NEW YORK CITY, Sept. 20-- More than seventy-five pediatricians, social workers, psychologists, and policy makers attended the Brock Lecture at the Academy last night to hear Moira Szilagyi, MD, PhD – the 2005 winner of The Millie and Richard Brock Award – deliver an engrossing, thought-provoking lecture on the many factors influencing wellness outcomes of maltreated children. Dr. Szilagyi began her talk by focusing on maltreatment – physical, emotional, and sexual – as being the single most potent adversity that children can suffer. It is, she said, "the most powerful predictor of poor long term outcomes in the lives of these children." Maltreatment rates are highest among infants and toddlers, with multiple types of abuse reported.
Overview: Occurrence and risk factors
Maltreatment is widespread. Three million abuse reports per year are received by various agencies, Dr. Szilagyi explained, resulting in two million investigations by child protective services, with 880,000 cases substantiated. Of these cases, 290,000 children are placed into foster care, according to 2002 data compiled by the Department of Health and Human Services.
(The balance of the children studied received kinship placements, remained at home, or, in some cases, died from maltreatment.)
Dr. Szilagyi defined wellness as what goes "right" in psychological adjustment and development, and then pinpointed the factors that influence wellness outcomes. These include the heterogeneity of abuse, its severity and duration, and mediating such as a nurturing caregiver and positive peer friendships that can ameliorate negative influences. Of particular interest was Dr. Szilagyi’s discussion of her "rule of 22" that she developed in 2001: where the family income is less than $22,000 per year, children are 22 times more likely to be victims of maltreatment.
Risk factors for maltreatment include: family homelessness/near homelessness; malnutrition; multiple caregivers; drug use by parents; mental heath issues in the family; domestic violence; and, limited access to health care. Of these factors, domestic violence figures prominently: 54 percent of the children in foster care had been exposed to domestic violence in their birth families. Further, 60 percent of the children in foster care came from families who were on public assistance; 46 percent from families where mental health problems were present; and 60 percent had lived in families where substance abuse was present. The rate of reported substance abuse by parents is even higher for younger children.
Longitudinal studies of impoverished maltreated and nonmaltreated children, controlled for age and gender, show that the most robust predictor of positive outcomes is the formation of secure attachments early in life. Children who were maltreated, the studies showed, were ineffective in developing peer relationships; adapted poorly to school; behaved more aggressively; and had a low degree of self-efficacy.
On a more positive note, protective factors among maltreated children include normal or above-average intelligence level; lack of physical abuse; having one stable, nurturing caregiver in the home; and holding a sense of positive expectations for the future.
Foster Care
Concluding her thorough overview, Dr. Szilagyi moved on to the topic that she professed as her great passion: foster care. Defined as a "temporary respite" with goals of the health, safety and permanency of children, foster care still has reunification with the family of origin as its most frequent outcome. About 150,000 young children enter the foster care system each year. A 2002 study showed 542,000 children to be in foster care; 87 percent of these children entered the system with a history of significant exposure to domestic and/or community violence.
The average stay in foster care is three years, according to the 2002 study, but 20 percent of the children ultimately returned to foster care after reuniting with their family of origin. Not that foster care is a failsafe: this living situation causes its own set of stressors for children, including issues of ongoing separation and loss, the fear of never seeing their parents again, and the complex system within which the children live. Indeed, Dr. Szilagyi emphasized the anxiety attendant upon having no voice as a young child in foster care. Even older children have difficulty participating in decisions affecting their own lives.
By far, the greatest concern facing the foster care system is the undermet mental health needs of the children and the families with whom children might be reunited. Mental health utilization is high in foster care but probably inadequate to children’s needs. Dr. Szilagyi cited a study by Mark Simms et al., stating that only 30 percent of mental health needs are ever diagnosed among children in foster care. Public policy must be enacted to ensure that mental health conditions are identified and treated early, Dr. Szilagyi said. Funding should support services such as foster parent mentoring and therapeutic visitation that have been shown to be successful, she said.
Turning to the positive aspects of foster care, Dr. Szilagyi noted evidence that stable foster care in good quality homes can improve wellness outcomes for children. Factors that have been shown to improve children’s outcomes are stable placements, an involved caseworker, social supports for foster families, and good mental health access. Again, the key issue of mental health comes into play when evaluating the chance of successful outcomes.
Remedies
Looking ahead, Dr. Szilagyi emphasized that in order for foster care to improve, social services and practices must be upgraded; meaningful measurement of outcomes must be developed; and standards must be adhered to. She recommended that a mental health and developmental evaluation be completed on all children in foster care within 60 days of their placement. Maltreated children are especially in need of periodic reassessment and support.
The lecture concluded with a lively question-and-answer session focused on issues of reunification, adoption, a model for "therapeutic visitation," readiness for motherhood, and the court system. At the end of the evening, Dr. Szilagyi was presented with The Millie and Richard Brock Award in Pediatrics by Dr. Sheila Palevsky, Chair of the Executive Committee of the Academy’s Section on Pediatrics. The award was established in 1995 on the occasion of the 100th anniversary of the Section on Pediatrics. Since its inception, the Brock program has sponsored distinguished leaders in pediatrics in visiting New York-area pediatric training programs to share their expertise with medical students, pediatric residents, fellows and attending staff, and to deliver the annual lecture at the Academy.
Biography of Dr. Szilagyi
Since 1990, Dr. Moira Szilagyi has been Medical Director of Foster Care Pediatrics, and Assistant Professor of Pediatrics, at the University of Rochester, New York, where she also teaches in the resident continuity clinic. She has been providing primary health care services for children in foster care since 1986. Dr. Szilagyi received her doctoral degree in biochemistry from the University of Rochester in 1980. She completed medical school in 1984 at the same institution, where she helped to establish the first Ethics in Medicine course. During her residency, Dr. Szilagyi solidified her interest in serving the needs of children at risk due to poverty. She was instrumental in establishing REACH, the hospital’s child abuse prevention program.
In addition to her clinical work, Dr. Szilagyi chairs the American Academy of Pediatrics District II Task Force on Foster Care Heath Care, which recently published the second edition of Fostering Health: Health Care for Children and Adolescents in Foster Care. Dr. Szilagyi continues to work closely with local, state, and national professionals to address the health care of foster children; she is a member of several task forces that work on those issues. Dr. Szilagyi also lectures nationwide and conducts trainings for health, child welfare and legal professionals on foster care health care issues.
Slides from Dr. Szilagyi’s lecture are viewable at www.nyam.org/grants/brockrecipients.shtml. For more information on the Brock Lecture, Award and Visiting Professorship in Pediatrics, please contact Ed North at enorth@nyam.org or 212-822-7204.
The New York Academy of Medicine, the country’s premier urban health policy and intervention center, focuses on enhancing the health of people living in cities through research, education, advocacy, and prevention.
Posted on 09/20/2005
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