective factors:
academic failure, 101t
adolescent substance abuse, 232t, 233–234
child abuse/neglect, 63t, 69t
delinquent behavior, 263, 264t, 265–266
mental health disorders, 135t
risk-protection-resilience model, 12t
Individual risk factors:
academic failure, 100t
adolescent substance abuse, 230t, 231–232
child abuse/neglect, 63t
delinquent behavior, 263, 264t, 265–266
mental health disorders, 131t
risk-protection-resilience model, 10t
Individuals with Disabilities Education Act:
1990, 72, 104t, 110, 211, 217t
1997, 105t, 111, 115
Individuals with Disabilities Education Improvement Act (2004),
105t, 111–112, 211, 213, 214, 216, 218
In re Gault (1967), 257t
In re Winship (1970), 257t
Intensive Aftercare Program (IAP), 282–283
Internet resources:
adolescent substance abuse, 241, 255
antipoverty programs, 34–36t, 50
child abuse/neglect, 59
children with disabilities, 226
child welfare policy, 71–76, 77, 96
education policy, 124
health policy, 200
juvenile justice policy, 296
mental health policy, 146, 166
Interpersonal protective factors:
adolescent substance abuse, 232t, 233
risk-protection-resilience model, 12t
Interpersonal risk factors:
613

adolescent substance abuse, 230t, 231
poverty, 28–29
risk-protection-resilience model, 10t
Investing in Innovation, 114
Jackson v. Hobbs (2011), 259t
Jobs and Growth Tax Relief Reconciliation Act (2003), 180t
Job-training programs, 33
Juvenile Delinquency Prevention and Control Act (1968), 257t
Juvenile Detention Alternatives Initiative, 259t, 280
Juvenile Justice and Delinquency Prevention Act (1974), 71, 74, 257t,
258t
Juvenile justice policy:
adjudication, 259
aftercare programs, 282–284
agency culture, 276–279
balanced approach, 258t
case example, 283–284
comprehensive strategy, 258t
cost-benefit analysis, 274–275
cost-effective programs, 275t
discussion questions, 285
evidence-based practice (EBP), 274–276
guided group interaction model, 272
historical development, 256–260
incarceration system, 271–272
Internet resources, 296
intervention programs, 279–284
juvenile defined, 259–260
parents patriae, 257t
positive peer culture model, 272
prevention programs, 281–282
reform efforts, 273–274
restorative justice, 258t, 273
risk-protection-resilience model, 271, 273–279
zero-tolerance, 258t
See also Delinquent behavior
Juvenile Psychopathic Institute, 136
Keeping Children and Families Safe Act, 73
614

Kennedy, Edward M., 156
Kennedy, John F., 136
Kent v. United States (1966), 257t
Kinship navigators, 80
Knitzer, J., 137, 155
Law enforcement, 237–239
Least restrictive environment, 212
Life-course development, 15–16
Low birth weight (LBW), 169–172
MacArthur Foundation, 79
Major depressive disorder, 127t, 128
Mann, Horace, 107
Marijuana Tax Act (1937), 236t
Massachusetts Compulsory School Attendance Act (1852), 107
Maternal, Infant, and Early Childhood Home Visiting, 142t, 152
Maternal and Child Health Services Block Grant, 179, 180t, 184–185,
215, 217t
McKeiver v. Pennsylvania (1971), 257t
Medicaid, 78, 79, 140, 168, 178, 180t, 181, 182, 242, 243
Mental health care, 188
Mental health disorders:
anxiety, 127–128
attention deficit and hyperactivity (ADHD), 127t, 128–129
biological risk factors, 130–131
childhood schizophrenia, 127t, 129
conduct disorder, 127t, 128
depression, 127t, 128
diagnostic categories, 126–129
dysfunctional parenting impact, 132–133
dysthymia, 127t, 128
eating disorders, 127t, 129
environmental risk factors, 131–134
extrafamilial protective factors, 135t
extrafamilial risk factors, 131t
family management impact, 133
family protective factors, 135t
family risk factors, 131t
gender differences, 130, 131t, 133–134
615

