Journal of Child and Family Studies, Vol. 7, No. 3, 1998, pp.

283-296

Mental Health Problems of Children in Foster

Care
June M. Clausen, Ph.D.,1,6 John Landsverk, Ph.D.,2 William Ganger,
MA.,3 David Chadwick, M.D.,4 and Alan Litrownik, Ph.D.5

We compared the rates of mental health problems in children in foster care

across three counties in California. A total of 267 children, ages 0 to 17, were
assessed two to four months after entry into foster care using a behavioral
screening checklist, a measure of self-concept and, in one county, an adaptive
behavior survey. Results confirmed previous research and indicated consistently
high rates of mental health problems across the three counties. Behavior
problems in the clinical or borderline range of the CBCL were observed at
two and a half times the rate expected in a community population. Fewer
children fell within the clinical range on the self-concept measure. No
significant differences in rates between the three county foster care cohorts were
observed, despite the different demographic characteristics of the counties. On
the adaptive behavior scale, the mean scores for children in foster care were
more than one standard deviation below the norm. Our findings suggest that
the most important mental health screening issue with children in foster care
is to identify what specific mental health problems need to be addressed so
that the most effective treatment services can be provided.
KEY WORDS: foster care; mental health; behavior problem; assessment.

1Assistant Professor, Department of Psychology, University of San Francisco, San Francisco,

CA.
2Professor, School of Social Work, San Diego State University, San Diego, CA.
3Research Associate, Center for Research on Child and Adolescent Mental Health Services,
San Diego, CA.
4Director Emeritus, Center for Child Protection, Children's Hospital, San Diego, CA.
5Professor, Department of Psychology, San Diego State University, San Diego, CA.
6Correspondence should be directed to June Madsen Clausen, Department of Psychology,
University of San Francisco, 2130 Fulton Street, San Francisco, CA 94117. Electronic mail
may be sent to ClausenJ@usfca.edu.

283
1062-1024/98/0900-0283$ 15.00/0 C 1998 Human Sciences Press, Inc.
284 Clausen, Landsverk, Ganger, Chadwick, and Litrownik

Research over the last two decades clearly indicates that children in
foster care are very much in need of attention by mental health profes-
sionals. Several studies, using clinical assessments (e.g., Benedict, Zuravin,
Somerfield, & Brandt, 1996; Fanshel & Shinn, 1978) and standardized
measures (e.g., Hochstadt, Jaudes, Zimo, & Schachter, 1987; Pilowsky,
1995; Trupin, Tarico, Jemelka, & McClellan, 1993) have demonstrated that
children entering foster care exhibit a significant number of behavior prob-
lems and adaptive functioning deficits, far in excess of that expected in the
general population.
Two major factors lead one to expect that children in foster care would
exhibit significantly higher risk for mental health problems than children
who are not in foster care. First, most of these children have experienced
one or more forms of maltreatment sufficiently severe to bring them to
the attention of Child Protective Services. For example, of the 93,294 chil-
dren who received public social services in the state of California from
January to March of 1987, 87% had experienced some form of documented
child maltreatment (California State Department of Social Services, 1988).
The short term (Browne & Finkelhor, 1986; Downs, 1993; Friedrich, 1993)
and long term traumatic effects (e.g. Briere & Runtz, 1993; Finkelhor, Ho-
taling, Lewis, & Smith, 1990; Saunders, Villeponteaux, Lipovsky, Kilpatrick,
& Veronen, 1992) of child maltreatment are well documented.
Second, children in foster care are at heightened risk for mental health
problems due to the negative effect of separation from their family. When
an abused child, who has likely experienced difficulty developing appropri-
ate attachment to his abusing caretakers, is removed from home and placed
in foster care, he/she suffers further due to an inability to separate in a
healthy way (Charles & Matheson, 1990; Kadushin, 1980). Indeed, the
movement from his own home to the foster home engenders feelings of
rejection, guilt, hostility, anger, abandonment, shame and dissociative re-
actions in response to the loss of a familiar environment and the separation
from family and community (e.g., Katz, 1987). Clearly, a child who is
abused or neglected and is subsequently removed from home is at great
risk for the development of mental health problems.
Each of the studies which has documented the high risk for mental
health problems among children in foster care has been confined to sam-
ples of children and adolescents in single child welfare systems. No studies
have systematically compared children in foster care living in different child
welfare systems and in different communities. As noted by Horan, Kang,
Levine, Duax, Luntz, and Tasa (1993), the use of such small, geographically
limited samples is methodologically problematic. Indeed, communities may
differ considerably in their referral patterns into foster care, as suggested
by studies of the impact of minority status and economic disadvantage on
Mental Health Problems of Foster Children 285

