Children and Youth Services Review 73 (2017) 100–106

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Emotional and behavioral problems of children in residential care:

Screening detection and referrals to mental health services
Carla González-García a, Amaia Bravo a,⁎, Ignacia Arruabarrena b, Eduardo Martín c,
Iriana Santos d, Jorge F. Del Valle a
a
Universidad de Oviedo, Spain
b
Universidad del País Vasco, Spain
c
Universidad de La Laguna, Spain
d
Universidad de Cantabria, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Adverse family conditions, abuse and neglect during childhood present important risk factors for the appearance
Received 28 September 2016 of emotional and behavioral problems. The main aim of this paper is to describe the presence of these kinds of
Received in revised form 12 December 2016 disorders in children in residential child care and to explore individual, socio-family and care process factors as-
Accepted 12 December 2016
sociated with the use of mental health services. The sample consisted of 1216 children 6–18 years old in residen-
Available online 13 December 2016
tial care in several Spanish regions. Information about emotional and behavioral problems was gathered
Keywords:
according to two criteria: receiving some kind of treatment services and/or being identified as within the clinical
Psychological disorders range in the Child Behavior Checklist (CBCL). Results showed that 49% of cases were receiving some kind of men-
Residential child care tal health treatment and 61% were identified as within the clinical range in some of the broad band scales of the
Mental health services CBCL. In terms of agreement between referral to treatment and CBCL scores, results showed that four out of ten
CBCL cases identified as within the clinical range were not receiving any kind of treatment. Several factors related to
the type of problems detected in the CBCL, personal variables, and child care arrangements are associated with
greater use of mental health services.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
National child welfare statistics show that in Spain 35,682 children
and adolescents were in an out-of-home placement due to severe situ-
ations of abuse or neglect at the end of 2014, of that number 13,563
were in residential care (Observatorio de la Infancia [Child
Observatory], 2016). These children have experienced very unfavorable
circumstances, living in family environments with many problems such
as adverse economic situations, gender violence, mental health prob-
lems, and drug addiction (Sainero, Bravo, & Del Valle, 2014). Research
has shown clear evidence of the way in which these adverse conditions
jeopardize psychological functioning, encourage the appearance of
emotional and behavioral disorders (D'Andrea, Ford, Stolbach,
Spinazzola, & van der Kolk, 2012; Greger, Myhre, Lydersen, & Jozefiak,
2015; McLaughlin et al., 2012; Segura, Pereda, Guilera, & Abad, 2016)
Abbreviations: CBCL, Child Behavior Checklist; UASC, unaccompanied asylum seeking
children.
⁎ Corresponding author at: Amaia Bravo. Facultad de Psicología, Plaza Feijoo s/n, 33003
Oviedo, Spain.
E-mail addresses: carla.gonzalez.garcia@gmail.com (C. González-García),
amaiabravo@uniovi.es (A. Bravo), ignacia.arruabarrena@ehu.es (I. Arruabarrena),
edmartin@ull.edu.es (E. Martín), iriana.santos@unican.es (I. Santos), jvalle@uniovi.es
(J.F. Del Valle).
and can lead to maladaptation, not only in childhood, but adulthood
as well (Jonson-Reid, Kohl, & Drake, 2012; Ramiro, Madrid, & Brown,
2010).
Research by Raviv, Taussig, Culhane, and Garrido (2010), demon-
strated the cumulative effect of adverse experiences; the more risk fac-
tors that are present, the more probable the presence of mental health
problems. Other studies identified factors like exposure to violence,
presence of severe neglect, age at first placement and number of place-
ments as predictors of various psychiatric disorders (Lehmann, Havik,
Havik, & Heiervang, 2013). Instability of care placement (foster and res-
idential) has been shown to be a factor with a significant impact on the
mental health of children and adolescents. Several changes of foster
family and residential placement have been associated with the pres-
ence of externalizing and internalizing emotional and behavioral prob-
lems (Del Valle, Bravo, Álvarez, & Fernanz, 2008; Newton, Litrownik, &
Landsverk, 2000; Rubin, O'Reilly, Luan, & Localio, 2007).
Consequently, these children present varied mental health prob-
lems, with externalizing disorders being particularly significant
(Schmid, Goldbeck, Nuetzel, & Fegert, 2008; Vanschoonlandt,
Vanderfaeillie, Van Holen, De Maeyer, & Robberechts, 2013). Keil and
Price (2006), analyzing a wide range of studies, estimated that an aver-
age of 42% of these children have this type of disorder. Other diagnoses,
such as depression (Jozefiak et al., 2016) and post-traumatic stress