generalized anxiety disorder, 127
individual protective factors, 135t
individual risk factors, 131t
life events impact, 133
major depressive disorder, 127t, 128
obsessive-compulsive disorder (OCD), 127–128
oppositional defiant disorder (ODD), 127t, 128
phobias, 127
posttraumatic stress disorder (PTSD), 127t, 128
poverty impact, 131–132
prevalence rates, 127t
protective factors, 134–135
risk factors, 130–134
risk-protection-resilience model, 129–130
separation anxiety disorder, 127
social anxiety disorder, 127
trauma exposure impact, 132
violence exposure impact, 132
Mental Health Parity Act (1996), 237
Mental Health Parity and Addiction Equity Act (2008), 237
Mental health policy:
case examples, 144–145, 147–150
community mental health centers, 136–137
discussion questions, 157
early childhood programs, 152–153
early policy development, 135–136
evidence-based practice (EBP), 145–146
historical development, 135–138
home-visiting program, 152
implementation evaluation, 143–144
Internet resources, 146, 166
legislative history, 141–142t
legislative impact, 153–154
limitations of, 150–151
probably efficacious treatment, 145
risk-protection-resilience model, 146–151
service integration, 140, 142–143
system framework, 139f
systems of care (SOC), 137–140, 142–143
system transformation goal, 151–154
616

well-established treatment, 145
Mental Health Systems Act (1980), 141t
Mental Retardation Facilities and Community Mental Health Center
Construction Act (1963), 136, 141t
Michigan Recession and Recovery Study, 39
Miller v. Alabama (2012), 259t
Milliken v. Bradley (1974), 103t, 109, 116
Mobilization for Youth, 257t
Monitoring the Future (MTF), 228–229
Monoamine oxidase (MAOA) enzyme, 263, 265
Moving to Opportunity (MTO), 33
Multiple births, 172
Narcotic Addict Rehabilitation Act (1966), 235–236
National Action Agenda (Surgeon General), 151
National Association for the Advancement of Colored People
(NAACP), 107
National Campaign to Reform State Juvenile Justice Systems, 259t,
280
National Drug Control Strategy, 247
National Institute of Mental Health (NIMH), 137
National Institute on Drug Abuse (NIDA), 227
National Registry of Effective Programs, 245
National Registry of Evidence-Based Programs and Practices, 146,
305
National Research Council, 280
National School Lunch Act (1946), 102t
National Youth Anti-Drug Media Campaign, 240–241
Native Americans:
adolescent substance abuse, 247
child demographics, 53t
child welfare policy, 72, 80
Nixon, Richard, 236
No Child Left Behind Act (2001), 105t, 111, 115, 121n8, 299
Norway, 37
Nurse-Family Partnership (NFP), 152
Obama, Barack, 113, 114, 183, 186, 237
Obesity, 171t, 173–174
Obsessive-compulsive disorder (OCD), 127–128
617

Office of Adolescent Health, 186
Office of Juvenile Justice and Delinquency Prevention (OJJDP), 258t
Office of National Drug Control Policy (ONDCP), 237
Oklahoma Publishing Co. v. District Court (1977), 258t
Omnibus Budget Reconciliation Act:
1981, 141t, 180t, 181t, 217t
1989, 180t, 181t, 182
1990, 182
Oppositional defiant disorder (ODD), 127t, 128
Overweight, 171t, 173–174
Panel Study of Income Dynamics, 38–39, 40
Parents Involved in Community Schools v. Seattle School District
No.1 (2007), 106t, 112
Partnership for a Drug-Free America, 240–241
Partnership for Drug-Free Kids, 240–241
Patient-Centered Medical Home (PCMH), 168, 184–185, 187
Patient Protection and Affordable Care Act (2010):
adolescent substance abuse, 236t, 237, 242, 243–244
health policy, 167–168, 181t, 183, 185, 186, 187, 299
mental health policy, 142t, 152, 153–154
Permanency roundtable (PRT), 52, 86n4
Perry Preschool Project (Chicago), 153
Personal Responsibility and Work Opportunity Reconciliation Act
(1996), 31, 32–33, 73, 180t, 182, 210, 217t
Personal Responsibility Education Program (PREP), 186
Phobias, 127
Physician Leadership on National Drug Policy, 227, 242
Plessy v. Ferguson (1896), 102t, 107, 116
Point of Engagement (Los Angeles), 77, 80, 82t
Positive peer culture model, 272
Post-Secondary Education Account (Singapore), 42
Posttraumatic stress disorder (PTSD), 127t, 128
Poverty:
child maltreatment impact, 54t, 64, 68, 87n8
children with disabilities, 201, 204–205, 208t
current status, 7
delinquency impact, 267
discussion questions, 43
education policy and, 108–109
618

