Given the rapid nature of development in early life (and the ability for developmental screenings to improve health trajectories), the American Academy of Pediatrics recommends that children attend regular well-child care visits (WCV) frequently between ages 0 and 5 years.1,2  Children involved in the child welfare system are more likely to have developmental delays compared with their peers.35  Thus, it is important for these children to attend recommended WCVs on time. National estimates suggest that 89% of children between ages 0 and 5 years attended a WCV in the past year.6  Yet we do not have comparable estimates for children involved in the child welfare system. Using state-level administrative data, we undertook the current study to identify the proportion of young children (aged 0–5 years) in state care who attended (1) all recommended WCVs on time (question 1) and (2) at least 1 WCV in the past year (question 2). We further explored correlates of WCV attendance.

The University of Michigan Institutional Review Board approved this research. We obtained child welfare administrative records for all substantiated referrals of child maltreatment in a midwestern state where the child entered state care between January 2017 and December 2019 (N = 12 824). Caseworkers enter information pertaining to their cases into the state administrative data system, and the study team extracted data pertinent to the current study from this system.

To address question 1, we excluded children who were older than 5 years (n = 7425), were in state custody for <1 month (n = 383), or had incomplete information on covariates (n = 1358), leaving an analytic sample of 3658.

To address question 2 and identify the proportion of children in care who attended a WCV in the past year (January 1, 2019, to –December 31, 2019), we further restricted our analytic sample to children who were in care for ≥1 year as of December 31, 2019, and who were still in care at this date (n = 2054).

State policy mandates that children in state care attend WCVs at 2, 4, 6, 9, 12, 15, and 18 months and at 2, 3, 4, and 5 years. Our question 1 outcome was a dichotomous variable indicating if a child attended all recommended WCVs while in care. For example, if a child was in care between ages 10 and 20 months, this child would have attended all WCVs if they had a 12-, 15-, and 18-month WCV. Our question 2 outcome was a dichotomous variable indicating if a child had attended any WCV within the 2019 calendar year. Covariates included child age, sex (male or female), race (Black or non-Black), duration of care, foster placement (kinship or nonkinship), and agency type (county or private).

To identify correlates of WCV attendance, we estimated multivariate logistic regressions and generated robust SEs clustered at the child welfare agency level.

Descriptive statistics stratified by race are provided in Table 1. Only 66% of children attended all age-appropriate WCVs, but 95% attended at least 1 WCV in 2019 while in state care. Bivariate analyses illustrate significant differences in the primary outcomes between Black and non-Black children. Namely, a lower proportion of Black children attended any WCV in the past year compared with non-Black children (P = .04), and a lower proportion of Black children attended all WCVs while in state care (P = .04). Additionally, a higher proportion of Black children were in kinship placements compared with non-Black children; however, this difference only reached significance within the question 1 analytic sample.

TABLE 1

Descriptive Statistics of the Analytic Samples, Stratified by Race

Question 1: Attending All WCVsQuestion 2: Attending Any WCV in 2019
BlackNon-BlackTotalBlackNon-BlackTotal
Attend all WCVs, % (n62 (719)a 68 (1702)a 66 (2421)a — — — 
Attend ≥1 WCV in 2019, % (n— — — 94 (748)a 96 (1202)a 95 (1950)a 
Age, y, mean (SD) 1.57 (1.6) 1.50 (1.5) 1.55 (1.5) 2.89 (1.1) 2.89 (1.1) 2.89 (1.1) 
Months in care, mean (SD) 15.1 (7.4)a 15.7 (7.5)a 15.5 (7.5)a 23.4 (9.2)a 21.4 (7.8)a 22.2 (8.4)a 
Agency type, % (n      
 County 54 (627) 54 (1361) 54 (1988) 25 (201) 29 (363) 28 (564) 
 Private 46 (531) 46 (1139) 46 (1670) 75 (598) 71 (892) 73 (1490) 
Sex, % (n      
 Male 53 (617) 52 (1302) 52 (1919) 54 (432) 52 (658) 53 (1090) 
 Female 47 (541) 48 (1198) 48 (1739) 46 (367) 48 (597) 47 (964) 
Placement type, % (n      
 Kinship 57 (665)a 53 (1335)a 45 (1658)a 47 (376) 38 (608) 48 (984) 
 Nonkinship 43 (493)a 47 (1165)a 55 (2000)a 53 (423) 52 (647) 52 (1070) 
Total 1158 2500 3658 799 1255 2054 
Question 1: Attending All WCVsQuestion 2: Attending Any WCV in 2019
BlackNon-BlackTotalBlackNon-BlackTotal
Attend all WCVs, % (n62 (719)a 68 (1702)a 66 (2421)a — — — 
Attend ≥1 WCV in 2019, % (n— — — 94 (748)a 96 (1202)a 95 (1950)a 
Age, y, mean (SD) 1.57 (1.6) 1.50 (1.5) 1.55 (1.5) 2.89 (1.1) 2.89 (1.1) 2.89 (1.1) 
Months in care, mean (SD) 15.1 (7.4)a 15.7 (7.5)a 15.5 (7.5)a 23.4 (9.2)a 21.4 (7.8)a 22.2 (8.4)a 
Agency type, % (n      
 County 54 (627) 54 (1361) 54 (1988) 25 (201) 29 (363) 28 (564) 
 Private 46 (531) 46 (1139) 46 (1670) 75 (598) 71 (892) 73 (1490) 
Sex, % (n      
 Male 53 (617) 52 (1302) 52 (1919) 54 (432) 52 (658) 53 (1090) 
 Female 47 (541) 48 (1198) 48 (1739) 46 (367) 48 (597) 47 (964) 
Placement type, % (n      
 Kinship 57 (665)a 53 (1335)a 45 (1658)a 47 (376) 38 (608) 48 (984) 
 Nonkinship 43 (493)a 47 (1165)a 55 (2000)a 53 (423) 52 (647) 52 (1070) 
Total 1158 2500 3658 799 1255 2054 

—, not applicable.

a

Significant difference in percentages or means between Black and non-Black children at α = .05 according to Pearson’s χ2 test (proportions) or the t test (means).