http://dx.doi.org/10.1016/j.childyouth.2016.12.011
0190-7409/© 2016 Elsevier Ltd. All rights reserved.
 C. González-García et al. / Children and Youth Services Review 73 (2017) 100–106
disorder are also frequent (Keller, Salazar, & Courtney, 2010), as is the
presence of comorbidity (Bronsard et al., 2011; Lehmann et al., 2013).
Other studies have noted the incidence of serious problems such as con-
sumption of addictive substances (Leslie et al., 2010; Traube, James,
Zhang, & Landsverk, 2012) and suicidal behaviors (Bronsard et al.,
2011; Heneghan et al., 2013; Taussig, Harpin, & Maguire, 2014).
Thus, the prevalence of mental health problems in this population is
particularly high ranging from 40% to 88% (Burns et al., 2004; Garland et
al., 2001; Jozefiak et al., 2016; McMillen et al., 2005) and clearly higher
than estimates in the general population (Ford, Vostanis, Meltzer, &
Goodman, 2007; Sempik, Ward, & Darker, 2008). Even though research
confirms the increased presence of clinical problems, the ratio of preva-
lence varies from study to study. This variation is likely due to different
factors such as the sample type (age, residential or family foster care),
differences between the child welfare systems in each country or the
methodology used.
Tellingly, a significant proportion of children with mental disorders
are not receiving mental health treatment (Burns et al., 2004; Sainero
et al., 2014; Tarren-Sweeney, 2010). Factors that have been associated
with higher probability of referral to these services include: a history
of sexual abuse (Leslie, Hurlburt, Landsverk, Barth, & Slymen, 2004),
older children (Raghavan, Inoue, Ettner, Hamilton, & Landsverk, 2010),
ethnic origin (Horwitz et al., 2012) and intellectual disability or mental
disorders in the parents (Farmer et al., 2010).
Given the importance of mental health disorders of children in care
and the lack of a nationwide study in Spain, this study has two goals: (a)
to describe the emotional and behavioral problems in children in resi-
dential care using the CBCL; and (b) to examine the therapeutic cover-
age they are receiving and determine which factors are associated
with referral to treatment and which may be hindering detection and
impeding the referral decision.
2. Method
2.1. Participants
The sample comprised 1216 children, 524 girls (43.1%) and 692 boys
(56.9%) between 6 and 18 years old (M = 13.43, SD = 2.97) who had
been living in residential facilities for at least 3 months. The sample in-
cluded all children of this age who were in residential care in the regions
of Asturias, Cantabria, Extremadura, Murcia, Guipúzcoa, Tenerife and
seven SOS Children's Villages located in various parts of Spain. Most of
the sample was Spanish, but there were also 153 children of immigrant
families (12.6%) and 94 unaccompanied asylum seeking children
(UASC) (7.7%).
2.2. Instruments and procedure
The following variables were collected through a questionnaire that
was designed for this research: (a) intervention process (length of stay,
number of changes of residential facility, reason for admission, type of
maltreatment); (b) family characteristics and background; and (c) exis-
tence of a diagnosis of intellectual disability, suicidal behavior, detection
of emotional and behavioral problems, therapeutic attention, and type
of mental health treatment (psychiatric, psychological and/or
pharmacological).
In order to objectively assess the need for clinical attention, the Child
Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) was used as a
screening tool. It has broad assurance of reliability and validity with a
Cronbach alpha coefficient of 0.92, test-retest reliability of 0.92 for
broad band scales (Achenbach et al., 2008) and has been widely used
with children in residential care. The CBCL provides eight specific clini-
cal subscales and three broad band scales: internalizing, externalizing,
and total score. The T-scores from the broad band scales allow classifica-
tion of cases into three ranges: normal, borderline, and clinical. Cases
are considered clinical only if scores are in the clinical range (excluding
101
the borderline range) in any of the broad band scales (internalizing, ex-
ternalizing, and/or total). The number of cases with CBCL assessment
was reduced to 1182 as 34 questionnaires were discarded for not meet-
ing validity criteria.
The data were collected during the year 2013 with the cooperation
of key residential workers (in Spain they are social educators) to com-
plete the questionnaires about intervention process, family background
and therapeutic services. CBCL assessments were carried out by psy-
chologists of the research team visiting all the residential facilities in
the sample. The study design was approved by the Ethics Committee
of the Faculty of Psychology of the University of Oviedo.
Bivariate analysis with chi-square and Student's t-test was carried
out. Logistic regression analysis was done to study the predictive capac-
ity of the case variables for referral to mental health treatment. The var-
iables included in the model were those that had been shown to have a
significant association with the variable “being in treatment”. The de-
gree of significance was established at p ≤ 0.05 in all analyses.
3. Results
3.1. Characteristics and risk factors in children, young people, and families
The mean stay in residential care was 42.6 months. The reason for
residential care in 61.8% of the cases was abuse or neglect experiences
when living with their families. Others were referred to care for aban-
donment or due to the child's behavioral problems. 43.7% of those
who were victims of abuse and neglect suffered various types of mal-
treatment. Physical and emotional neglect were the most frequent
types of maltreatment (43.9% and 36.7% of children in this sample).
Emotional abuse was suffered by one in four children, physical abuse
by one in five and 4.5% of the sample presented a history of sexual
abuse. Near 80% of the children had at least one family risk factor or
background of psychosocial problems. The most common risk factors
were an adverse economic situation (41.3%), and alcohol and other sub-
stance abuse (40.3%). In addition, a third of the sample had a family his-
tory mental health issues (30.3%).
3.2. Mental health problems and associated factors
Almost half of the children, 48.7% had been referred for some kind of
mental health treatment (of those, 48.4% received only psychological
treatment, 13% only psychiatric treatment, and 34% received both treat-
ments simultaneously). 43.2% of the children being treated were receiv-
ing psychotropic medication, in 3% of the cases this was the only
treatment received, with no associated psychiatric or psychological
treatment. 16.5% had a diagnosis of intellectual disability, of whom
71.9% received mental health treatment and 50.3% received psychotro-
pic medication. Furthermore, 7.5% of the children had displayed suicidal
behaviors in the form of threats (6%) or attempts (2.4%).
In the CBCL, 61.1% of the cases were in the clinical range in some
broad band scale (51.1% on the externalizing scale and 30.7% on the in-
ternalizing scale). Table 1 shows detailed results of the rest of the
subscales.
Table 2 shows the relationship between scoring in the clinical range
of the CBCL and personal, family, or care process variables; the following
values were found to be positively significant: changes of residential fa-
cility (t = −2.209, p = 0.027), intellectual disability (χ2 = 4.828, p =
0.028), receiving pharmacological (psychotropic) treatment (χ2 =
44.119, p b 0.001), suicidal behaviors (threats or attempts) (χ2 =
32.660, p b 0.001), and parental incapability of controlling the child's be-
havior as the reason for care (χ2 = 27.505, p b 0.001). The following var-
iables were associated with a lower probability of being in the clinical
range: age between 6 and 8 (χ2 = 8.446, p = 0.038), good academic
performance (χ2 = 23.098, p b 0.001), and being an unaccompanied
asylum seeking child (χ2 = 13.213, p b 0.001).
102 C. González-García et al. / Children and Youth Services Review 73 (2017) 100–106