child welfare processes (e.g., Garland, Ellis-MacLeod, Landsverk, Ganger,

& Johnson, 1998; Jenkins et al., 1983;). Because minority status and social
class have been shown to be associated with rates of children's mental
health problems (Cohen & Hesselbart, 1993), different rates of mental
health problems might also be found in communities which differ on these
background characteristics.
Furthermore, there are a limited number of studies which have used
standardized measures with well established norms to estimate the mental
health problems of children in foster care. The aim of our study is to con-
duct a comparative analysis, based on standardized assessment instruments,
of children in foster care who were examined for behavior problems, social
competence problems, self-concept, and adaptive functioning in three dif-
ferent counties in California.

METHOD

Subjects

The subjects were children, ages 0 to 17, who were part of the Foster
Children's Health Project, a program designed to enhance the physical and
mental health of children in foster care in three California counties. The
overall study employed a cohort design to examine children consecutively
entering the foster care system in three California counties (Santa Cruz,
Monterey, and San Diego). The counties were heterogeneous with regard
to population size (2.5 million in San Diego, 230 thousand in Santa Cruz,
and 356 thousand in Monterey, respectively), density (585, 515, and 107
persons per square mile for San Diego, Santa Cruz, and Monterey, respec-
tively), and minority population percentage (34.6%, 25.5% and 47.7% for
San Diego, Santa Cruz, and Monterey, respectively), according to the 1990
census (Census Bureau, 1990). All children entering a new episode of foster
care during the one year study enrollment period were eligible for inclusion
in the study.
Comparable study eligibility and data collection methods were used in
the three collaborating sites. Eligibility criteria included: (1) child was in
a new episode of care (determined by the lack of an open case in the local
child welfare system) at the time of entry into foster care; (2) child was
less than 18 years of age at entry into the system; (3) child was placed at
legal disposition into family foster care with a non-relative caretaker; and,
(4) child had remained in the same family foster care placement for at
least two months. The assessments were conducted during the third and
fourth months of placement.
286 Clausen, Landsverk, Ganger, Chadwick, and Litrownik

During the enrollment period, a total of 267 assessments were com-

pleted (130 in San Diego County, 75 in Monterey County and 62 in Santa
Cruz County), comprising 83.4% of the children in foster care who were
eligible to participate in the study. Refusals constituted one third of the
missed assessments. Demographic characteristics of the study sample are
presented in Table 1. Because the research team discovered substantial dif-
ferences between social worker methods for assigning the Welfare and
Institutions Code for the type of abuse, comparisons between the three
counties on type of maltreatment are not reported. Thus, the degree to
which the three cohorts of children in foster care differed in type of mal-
treatment is unknown.

Measures

Due to age restrictions of each measure, some children were assessed

with multiple measures while others completed only a single instrument.
In all three counties, for children in foster care who were age 4-16 at the
time of the assessment (n = 140), the Parent Report Form (PRF) of the
Child Behavior Checklist (CBCL) was used to measure the domains of be-
havior problems and social competence (Achenbach, 1991), as reported by
the primary licensed foster care parent (usually the foster mother).
In all three counties, children age 8-16 at the time of the assessment
(n = 86) completed the Piers-Harris Children's Self-Concept Scale (SCS;
Piers, 1984). The Piers-Harris SCS generates six cluster scores (behavior,
intellectual and school status, physical appearance and attributes, anxiety,
popularity, happiness and satisfaction) as well as a total score. The instru-
ment consists of 80 statements which are answered yes or no. Test-retest
reliabilities range from .43 to .96 with a mean of .73. Internal consistency
coefficients range from .73 to .81 for the cluster scales, with .90 for the
total scale score (Piers, 1984).

Table 1. Demographic Characteristics of Study Sample

San Diego Monterey Santa Cruz
(n = 130) (n = 75) (n = 62)

Percent Male 45.4 56.0 46.8

Percent White* 62.9 34.7 38.8
Mean Age at Time of Removal 5.1 5.7 5.4
from Home (years) SD = 4.8 SD = 5.0 SD = 5.6
*Chi square = 42.4, df = 10, p = .00001.
Mental Health Problems of Foster Children 287

Finally, for subjects in San Diego County only (n = 128), the foster
parent completed the Survey Form of the Vineland Adaptive Behavior
Scales (VABS) (Sparrow, Balla, & Cichetti, 1984), designed for use with
children from birth through age 18. The 297-item VABS is a semi-struc-
tured interview which provides a general assessment of adaptive behavior
across four domains: communication, daily living skills, socialization, and
motor skills. An adaptive behavior composite score is derived from the sum
of the domain scores. Reliability and validity of this instrument is well es-
tablished and documented (Sparrow, Balla, & Cichetti, 1984).