Results of logistic regressions are provided in Table 2. Of note, Black children had lower odds of attending all WCVs while in state care compared with non-Black children (odds ratio [OR]: 0.78; 95% confidence interval [CI]: 0.64–0.94), and Black children also had lower odds of attending a WCV in the past year while in care (OR: 0.60; 95% CI: 0.38–0.94). Children placed with a relative had lower odds of attending all WCVs compared with children in nonkinship placements (OR: 0.87; 95% CI: 0.76–0.99).

TABLE 2

ORs and Corresponding CIs for Children Aged 0–5 Years Attending (1) All WCVs (Versus Not Attending All Visits) and (2) at Least 1 WCV in the 2019 Calendar Year (Versus No Visits) While in State Custody

VariableQuestion 1: Attending All WCVs While in State CareQuestion 2: Attending Any WCV in 2019
Private agency (reference: county), OR (95% CI) 1.31 (1.01–1.70)* 1.34 (0.86–2.08) 
Months in care, OR (95% CI) 1.03 (1.02–1.04)*** 1.02 (0.99–1.05) 
Black (reference: non-Black), OR (95% CI) 0.78 (0.64–0.94)* 0.60 (0.38–0.94)* 
Age (y), OR (95% CI) 0.96 (0.89–1.03) 0.50 (0.44–0.58)*** 
Male sex (reference: female), OR (95% CI) 0.90 (0.79–1.03) 1.21 (0.80–1.83) 
Kinship placement (reference: nonkinship), OR (95% CI) 0.87 (0.76–0.99)* 1.31 (0.84–2.03) 
Total 3649 2054 
VariableQuestion 1: Attending All WCVs While in State CareQuestion 2: Attending Any WCV in 2019
Private agency (reference: county), OR (95% CI) 1.31 (1.01–1.70)* 1.34 (0.86–2.08) 
Months in care, OR (95% CI) 1.03 (1.02–1.04)*** 1.02 (0.99–1.05) 
Black (reference: non-Black), OR (95% CI) 0.78 (0.64–0.94)* 0.60 (0.38–0.94)* 
Age (y), OR (95% CI) 0.96 (0.89–1.03) 0.50 (0.44–0.58)*** 
Male sex (reference: female), OR (95% CI) 0.90 (0.79–1.03) 1.21 (0.80–1.83) 
Kinship placement (reference: nonkinship), OR (95% CI) 0.87 (0.76–0.99)* 1.31 (0.84–2.03) 
Total 3649 2054 

In the analysis, clustered robust SEs were used for generating CIs at the agency level.

*

P < .05.

**

P < .01.

***

P < .001.

Although it is mandated that children entering state care attend all American Academy of Pediatrics–recommended WCVs, only 66% of 0- to 5-year-old children met this requirement. The percentage of young children in state care attending any WCV in the past year, however, was 95%, higher than both national (89%) and state (92%) levels.6  This proportion was also higher than that of other subgroups of children. Nationally, 82% of children with >1 adverse childhood experience (eg, parent or guardian served time in jail) and 76% of children living in poverty attended a WCV in the past year.6  Thus, being in state care may engage some children in WCVs who otherwise would not have received preventive care. A limitation of the current study, however, is that data only included information on WCVs while a child was in state care. Thus, we were unable to compare WCVs attended for children who were not in state care.

Children placed in kinship care were less likely to attend all WCVs while in care, and we posit that this is due to less caseworker involvement in kinship care cases compared with nonrelative foster care. Children in kinship placements experience fewer behavioral problems and mental health disorders, better well-being, and less placement disruption.7,8  Given time and resource constraints, we hypothesize that caseworkers might bias their efforts toward nonrelative foster care cases, including ensuring that these cases are adhering to state policy (eg, WCV attendance). Additionally, there are likely caseworker reporting errors within the administrative data system. These errors may be systematic (eg, caseworkers might be less likely to collect data from kinship placements compared with nonkinship placements); however, we do not know the exact nature of such biases.

Although more children in a midwestern state’s care attended WCVs compared with children in the general or other high-risk populations, Black children were less likely to attend WCVs. Not only are Black children more likely to become involved in the child welfare system,9  but our analyses also suggest that Black children do not receive equal treatment within the system. As described above, this may be due to caseworkers focusing more on certain cases at the expense of others. Indeed, we found a higher proportion of Black children in kinship placements compared with non-Black children, and kinship placements may not receive equal caseworker effort compared with nonkinship placements. Yet significant racial disparities in WCV attendance remained even after controlling for placement type. Given systematic biases and the overrepresentation of Black children within the child welfare system, this finding may be an artifact of caseworker overload in counties with a higher proportion of Black individuals as a percentage of the total population. In future work, researchers should consider how primary care providers and caseworkers can support Black children in state care to encourage on-time WCVs.

Children within state care attend WCVs at higher rates compared with children in the general population and other at-risk groups. Racial disparities in WCVs, however, perpetuate within the child welfare system.

Dr Sokol conceptualized and designed the study, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Miller and Ryan supported the conceptualization of the study, reviewed and revised the analytic plan, and critically reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded by a postdoctoral award through the Eunice Kennedy Shriver National Institute of Child Health and Human Development (F32HD100021-01). Funded by the National Institutes of Health (NIH).

CI

confidence interval

OR

odds ratio

WCV

well-child care visit

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.