Table 1 Logistic regression was carried out in order to examine the factors
Cases within the CBCL clinical range receiving treatment. predicting referral for treatment. The significant variables from the bi-
CBCL Scale CBCL (n = 1171) variate analysis were added to the model along with the
Clinical range n Clinical cases receiving treatment n
sociodemographic variables (age and sex) due to their possible influ-
(%) (%) ence as significant factors on the results. This analysis showed the vari-
ables which were better at predicting treatment referral. A significant
Anxiety-depression 127 (10.8) 102 (80.3)
Withdrawal-depression 197 (16.8) 126 (64.0) function [χ2 (26) = 266.749; p b 0.001; 001; Negelkerke's R2 =
Somatic complaints 102 (8.7) 71 (69.6) 0.361] that accounted for 73.9% of cases was found. The results (Table
Social problems 213 (18.2) 169 (79.3) 3) showed that the individual factors, intellectual disability (OR =
Thought problems 123 (10.5) 104 (84.6) 2.59, p ≤ 0.001), suicidal behaviors (OR = 2.34, p = 0.023), having suf-
Attentional problems 214 (18.3) 151 (70.6)
Disruptive behavior 290 (24.8) 187 (64.5)
fered sexual abuse (OR = 2.28, p = 0.044), experiences of previous fos-
Aggressive behavior 329 (28.1) 219 (66.6) ter care or adoption breakdown (OR = 1.80, p = 0.017), and
Internalizing 359 (30.7) 248 (69.1) background of mental health disorders in the family (OR = 1.56, p =
Externalizing 598 (51.1) 362 (60.5) 0.050) all increase the likelihood of receiving treatment. Likewise, the
Total 543 (46.4) 360 (66.3)
identification of a clinical range in the CBCL in the internalizing
Any broadband 715 (61.1) 426 (59.6)
(OR = 1.75, p = 0.017) and total scales (OR = 2.37, p = 0.001) but
not in the externalizing scale were significant predictors. Lastly, being
3.3. Match between mental health needs detected and the use of mental an unaccompanied asylum seeking child was associated with a lower
health services probability of receiving treatment (OR = 0, 11, p ≤ 0.001).