Design and Procedure

Standardized assessment instruments were completed by the foster

child and his or her primary foster parent during an in-home interview
conducted two to four months after the child's placement into the foster
home. The two month minimum time in placement was chosen in order
to decrease the likelihood of measuring the immediate acute effects of
separation from the natural parent home. The intent of the current study
was to determine the prevalence of mental health problems remaining after
the acute transitional stage. In addition, the requirement that the foster
parent informant would have known the foster child for a minimum of two
months was important in order to standardize the measurement process in
an unconventional home living situation.

Analysis

Items on the PRF were used to generate narrow band, broad band,
and total scores for behavioral problems as well as narrow band and total
scores for social competence. Standardized scores, as well as percent of
children reaching borderline and clinical cut-points, were used to compare
children between the three study sites. Tests for statistical significance were
conducted using Chi Square Analysis (for percent differences) and One
Way Analysis of Variance (for differences in mean standardized scores).
The alpha level was set at .05 and was not adjusted for the large number
of comparisons. Rather, in order to decrease the risk of Type II errors
(falsely overlooking differences between the three sites) a higher risk of
Type I errors (falsely finding differences between the three sites) was al-
lowed. Given that the current analysis was designed to explore the
possibility of differences in mental health status based on geographical vari-
ables, this more conservative statistical approach was used to allow for
discovery of any differences that may truly exist between counties.
288 Clausen, Landsverk, Ganger, Chadwick, and Litrownik

RESULTS

The CBCL PRF T-score means and standard deviations by county co-
hort for children ages 4 through 17 on all narrow band, broad band, and
total behavior problem scores are presented in Table 2. All mean scores
are elevated; many are near or at one standard deviation above the mean.
While there are differences between the cohorts, no pattern is readily dis-
cernible, nor are any of the cohort differences statistically significant at the
alpha level of ,05.
The finding of no differences between study sites is repeated in Table
3, which depicts CBCL PRF narrow band and total social competence T-
scores. While all of the scores are depressed (i.e. fall in the direction of

Table 2. Child Behavior Checklist Behavior Scales by Site— Age 4 to 16 Parent Report
Form— Standardized Scores (T)
San Diego Monterey Santa Cruz
(n = 70) (n = 40) (n = 30)

Narrow Band Scales

Withdrawn MEAN 56.9 57.5 57.9
(S.D.) (9.5) (10.0) (7.6)
Somatic Complaiants MEAN 54.9 53.0 56.1
(S.D.) (6.6) (5.2) (8.8)
Anxious/Depressed MEAN 56.3 57.9 59.3
(S.D.) (9.4) (10.3) (7.6)
Social Problems MEAN 60.2 59.3 60.6
(S.D.) (12.2) (9.3) (11.6)
Thought Problems MEAN 60.2 56.0 59.4
(S.D.) (12.0)
\ -----/ (8.5) (9.4)
\----/
\ — /
Attention Problems MEAN 61.3 60.5 59.8
(S.D.) (11.7) (11.9) (8.8)
Delinquent Behavior MEAN 59.9 60.1 57.4
(S.D.) (10.3) (11.4) (9.0)
Aggressive Behavior MEAN 59.5 60.1 60.0
(S.D.) (11.1)
\ / (12.4)
\------ '/ (11.7)
\----'/
Sex Problems MEAN 54.3 54.2 58.1
(S.D.) (8.7) (8.7) (10.6)
(n = 56) (n = 28) (n = 18)
Broad Band Scales
Internalizing MEAN 53.6 53.6 57.4
(S.D.) (11.5) (12.2) (10.7)
Externalizing MEAN 56.1 55.3 57.4
(S.D.) (14.5) (16.8) (12.3)
Total Behavior Problems MEAN 56.7 55.7 59.5
(S.D.) (14.3) (14.7) (11.1)
Mental Health Problems of Foster Children 289

