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Anne M. Libby, PhD, Heather D. Orton, MS, Richard P. Barth, PhD, Mary Bruce Webb, PhD, Barbara J. Burns, PhD, Patricia Wood, MS and Paul Spicer, PhD

Anne M. Libby, Heather D. Orton, and Paul Spicer are with the American Indian and Alaskan Native Programs at the University of Colorado, Denver, and Health Sciences Center, Aurora. Richard P. Barth is with the University of North Carolina, Chapel Hill. Mary Bruce Webb is with the Administration for Children and Families, US Department of Health and Human Services, Washington, DC. Barbara J. Burns is with Duke University, Durham, NC. Patricia Wood is with the Child and Adolescent Services Research Center, San Diego, Calif.

Correspondence: Requests for reprints should be sent to Anne M. Libby, PhD, University of Colorado Health Sciences Center, School of Medicine, Nighthorse Campbell Native Health Building, PO Box 6508, Campus Box F800, Aurora, CO 80045 (e-mail: anne.libby{at}uchsc.edu).

	ABSTRACT

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We used data on a national sample of children involved with child welfare systems to compare American Indian caregivers with White, Black, and Hispanic caregivers in their need for, and receipt of, specialty alcohol, drug, and mental health treatment. American Indian caregivers were significantly less likely to receive services than were Hispanic caregivers (P<.05) but not significantly less likely than were White or Black caregivers. Child placement, child age, and caregiver psychiatric comorbidity were significantly associated with service receipt.

	INTRODUCTION

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Mental and substance abuse disorders generate costs to society estimated in the billions of dollars.^1,2 American Indians have increased morbidity and mortality rates compared with the rest of the United States,^3,4 especially alcohol problems and trauma.^5–11 In addition, child abuse and neglect have been shown to be elevated in some tribal communities.^12,13 Child welfare systems aim to protect child safety and often provide care for parental alcohol, drug, and mental health problems.¹⁴ As many as 40% to 80% of families involved with child welfare systems have substance abuse problems, although no established methods are available to measure this nationally.^2,15,16 This study used a national sample of children involved with child welfare systems to compare American Indian caregivers with White, Black, and Hispanic caregivers in their need for, and receipt of, treatment for alcohol, drug, and mental health problems.

	METHODS

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The National Survey of Child and Adolescent Well-Being is a nationally representative longitudinal study of children aged 0 to 14 years who were subjects of investigations of child abuse or neglect conducted by Child Protective Services. Analysis weights were used to make nationally representative inferences for the total population. Detailed information about the National Survey of Child and Adolescent Well-Being study design is published elsewhere.^17–19

Caregiver race/ethnicity was categorized as American Indian; White, non-Hispanic; Black, non-Hispanic; and Hispanic. Caregivers classified as "other" (2.5%) were excluded.

At baseline, child placement was categorized as in-home or out-of-home. Child age was categorized as younger than 3 years, 3 to 5 years, 6 to 10 years, and 11 years and older.

At baseline (the time of the investigation), a child welfare worker assessed the following caregiver risk factors: serious alcohol or drug problems; serious mental health or emotional problems; physical impairment; impaired parenting (i.e., poor parenting skills, inappropriate or excessive discipline); monetary problems (i.e., problems paying for basic necessities); and active and current domestic violence. The first 2 items were combined—alcohol, drug, and mental health problems. At 18 months, the child welfare worker indicated whether the caregiver received assessments, referrals, and services for alcohol, drug, and mental health problems since baseline.

Weighted descriptive statistics were obtained with analysis weights and Stata software, Release 7.0 (Stata Corp, College Station, Tex), survey procedures. Weighted multivariate logistic regression was used to estimate relations between baseline independent variables and 18-month service receipt, including only those caregivers who had baseline alcohol, drug, and mental health problems.