environmental risk factors, 30
female-headed households (1960–2012), 24f
food insecurity, 28
Great Recession (2007–2009), 38–40
health impact, 172, 174
historical trends, 23–27
household type (1960–2012), 24f
income-threshold measure, 23
influential spheres, 27–28, 29f
interpersonal risk factors, 28–29
mental health impact, 131–132
neighborhood poverty, 25–27
net worth by household type (1989–2010), 26f
net worth by racial/ethnic populations (1983–2010), 25f
racial/ethnic populations (1960–2012), 23f, 24–25, 26–27
social risk factors, 28–29
substance abuse impact, 231
Supplemental Poverty Measure, 23
See also Antipoverty programs
Power, Kathryn, 151
Pregnancy, 304
Preschool for All, 113
President’s New Freedom Commission Report on Mental Health and
the Federal Action Agenda, 142t, 151
Prevention Intervention Development Initiative (Los Angeles), 77
Primary health care services, 187
Probably efficacious treatment, 145
Project D.A.R.E., 241
Project LAUNCH (2008), 142t, 154
Promise Neighborhood, 41
Promotive factors:
delinquent behavior, 263, 264–265t
risk-protection-resilience model, 13
Protective factors:
adolescent substance abuse, 232–234
child abuse/neglect, 63–64t, 67–70
children with disabilities, 207–208
delinquent behavior, 262–270
ecological theory, 301
health conditions, 177–178
619

mental health disorders, 134–135
risk-protection-resilience model, 9, 10–11, 12t
Psychiatric residential treatment facility (PRTF), 140
Pure Food and Drug Act (1906), 235, 236t
Race to the Top, 113, 114
Race to the Top-Equity and Opportunity, 114
Racial/ethnic populations:
adolescent substance abuse, 229, 247
asthma, 171t, 172
child abuse/neglect, 56–57, 66–67, 68, 70
children with disabilities, 201, 204, 214–215
child welfare policy, 79–80
delinquent behavior, 261, 268
education policy, 102t, 106t, 107–108, 112
graduation rates (2010–2012), 98, 99t
health conditions, 170, 171t
low birth weight (LBW), 170, 171t
overweight/obesity, 171t, 173
poverty rates, 23f, 24–25, 26–27
See also specific race/ethnicity
Rebuilding Communities and Making Connections, 41
Reproductive health care, 188
Republican Party, 112, 113
Resilience factors:
adolescent substance abuse, 234
child abuse/neglect, 66–67
risk-protection-resilience model, 11–13
Restorative justice, 258t, 273
Risk factors:
adolescent substance abuse, 230–232
child abuse/neglect, 62–66
children with disabilities, 204–205, 208t
delinquent behavior, 262–270
ecological theory, 301
health conditions, 169–177
mental health disorders, 130–134
risk-protection-resilience model, 9, 10t, 11
Risk-protection-resilience model:
adaptation, 13
620

adolescent substance abuse, 235–244
child abuse/neglect, 61, 62–70
children with disabilities, 208–211
child welfare policy, 70–71
current youth status, 6–7
ecological theory, 15–16, 300–307
education policy, 115–116
environmental protective factors, 12t
environmental risk factors, 10t
individual protective factors, 12t
individual risk factors, 10t
interpersonal protective factors, 12t
interpersonal risk factors, 10t
juvenile justice policy, 271, 273–279
life-course development, 15–16
mental health disorders, 129–130
mental health policy, 146–151
model illustration, 15f
policy applications, 13–14, 15f
policy limitations, 7–8
promotive factors, 13
protective factors, 9, 10–11, 12t
public health perspective, 8–13
resilience factors, 11–13
risk factors, 9, 10t, 11
social protective factors, 12t
social risk factors, 10t
Robert Wood Johnson Foundation Mental Health Services Program
for Youth, 145
Roper v. Simmons (2005), 259t
Runaway, Homeless, and Missing Children Protection Act, 74
Safe and Drug-Free Schools and Communities Program, 109, 110,
241–242
Saving for Education, Entrepreneurship, and Downpayment (SEED),
42
Savings accounts, 33, 37, 41–42
Scared-Straight program, 258t, 274–275
Schall v. Martin (1984), 258t
School-Based Health Center (SBHC), 186–190, 242
621