clinical significance), only the total social competence T-score means fall
below the defined cut-points (borderline: <41 and clinical: <37).
In Tables 4 and 5, the results of the CBCL PRF are displayed from
a different perspective, namely, the proportion of children in each site who
meet the borderline and clinical cut-points. In the domain of behavior prob-
lems (Table 4), the published T-score clinical cut-point is 70/71 for narrow
band scales and 63/64 for the broad band and total scales. The published
T-score borderline cut-point is 66/67 for narrow band scales, 59/60 for
broad band and total scales. Over 50% of the children in foster care in
each site have a score over the borderline cut-point and well over 40%
have a score over the clinical cut-point on either a narrow band, broad
band or total behavior problems scale. While there is variation across the
sites, the only statistically significant difference is on the sex problems nar-
row band scale, where significantly more children in foster care from Santa
Cruz County meet the borderline cut-point.
Using the same type of descriptive cut-point analysis, the prevalence
of elevated profiles for children in foster care in the three study sites is
even more pronounced for the CBCL PRF social competence scales. As
seen in Table 5, 47% to 65% of the children have standard scores on at
least one of the social competence scales which are in the clinical range
and over 74% reach the borderline cut-point on at least one scale. How-
ever, only one difference is statistically significant between counties—few
children in foster care in Santa Cruz County fall below the clinical and
borderline cut-points on the activities narrow band scale, as compared to
the children in foster care from the two other counties.
Comparisons between children in foster care age 8-17 across the three
sites on Piers-Harris SCS sub-scale and total scale scores are displayed in
Table 6. The differences between the three sites are not large, do not ap-

Table 3. Child Behavior Checklist Social Competency Scales by Site— 4 to 16 Parent

Report Form— Standardized Scores (T)
San Diego Monterey Santa Cruz
(n = 47) (n = 34) (n = 23)
Narrow Band Scales
Activities MEAN 38.9 42.2 44.0
(S.D.) (11.7) (8.8)
\ / (7.1)
\ /
Social MEAN 38.3 37.6 36.9
(S.D.) (9.4) (8.6) (8.7)
School MEAN 37.0 39.9 35.9
(S.D.) (8.7) (10.3) (8.4)
Total Social Competence MEAN 35.6 36.1 35.9
(S.D.) (10.4) (8.6) (7.9)
290 Clausen, Landsverk, Ganger, Chadwick, and Litrownik

Table 4. Child Behavior Checklist Behavior Scales by Site— Age 4 to 16 Parent Report
Form— Percent with Scores Over Two Clinical Cutpoints
San Diego Monterey Santa Cruz
(n = 70) (n = 40) (n = 30)

Narrow Band Scales

Withdrawn (T > 70) 10.0% 7.5% 10.0%
(T > 66)
V. WJ
14.3% 15.0% 16.7%
Somatic Complaints (T > 70) 2.9% 0.0% 6.7%
(T > 66) 8.6% 2.5% 13.3%
Anxious/Depressed (T > 70) 10.0% 10.0% 3.3%
(T > 66) 11.4% 22.5% 16.7%
Social Problems (T > 70) 17.1% 10.0% 20.0%
(T > 66) 27.1% 25.0% 26.7%
Thought Problems (T > 70) 14.3% 12.5% 16.7%
(T > 66) 22.9% 12.5% 23.3%
Attention Problems (T
V > 70)/ 17.1% 22.5% 13.3%
(T > 66) 32.9% 35.0% 23.3%
Delinquent Behavior (T > 70) 22.9% 20.0% 13.3%
(T > 66) 35.7% 27.5% 23.3%
Agggressive Behavior (T > 70) 18.6% 22.5% 23.3%
(T > 66) 28.6% 27.5% 30.0%
Sex Problems (T > 70) 8.9% 7.1% 22.2%
(T > 66) 10.7% 10.7% 33.3%*
(n = 56) (n = 28) (n = 18)
Broad Band Scales (T > 63) 22.9% 27.5% 30.0%
Internalizing (T > 59) 24.3% 30.0% 46.7%
(T > 63) 35.7% 32.5% 30.0%
Externalizing (T > 59) 47.1% 37.5% 36.7%
Total Behavior (T > 63) 37.1% 37.5% 36.7%
Problems (T > 59) 50.0% 40.0% 50.0%
Any Narrow, Broad (Clinical) 50.0% 42.5% 46.7%
or Total (Borderline) 55.7% 50.0% 66.7%
*p .05.

pear in a pattern, and are not statistically significant. Furthermore, the

mean T scores in all three groups are very close to the T score obtained
from populations of normal children. Indeed, none of the group means is
below the clinical cut-point of 40, which is one standard deviation below
normal.
Similar findings from the Piers-Harris SCS are shown in the display
of the percent of children whose scores are below the cut-point (and thus
in the clinical range) of a T-score of 40 (also shown in Table 6). Only one
statistically significant difference appears; there are significant differences
across the counties on the sub-scale "physical appearance and attributes."
Mental Health Problems of Foster Children 291