	RESULTS

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The unit of analysis was the current care-giver; thus, only caregivers who responded at both baseline and 18 months were described (N = 3340). Five percent were American Indian (Table 1). In nearly all cases, child placement was in-home at baseline. The most prevalent risk factor for American Indians (30%) was impaired parenting skills. At the time of the investigation, 22% of the caregivers had alcohol, drug, and mental health problems. Only 15% of the American Indian caregivers with alcohol, drug, and mental health problems at baseline received a formal assessment. About 25% were referred for services, and only 12% received any type of specialty service for alcohol, drug, and mental health problems.

Most families served by child welfare agencies do not use foster care (i.e., are in-home cases). These caregivers were nearly 50% less likely to receive services for alcohol, drug, and mental health problems (OR = 0.53; P < .05), indicating lower access to care that could be preventive. Comorbid problems more than doubled a caregiver’s chance of receiving services compared with having only a substance use problem (P < .05). No other baseline risk factors were significant in the multivariate model.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
Results suggested racial and ethnic disparities in referral to, and receipt of, specialty services for alcohol, drug, and mental health problems. At a national level for all families involved with child welfare, we concluded that most of the caregivers with identified alcohol, drug, and mental health problems were not provided treatment services by those child welfare agencies. Hispanic caregivers fared the best, perhaps because of language-specific resources, surpassing other groups in assessment, referral to services, and prior receipt of alcohol, drug, and mental health problems services.

American Indian families face tribal and county child welfare agencies enmeshed in a complex web of funding and authority with states, partially established with the 1978 Indian Child Welfare Act.^2,20–22 Education for nontribal providers and technical assistance to tribes in using available funding are needed to improve service systems.

Because of the sample size, this study was unable to generate national estimates of minority parents. Descriptive statistics of American Indian, Hispanic, and Black, non-Hispanic, caregivers must be confirmed by additional research. Future surveys should oversample American Indian persons to produce reliable estimates for this important population.

	Acknowledgments

 
This work was partially supported by a Faculty Scholars Award from the William T. Grant Foundation (A.M. Libby, Principal Investigator, grant no. 2052), a grant from the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation (47400; P. Spicer, Principal Investigator), and a Caring for Children in Child Welfare grant from the National Institute of Mental Health (MH59672).

This document draws on data from the National Survey on Child and Adolescent Well-Being, developed under contract with the Administration for Children and Families, US Department of Health and Human Services.

We gratefully acknowledge staff and participants of the National Data Archive on Child Abuse and Neglect 2004 Special Research Meeting, especially Kathryn Dowd.

Human Participant Protection
The study was reviewed and approved by the institutional review board of the University of Colorado at Denver and Health Sciences Center.

	Footnotes

 
Peer Reviewed

Note. The information and opinions expressed herein reflect solely the position of the authors and should not be construed to indicate the support of or endorsement by Administration for Children and Families, US Department of Health and Human Services.

Contributors
A. M. Libby originated the study, supervised all aspects of the implementation of the study, and assisted with the writing of the brief. H. D. Orton led the analyses and assisted with the writing of the brief. R. P. Barth, M. B. Webb, and P. Spicer each assisted with the study, analyses, and writing of the brief. B. J. Burns assisted with the study and analyses. P. Wood assisted with the study and completed the analyses and weighting to account for the complex survey design. All authors helped conceptualize the analysis plan, interpret the findings, and review drafts of the article.

Accepted for publication February 18, 2005.

	References

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4. Regional Differences in Indian Health. Washington, DC: US Dept of Health and Human Services; 1997.

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22. Child Welfare League of America. Alcohol, Other Drugs, and Child Welfare. Washington, DC: Child Welfare League of America; 2001.

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This Article Abstract Full Text (PDF) All Versions of this Article: AJPH.2004.059436v1 96/4/628    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Libby, A. M. Articles by Spicer, P. Search for Related Content PubMed PubMed Citation Articles by Libby, A. M. Articles by Spicer, P. Related Collections Health Care Facilities/Services Other Health Service Delivery Mental Health Other Child and Adolescent Health Native Americans Other Race/Ethnicity Alcohol Drugs