School choice, 113
School environment:
academic promotive factors, 101t
academic protective factors, 101t
academic risk factors, 100t
School funding, 117–118
School segregation, 102t, 103t, 107, 109, 116
School violence, 6, 110
Section 8 vouchers, 33, 35t
Separation anxiety disorder, 127
Serious and Violent Offender Re-entry Initiative, 259t
Serious Emotional Disturbances (SED):
diagnostic categories, 126–129
prevalence rates, 125–126, 127t
protective factors, 134–135
risk factors, 130–134
risk-protection-resilience model, 129–130
See also Mental health disorders; Mental health policy
Sexual abuse, 176–177
Sexual behavior:
health policy, 185–186
risky behaviors, 176–177
Sexually transmitted infections (STIs), 174–177
Sheppard-Towner Maternity and Infancy Act (1921), 179, 180t
Singapore, 42
Skillman Foundation, 41
Smith v. Daily Mail (1979), 258t
Social anxiety disorder, 127
Social control theory, 14
Social development model (SDM), 14
Social Development Research Group, 14
Social learning theory, 14, 61–62
Social model of disability, 203–204
Social protective factors:
academic failure, 101t
adolescent substance abuse, 232t, 233
delinquent behavior, 264t, 266–267
risk-protection-resilience model, 12t
Social risk factors:
adolescent substance abuse, 230t, 231
622

delinquent behavior, 264t, 266–267
poverty, 28–29
risk-protection-resilience model, 10t
Social Security Act (1935):
antipoverty programs, 31
Title V, 179, 180t, 184–185, 215, 217t
Title X, 209
Title XIX, 71, 180t
Social Security Amendments (1965), 141t
Social Security Disability Insurance, 209
Social support theory, 62
Soviet Union, 108
Special education. See Children with disabilities
Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC), 32, 34t
Sputnik, 108
Stanford v. Kentucky (1989), 258t
State Children’s Health Insurance Program (SCHIP), 79, 180t,
182–183, 184, 236t, 243
Strengthening America’s Schools Act (2013), 113
Student Success Act (2013), 113
Subsidized housing, 33, 34t
Substance abuse. See Adolescent substance abuse
Substance Abuse and Mental Health Services Administration
(SAMHSA), 138–139, 143, 146, 154, 227,
240, 242, 243, 245, 305
Substance Abuse Prevention and Treatment Block Grant, 243
Supplemental Nutrition Assistance Program (2008):
antipoverty program, 31–32
changes to, 78
characteristics of, 34t
Supplemental Poverty Measure, 23
Supplemental Security Income (SSI):
antipoverty program, 33
characteristics of, 34t
income transfers, 209–210, 217t
Surgeon General’s reports, 142t, 151
Sweden, 37
Systems of care (SOC), 137–140, 142–143
623

Tax credit, 32, 35t
Tea Party, 112
Temporary Assistance for Needy Families (TANF), 31, 32, 36t, 73,
182, 209, 210–211, 217t
Thompson v. Oklahoma (1988), 258t
Trauma theory, 61
Tribal Youth Initiative, 247
Unclaimed Children (Knitzer), 137, 155
Uninterrupted Scholars Act (2013), 76
United Kingdom, 42
U.S. Census Bureau, 23
U.S. Department of Child and Family Services, 82
U.S. Department of Education, 113, 114, 240, 241–242
U.S. Department of Health and Human Services, 113, 243
U.S. Department of Housing and Urban Development, 33
Ventura County System of Care (California), 146, 149–150
Very low birth weight (VLBW), 169–170
Volstead Act (1919), 235, 236t
War on Drugs, 236
Washington State Institute for Public Policy, 306
Well-established treatment, 145
What Works Initiative, 259t
White population:
adolescent substance abuse, 229
asthma, 171t
child demographics, 53t
delinquent behavior, 261
graduation rates (2010–2012), 98, 99t
low birth weight (LBW), 170, 171t
overweight/obesity, 171t, 173
poverty, 23f, 24–25, 26–27
single-parent households, 53t
Willie M. et al. v. James B. Hunt, Jr. et al. (1980), 147–148
Willie M. Program (North Carolina), 146, 147–148
Workforce Investment Act (1998), 33, 36t
Wraparound Milwaukee, 279–280
Zero-tolerance policy:
624