Data analysis allowed the appraisal of the level of agreement be-
tween the detected need (results of the CBCL) and care received
(cases that were referred to treatment).
Table 1 shows the percentages of clinical cases in the narrow and
broad band scales and the proportion of those cases receiving treat-
ment. The percentage of referrals to treatment was lower for the aggres-
sive and disruptive scales and for the internalizing scale of withdrawal-
depression. In contrast, there were more referrals for the scales of
thought problems and anxiety-depression.
The analysis of the match between cases identified by the CBCL as
clinical range in any of the broad band scales and the use of mental
health services indicates that 40.4% of cases within the clinical range
did not receive treatment. This group, which constitutes 24.7% of the
total sample, deserves special attention.
3.4. Factors associated with the use of mental health services.
In order to examine the factors that may be related to referral to
mental health services more deeply, an analysis was performed on the
association of personal, family, and care process variables with the use
of these services. In terms of the individual factors related to the use
of therapeutic services (Table 2), mean age was found to be significantly
higher in the group of cases receiving treatment (t = − 2.078, p =
0.038). This difference is explained by the lower rate of referrals in the
group of children aged 6–8 (χ2 = 8.344, p = 0.039), where fewer clin-
ical problems were detected. Other individual variables associated with
receiving treatment were intellectual disability (χ2 = 50.892, p b 0.001),
and suicidal behaviors (χ2 = 44.268, p b 0.001).
Four factors of the care process associated with receiving mental
health treatment (Table 2) were identified: a significantly higher
mean length of stay in the group receiving treatment (t = − 2.060,
p = 0.040), experiences of breakdown (of adoption or foster care)
(χ2 = 12.130, p b 0.001), the number of changes of residential facilities
(t = − 3.025, p = 0.003), and the following reasons for admission:
emotional neglect (χ2 = 17.711, p b 0.001), physical abuse (χ2 =
12.642, p b 0.001), emotional abuse, (χ2 = 36.444, p b 0.001), sexual
abuse (χ2 = 13.539, p b 0.001) and parental inability to control child's
behavior (χ2 = 38.622, p b 0.001). When it comes to variables related
to the family, the following were significant; background of mental
health disorders (χ2 = 18.359, p b 0.001), intellectual disability in one
of the parents (χ2 = 4.402, p = 0.036), and the mean of associated fam-
ily risk factors (t = −2.447, p = 0.015). In contrast, individual variables
such as good academic performance (χ2 = 25.654, p b 0.001) or being
unaccompanied asylum seeking children (χ2 = 42.161, p b 0.001)
were associated with a lower probability of receiving treatment.
4. Discussion
The first goal of this study was to analyze the presence of emotional
and behavioral problems in cases that had been identified by the CBCL
as within the clinical range. The results reveal a high presence of emo-
tional and behavioral alterations in this population, as almost two-
thirds (61%) scored in the clinical range of the CBCL. These results are
in line with international studies of reference, such as Burns et al.
(2004) in the USA, who, using CBCL data in a sample of 3803 children
between 2 and 14 years in out-of-home care, concluded that 47.9%
were within the clinical range, a figure that rose to 88.6% in the case of
children in residential care. Although these figures and those in other
studies such as Ford et al. (2007) in Great Britain are higher than
those in the current study, it should be noted that residential care is ap-
plied restrictively in those countries, only to cases of adolescents with
severe behavioral problems.
Our results also showed a greater presence of externalizing disorders
(51.1%) versus internalizing disorders (30.7%) in agreement with previ-
ous research (Schmid et al., 2008; Vanschoonlandt et al., 2013).
Other factors of clinical relevance were also seen in the current
study, such as the high presence of cases with intellectual disability
(16.5%), most of whom (72%) were receiving treatment. Various studies
show that cases with intellectual disability in residential care are more
unstable and undergo more breakdowns and changes in care place-
ments (Hill, 2012), as well as presenting a greater number of clinical
problems with a different progression from that of other children in res-
idential care (Sainero, Del Valle, López, & Bravo, 2013). No doubt, chil-
dren with intellectual disability in residential care as a group should
receive more research and intervention attention (Tarren-Sweeney,
2008), due to their specific needs and vulnerable situation (Trout et
al., 2009). It is also important to highlight the onset of suicidal behaviors
among these children. Suicidal behaviors (threats and attempts)
accounted for 7.5% of the sample, but this might be an underestimation
bearing in mind that the information was obtained from social educa-
tors. The prevention and early detection of self-harming behaviors are
fundamental due to the severe consequences they imply.
Another of the study's goals was to analyze referrals to therapeutic
services and to determine which individual, socio-family, and care pro-
cess factors are associated with presenting clinical range problems and
with receiving treatment. With regard to therapeutic coverage, almost
half of the sample was receiving mental health treatment. The identifi-
cation of clinical ranges was significantly more frequent in children who
had changed residential care placement more times, cases of intellectual
disability, suicidal behavior, and those in which the child's behavioral
problems were the reason for admission into care. In contrast, the clin-
ical range was less frequent in children with good school adjustment,
 C. González-García et al. / Children and Youth Services Review 73 (2017) 100–106 103