juvenile justice, 258t
school violence, 110
625

About the Editors
Jeffrey M. Jenson, PhD,
is the Philip D. and Eleanor G. Winn Professor for Children and
Youth at Risk in the Graduate School of Social Work, University of
Denver. His research focuses on the application of a public health
approach to preventing child and adolescent health and behavior
problems and on the evaluation of preventive interventions aimed at
promoting positive youth development. Dr. Jenson has published
seven books and numerous articles and chapters on topics of
prevention and child and adolescent development. His 2014 book
(with K. Bender), Preventing Child and Adolescent Problem
Behavior: Evidence-Based Strategies in Schools, Families, and
Communities (Oxford University Press), is a comprehensive review
of empirical evidence pertaining to the efficacy of universal, selected,
and indicated preventive interventions for children and youth. Dr.
Jenson has received several awards for his scholarship, including the
Aaron Rosen Award from the Society for Social Work and Research.
He is the recipient of Distinguished Scholar and University Lecturer
awards from the University of Denver and is a former editor-in-chief
of the journal Social Work Research. Dr. Jenson is a fellow of the
American Academy of Social Work and Social Welfare and the
Society for Social Work and Research.
Mark W. Fraser, PhD,
holds the Tate Distinguished Professorship at the School of Social
Work, University of North Carolina, where he serves as Associate
Dean for Research. He has won numerous awards for research and
teaching, including the Aaron Rosen Award and the Distinguished
Achievement Award from the Society for Social Work and Research.
His work focuses on risk and resilience, child behavior, child and
family services, and research methods. He has published widely and,
in addition to Social Policy for Children and Families, is the co-
author or editor of eight books. These include Families in Crisis, a
study of intensive family-centered services, and Evaluating Family-
Based Services, a text on methods for family research. In Risk and
Resilience in Childhood, he and his colleagues describe resilience-
based perspectives for child maltreatment, substance abuse, and other
social problems. In Making Choices, Dr. Fraser and his co-authors
626

outline a program to help children build sustaining social
relationships. In The Context of Youth Violence, he explores violence
from the perspective of resilience, risk, and protection, and in
Intervention with Children and Adolescents, he and his colleagues
review advances in intervention knowledge for social and health
problems. In Intervention Research: Developing Social Programs, he
and his colleagues describe the design and development of social
programs. His most recent book is Propensity Score Analysis:
Statistical Methods and Applications. Dr. Fraser serves as editor of
the Journal of the Society for Social Work and Research. He is a
fellow of the National Academies of Practice, the Society for Social
Work and Research, and the American Academy of Social Work and
Social Welfare.
627

About the Contributors
Elizabeth K. Anthony, PhD,
is an Associate Professor in the School of Social Work and a
Research Faculty Affiliate of the Southwest Interdisciplinary
Research Center at Arizona State University, where she teaches
courses in applied research and clinical practice with children and
adolescents. Dr. Anthony’s research and publications focus on
resilience among low-income adolescents and interventions to
promote healthy outcomes among children and adolescents living in
poverty. Prior to joining the faculty at Arizona State University, she
served as Research Director on a longitudinal study of at-risk youth
living in Denver public housing neighborhoods and as a postdoctoral
fellow at the University of California, Berkeley.
William H. Barton, PhD,
is Professor Emeritus in the Indiana University School of Social
Work at Indiana University–Purdue University in Indianapolis, where
he taught courses in juvenile justice policy, research methods,
leadership, and the philosophy of science until his retirement in 2014.
Dr. Barton’s research interests include juvenile justice, delinquency
prevention, youth development, and community practice. For more
than 30 years, he has conducted evaluations of juvenile justice
programs and policies throughout the United States. Among his many
publications are numerous journal articles, book chapters, and two co-
authored books.
Sandra K. Danziger, PhD,
is a Professor of Social Work, School of Social Work, and Research
Professor of Public Policy, Gerald R. Ford School of Public Policy, at
the University of Michigan. Her primary research interests and
publications examine the effects of public antipoverty and social
service programs and policies on the well-being of disadvantaged
families, particularly single mothers and their children. She is a Co-
Investigator on the Michigan Recession and Recovery Study and was
Principal Investigator on the Women’s Employment Study that
tracked the effects of the 1996 welfare reform. Professor Danziger
was a 2009 Scholar in Residence at the Rockefeller Foundation
Bellagio Center, Bellagio, Italy. She received the 2006 Society for
Social Work Research Excellence in Research Award. She was a
628

Visiting Scholar at the Russell Sage Foundation, New York, in 2002
to 2003, and, in 1994, was Visiting Research Scientist, Office of the
Secretary, Assistant Secretary for Planning and Evaluation, U.S.
Department of Health and Human Services, Washington, D.C.
Mary E. Fraser, DSW,
has worked as a program and policy consultant to mental health
departments in three states. Dr. Fraser wrote the Child and Adolescent
Service System Program grant for the state of Utah in the early 1990s
and served as that office’s first director. She worked in the capacity of
executive staff member to the North Carolina Legislative Oversight
Committee on Mental Health Reform in 2000. Dr. Fraser’s numerous
publications focus on mental health policy and practice for children
and families. She was previously a clinical adjunct professor in social
work and psychiatry at the University of North Carolina at Chapel
Hill.
Andy J. Frey, PhD,
is a Professor and Chair of the school social work specialization in the
Kent School of Social Work at the University of Louisville. Dr.
Frey’s research interests and publications address the provision of
school-based mental health and school social work services and
prevention and intervention for young children with challenging
behavior. Prior to his appointment at the University of Louisville, he
was a school social worker and behavioral consultant in Douglas
County, Colorado.
William J. Hall, MSW,
is a doctoral candidate at the School of Social Work, University of
North Carolina at Chapel Hill. His research has included process
evaluation for a school-based intervention for pediatric obesity and
type-2 diabetes, school bullying and climate issues for sexual
minority youth, and the evaluation of visual interventions for implicit
ethnic bias among school and health-care professionals.
Markell Harrison-Jackson, PhD,
is an Independent Educational Leadership and Child Welfare
Consultant. In this role, he has developed programs for domestic and
international child welfare, foster care, and educational systems. Dr.
Jackson’s work spans 16 years in educational settings and includes
experience as a special education teacher, principal, and school
administrator. He also teaches independent living skills to foster care
youth and provides individual and group counseling to at-risk youth.
Matthew O. Howard, PhD,
629