Table 2
Individual, family, and care process factors and differences in the CBCL results and use of therapeutic services.

Variable Total Clinical range CBCL Mental health treatment

(N = 1216) (n = 1182) (n = 1204)

% or M (SD) Yes % or M No % or M Yes % or M No % or M

(SD) (SD) (SD) (SD)

TOTAL 100 61.3 38.9 48.7 51.3

Sex
Male 56.9 55.2 58.5 58.3 55.6
Female 43.1 44.8 41.5 41.7 44.4

Age 13.43 13.52 13.25 13.62 13.27

(2.97) (3.15) (2.86) (2.75)⁎ (3.15)
6–8 8.3 6.6⁎ 11.1 5.8⁎ 10.2
9–11 17 18 15.5 16.8 17.4
12–14 30.1 31.2 28.6 31.8 28.9
15–17 44.6 44.2 44.8 45.6 43.5

Ethnic group
Gypsy ethnic group 12.5 13.5 11.2 10.8 14.4
Immigrant family 12.6 12.9 12.5 12.5 12.8
UASC 7.7 5.2⁎⁎⁎ 11.2 2.6⁎⁎⁎ 12.8

Mean stay 42.61 44.42 40.55 45.35⁎ 40.50

(37.62) (38.97) (35.25) (42.14) (33.10)

Break-down 13 13.5 12.6 16.8⁎⁎⁎ 9.5

Foster care break-down 11.1 11.3 11.4 13.8 8.6
Adoption break-down 1.9 2.2 1.2 2.9 0.9

Number of changes of residential facility 0.90 0.94(1.05)⁎ 0.81(0.92) 1.0(1.08)⁎⁎ 0.82(0.94)

(1.0)
0 39.7 38.2 42.7 36.9 42.1
1 40.7 40.7 41.8 38 43.1
2 12.7 14.2 9 17.8⁎⁎⁎ 8.1
≥3 6.9 6.9 6.5 7.3 6.7

Academic performance
Good 10.9 8.3⁎⁎⁎ 15.7 6.9⁎⁎⁎ 14.7
Medium 19.1 17.2 22.2 17 21
Poor 62.2 67 55.2 66.5 58