is the Frank A. Daniels Jr. Distinguished Professor of Human
Services Policy Information in the School of Social Work and Faculty
Research Fellow in the Cecil G. Sheps Center for Health Services
Research at the University of North Carolina at Chapel Hill. Dr.
Howard has published more than 220 articles in the field of substance
abuse and is the recipient of three research grants from the National
Institutes of Health aimed at understanding the natural history of
inhalant abuse. Dr. Howard has served as Editor-in-Chief of Social
Work Research and the Journal of Social Service Research and is
currently North American Editor of the British Journal of Social
Work. Dr. Howard was named a Fellow of the Society for Social
Work and Research and a Fellow of the American Academy of Social
Work and Social Welfare and received the University of North
Carolina Excellence in Graduate Teaching Award in 2014.
Guadalupe V. Huitron, MSW, MPH
is Country Director for Belize at Population Services International, a
global health organization focusing on maternal and child health and
HIV and AIDS.
Leah Igdalsky, BA,
is a Research Associate at the Lurie Institute for Disability Policy in
the Heller School for Social Policy and Management at Brandeis
University. Her research interests include women’s issues, aging, and
disability policy.
Paul Lanier, PhD,
is an Assistant Professor at the University of North Carolina at
Chapel Hill School of Social Work, where he teaches courses in
social policy and program evaluation. His research focuses on the
prevention of child maltreatment, with an emphasis on improving the
availability of evidence-based mental health services. Dr. Lanier
received training as part of the Doris Duke Fellowship for the
Promotion of Child Well-Being and the NIMH Pre-Doctoral
Fellowship at the Center for Mental Health Services Research at the
Brown School at Washington University in St. Louis. Dr. Lanier
previously worked in an adolescent psychiatric treatment setting in
North Carolina as an aftercare counselor.
Myrna R. Mandlawitz, JD,
is president of MRM Associates, LLC, a Washington, D.C., lobbying
firm, and has represented the School Social Work Association of
America as its Director of Government Relations since 1999. She is a
specialist in legal and policy issues related to special education and
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children’s mental health. Prior to establishing her own government
relations practice, Ms. Mandlawitz served as Government Relations
Director for the National Association of State Directors of Special
Education and spent 14 years as a classroom teacher in a large
rural/suburban school district near Richmond, Virginia.
Susan L. Parish, PhD, MSW,
is the Nancy Lurie Marks Professor of Disability Policy and Director,
Lurie Institute for Disability Policy, at The Heller School for Social
Policy and Management, Brandeis University. Her research examines
the health and well-being of children and adults with disabilities and
their caregiving families. She teaches courses in social policy and
research methods.
Peter J. Pecora, PhD,
is the Managing Director of Research Services for Casey Family
Programs and Professor in the School of Social Work at the
University of Washington. Dr. Pecora has worked with state
departments of social services in the United States and in other
countries to refine foster care programs, develop evaluation strategies,
and implement intensive home-based services and risk assessment
systems for child protective services. His co-authored books and
articles focus on child welfare program design, administration, and
research. In 2009, he was elected to the American Academy of Social
Work and Social Welfare as a fellow and inaugural board member.
Armon R. Perry, PhD,
is an Associate Professor in the Kent School of Social Work at the
University of Louisville. Dr. Perry’s research interests include
fathers’ involvement with their children and social welfare policy.
Prior to his appointment at the University of Louisville, Dr. Perry was
a child protective services social worker in Montgomery, Alabama.
Kathleen A. Rounds, PhD,
is a Professor in the School of Social Work at the University of North
Carolina at Chapel Hill. She is the Director of the Leadership in
Public Health Social Work Program and Co-Chair of the dual degree
program in social work and public health. Dr. Rounds’s research has
included evaluations of services for people with HIV, services for
pregnant and postpartum women using substances, adolescent
parenting programs, and interdisciplinary leadership and workforce
development in maternal and child health.
Alison W. Saville, MSW, MSPH,
is the Project Manager for the Children’s Outcomes Research
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Program (COR) at University of Colorado–Denver. She currently
manages an investigation funded by the National Institutes of Health
entitled Population versus Practice-Based Interventions to Increase
Immunizations.
Jamie G. Swaine, MSW,
is a Clinical Instructor in the Developmental Disabilities Training
Institute at the School of Social Work, University of North Carolina
at Chapel Hill. She currently manages a project funded by the U.S.
Department of Education that is testing the effectiveness of a
community-based intervention to improve cervical and breast cancer
screening rates for women with intellectual disabilities.
Hill M. Walker, PhD,
is a Professor of Special Education, Co-Director of the Institute on
Violence and Destructive Behavior, and Research Director of the
Center on Human Development, in the College of Education at the
University of Oregon. He has a longstanding interest in behavioral
assessment and in the development of effective intervention
procedures for use in school settings with a range of behavior
disorders. His research interests include social skills assessment,
curriculum development and intervention, longitudinal studies of
aggression and antisocial behavior, and the development of early
screening procedures for detecting students who are at risk for social-
behavioral adjustment problems and/or later school dropout.
Trina R. Williams Shanks, PhD,
is an Associate Professor in the School of Social Work at the
University of Michigan. She is Co-Principal Investigator on the
SEED impact assessment survey, a quasi-experimental study of
children’s savings accounts among preschool families. Her interests
include asset-building policy and practice across the life cycle, the
impact of poverty and wealth on child development outcomes, and
community and economic development in urban areas.
632

Half Title
Publisher Note
Title Page
Copyright Page
Contents
Acknowledgments
Introduction
Chapter 1 A Risk and Resilience Framework for Child, Youth, and Family Policy
Chapter 2 Antipoverty Policies and Programs for Children and Families
Chapter 3 Child Welfare Policies and Programs
Chapter 4 Education Policy for Children, Youth, and Families
Chapter 5 Child Mental Health Policy Promise Without Fulfillment?
Chapter 6 Health Policy for Children and Youth
Chapter 7 Policies and Programs for Children and Youth With Disabilities
Chapter 8 Policies and Programs for Adolescent Substance Abuse
Chapter 9 Juvenile Justice Policies and Programs
Chapter 10 Toward the Integration of Child, Youth, and Family Policy Applying Principles of Risk, Resilience, and Ecological Theory
Index
About the Editors
About the Contributors