Intellectual disability 16.5 18.2⁎ 13.2 24.4⁎⁎⁎ 8.9

Medication 20.8 26.9⁎⁎⁎ 10.6 – –

Suicidal behavior 7.5 10.9⁎⁎⁎ 1.8 12.9⁎⁎⁎ 2.5

Threats 6 8.8 1.5 10.3 2
Attempts 2.4 3.4 0.4 4.3 0.5

Reason for care

Physical neglect 43.9 45.7 41.6 46.7 40.8
Emotional neglect 36.7 39.5 33.9 42.8⁎⁎⁎ 30.6
Physical abuse 19.8 21.2 18.2 24.2⁎⁎⁎ 15.6
Emotional abuse 26.7 28.9 24.5 34.9⁎⁎⁎ 18.9
Sexual abuse 4.5 5.5 3.3 7⁎⁎⁎ 2.2
Abandonment 11.3 12.4 9.8 12.9 9.8
Out of parental control 35.5 41.3⁎⁎⁎ 25.7 44.4⁎⁎⁎ 26.6

Family antecedents
Substance abuse 40.1 40.5 40.2 40.5 40.1
Mental health disorders 30.3 31.9 28.6 36.2⁎⁎⁎ 24.7
Criminal acts 18.8 18.6 20.2 20 17.7
Intellectual disability 15.7 15.6 15.5 18.2⁎ 13.6
Suicide 7.8 8.3 7.2 8.9 6.8
Gender violence 25.1 27.1 22.6 26.5 24
Poverty 41.3 42.7 38.6 39.7 42.5
Mean factors 1.79(1.44) 1.85(1.44) 1.73(1.46) 1.89(1.46)⁎ 1.69(1.41)
⁎ p ≤ 0.05.
⁎⁎ p ≤ 0.01.
⁎⁎⁎ p ≤ 0.001.

younger children (6–8 years), and unaccompanied asylum-seeking
children.
Several of these factors deserve special attention. Changes of resi-
dential placement may be an expression of the child's emotional and be-
havioral problems that impair his or her adaptation to those facilities.
However, the changes in themselves may also be worsening the clinical
problem, given that new experiences of breakdown and failure can
increase these children's emotional distress (Uliando & Mellor, 2012).
Good school performance is among the factors associated with fewer
problems, becoming an indicator of adaptation that has also been linked
to these youngsters' well-being (Casas, Bello, González, & Aligué, 2012).
The results referring to unaccompanied asylum-seeking children, how-
ever, must be taken with caution, as the expression of their emotional
problems depends on cultural patterns, and practitioners could have
104 C. González-García et al. / Children and Youth Services Review 73 (2017) 100–106

Table 3 not presenting such clinical indicators. This may reflect how other fac-
Logistic regression model of the use of mental health services. tors, such as a history of sexual abuse or intellectual disability, among
Selected variables OR 95% CI others, drive referral to therapy because their impact as risk factors
Sociodemographic variables
might be recognized by the professionals. In contrast, it is also signifi-
Sex 1.39 0.99–1.94 cant that, of those who present clinical symptomatology, 60% receive
Age 1.00 0.94–1.06 treatment, but four out of ten cases do not receive treatment (due to
Unaccompanied asylum seeking child UASC (vs no UASC) 0.11⁎⁎ 0.04–0.29 lack of identification of the problem or child's rejection of therapy).
Variables of the care process This group primarily presents externalizing problems, with overrepre-
Time in residential care 1.00 0.99–1.00 sentation of unaccompanied asylum-seeking children. The existence of
Experiences of break-down 1.80⁎ 1.11–2.91 protocols and systematic detection tools of mental health needs should
Number of facilities 1.08 0.90–1.30
be a key strategy to ensure detection and early referral to treatment (He,
Individual factors Lim, Lecklitner, Olson, & Traube, 2015; Pecora, Jensen, Romanelli,
Intellectual disability 2.59⁎⁎ 1.59–4.22 Jackson, & Ortiz, 2009).
Suicidal behavior 2.34⁎ 1.12–4.86

Type of vulnerability 4.1. Limitations

Emotional neglect 0.98 0.68–1.41
Physical abuse 1.17 0.72–1.89
Among the limitations of this work is the fact that it is impossible to
Emotional abuse 1.22 0.78–1.91
Out of parental control 1.39 0.97–2.00 determine whether the reason for not having been referred to a thera-
Sexual abuse 2.28⁎ 1.02–5.09 peutic service is the difficulty of detecting the clinical problem or
some other reason, such as the child's reluctance to receive therapy
CBCL Clinical range
Clinical externalizing (vs. non-clinical) 1.33 0.71–2.47
(Aventin, Houston, & Macdonald, 2014), the educators' decision to ad-
Clinical internalizing (vs. non-clinical) 1.75⁎ 1.10–2.76 dress some problems (especially externalizing problems) using their
Total Clinical (vs. non-clinical) 2.37⁎⁎ 1.45–3.87 own resources, or even structural issues, such as the availability and
Any broad-band score 0.913 0.45–1.83 heterogeneity of the therapeutic resources employed (Galan, 2014).
Family antecedents The use of the CBCL as the unique instrument to detect mental health
Intellectual disability 0.96 0.58–1.60 disorders could be another limitation. However, the CBCL is used in
Mental health antecedents 1.56⁎ 0.99–2.44 this study just as a screening tool to classify children in clinical and
Mean risk factors 0.89 0.76–1.05
non-clinical categories. A proper mental health assessment would
⁎ p ≤ 0.05. need specific diagnostic interviews and other multi-informant
⁎⁎ p ≤ 0.001.
approaches.

difficulties detecting and interpreting some behaviors and emotions 5. Conclusions

(Westwood, 2012). There is a broad range of research on the emotional
problems of these young people that confirms the presence of disorders
derived from the immigration experience, family and cultural break-
down, lack of support, and problems of adaptation in the host country
(Bravo & Santos, 2016; Bronstein, Montgomery, & Ott, 2013; Jakobsen,
Demott, & Heir, 2014). Much more research is required about this spe-
cific group, taking into account those cultural factors and the peculiari-
ties of these youngsters' emotional and behavioral expression.
The relationship between the symptomatology detected in the CBCL
and the use of therapeutic services was also analyzed. Externalizing
problems and problems of withdrawal and depression were referred
to therapy in a lower proportion than anxiety and thinking disorders.
This could be explained by different hypotheses that are still to be ex-
plored. One suggestion is that in spite of externalizing problems being
easier for educators to detect (Sainero, Del Valle, & Bravo, 2015), they
may also be associated with greater rejection of therapy by those ado-
lescents. A second hypothesis is that the behavioral and emotional prob-
lems expressed in the form of violence and disruptive behavior may be
accepted by the care workers as part of their work goals. In contrast,
when faced with internalizing problems and psychological disorders
too complex to be addressed by “socio-educative” intervention strate-
gies, they tend to demand therapeutic services. The recent development
of residential child care in Spain, increasingly oriented towards adoles-
cents with severe disruptive problems (Bravo & Del Valle, 2009), has led
to the specialization of many educators and the development of strate-
gies to address these kinds of externalizing problems but training on
how to address internalizing problems is still very scarce. In this sense,
we believe that educators should also be trained in the detection and
management of internalizing problems of children in residential care
(Raghavan et al., 2010; Romanelli et al., 2009).
Besides clinical symptomatology, other factors appear to be associat-
ed with greater use of these services. According to the results of this
study, three out of four children who receive treatment present clinical
symptomatology, whereas one child in four receives therapy in spite of
This study analyzes the psychological needs of children and young
people in residential care in Spain for the first time. The results show a
high prevalence of emotional and behavioral problems congruent with
adverse early experiences and the risk factors to which these victims
of maltreatment have been exposed. Similarly, this study highlights
how referral to treatment varies depending on the type of disorder
and on criteria that are not objective; some children with clinical prob-
lems are not referred to treatment while some children with no clinical
indicators are receiving therapy. We would also like to highlight the ex-
istence of two groups with special characteristics. On the one hand,
there is a significant presence of children with intellectual disability,
who are also affected by important clinical problems and adaptation dif-
ficulties. Future research should look more deeply into the alternative of
family foster care to provide a more stable environment as well as more
individualized care, as has been pointed out in other studies (Sainero et
al., 2013). On the other hand, addressing the emotional and behavioral
problems of unaccompanied asylum-seeking children requires specific
strategies. There is a need to establish mechanisms to ensure the detec-
tion of mental health problems in this group, developing instruments
adapted and sensitive to their particularities, as well as training the pro-
fessionals who work directly with them about the types of disorders
these youngsters present. Likewise, the need to develop strategies to en-
courage children to accept therapy (including the role of the profes-
sionals to engage them in a therapeutic relationship), as well as
professionals' recognition of the importance of externalizing symptom-
atology as an expression of these children's suffering and distress, are
important practical conclusions of this research.
Funding
This research has been supported by the Ministry of Economy and
Competitiveness of Spain through the National Plan of I + D + i
(PSI2012-33185).
 C. González-García et al. / Children and Youth Services Review 73 (2017) 100–106
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