Table 5. Child Behavior Checklist Social Competence Scales by Site— School Age Parent
Report Form— Percent with Scores Under Two Clinical Cutpoints
San Diego Monterey Santa Cruz
(n = 47) (n = 34) (n = 23)

Narrow Band Scales

Activities (T < 30) 21.3% 5.9% 0.08%*
(T < 34) 36.2% 26.5% 4.3%*
Social (T < 30) 19.6% 20.6% 26.1%
(T < 34) 32.6% 29.4% 39.1%
School (T < 30) 22.2% 21.9% 26.1%
(T < 34) 40.0% 37.5% 39.1%
Total (T < 37) 60.5% 43.8% 52.2%
Social Competence (T < 41) 67.4% 68.8% 73.9%
Any Narrow (CLINICAL) 65.1% 46.9% 56.5%
or Total (BORDERLINE) 74.4% 75.0% 78.3%
*p .05.

Table 6. Piers-Harris Children's Self Concept T-Scores (Means) and Percent Below
Clinical Cutpoint (T < 40) by Site
San Diego Monterey Santa Cruz
(N = 36) (N = 31) (N = 19)
Behavior MEAN 52.6 49.5 52.3
(S.D.) (9.8) (14.8) (11.0)
(T< 40) 13.9%) 19.4%) 10.5%
Intellectual and MEAN 54.5 50.8 48.8
School Status (S.D.) (9.0) (13.1) (11.0)
(T < 40) 11.1% 22.6% 21.1%
Physical Appearance MEAN 55.5 51.2 53.7
and Attributes (S.D.) (8.3) (13.7) (11.3)
(T < 40) 0.0% 22.6% 10.5*
Anxiety MEAN 50.6 52.5 49.7
(S.D.) (9.3) (11.5) (13.1)
(T< 40) 11.1% 12.9% 31.6%
Popularity MEAN 49.3 48.1 48.9
(S.D.) (9.1) (11.0) (10.6)
(T < 40) 11.1% 16.1% 21.1%
Happiness and MEAN 53.7 51.3 50.5
Satisfaction (S.D) (7.5) (13.2) (12.4)
(T < 40) 5.6% 19.4% 15.8%
Total Score MEAN 55.1 53.8 52.9
(S.D) (8.1) (12.6) (11.4)
(T < 40) 5.6% 16.1% 10.5%
*p <: .05.
292 Clausen, Landsverk, Ganger, Chadwick, and Litrownik

It should be noted that much smaller percentages of children in foster care

fall in the "clinical" range on this foster child self-report measure, as com-
pared with the parent informant measures of behavior problems and social
competence seen on the CBCL.
Table 7 displays the results of the Vineland Adaptive Behavior Scales
(VABS) for the San Diego site, which was administered to foster parents
of children age 0-18. The VABS standard scores have a mean of 100 and
a standard deviation of 15. For this sample of children in foster care, mean
scores on the Communication and Socialization sub-scales and on the
Adaptive Behavior Composite scores are more than one standard deviation
below the average. In fact, none of the means on any of the scales are
near the normalized average of 100. The VABS results are also shown in
terms of percent of children within adaptive levels. Only 1% to 6% are in
the moderately high and high levels while from 21% to 54% score in the
moderately low to low levels. In fact, over 20% score in the lowest level
on all scales (except for Motor Skills) and a full 29% score at this lowest
level on the Adaptive Behavior Composite.

DISCUSSION

This multi-site study replicates and extends previous research con-

ducted in other states which indicate that children in foster care
demonstrate very high levels of mental health and behavior problems, as
well as significant adaptive functioning deficits. Seventy-five to 80% of the
school age children scored in the problematic range (either clinical or bor-
derline) on one or both of the behavior problem and social competence
domains of the CBCL.
In the domain of behavior problems, almost two out of five children
in foster care, age 4-16, scored above the clinical cut-point on total behavior
problems while, in two of the three study sites, one out of two scored above
the borderline cut-point. These high levels of behavior problems are com-
parable to findings in Tennessee by McIntyre and Keesler (1986) and in
Washington State by Olmstead (1981).
Furthermore, across the three California counties, there was evidence
of difficulties in the social competence domain, with over 50% of school
age children in foster care scoring in the clinical range on the total score
and over 65% scoring in at least the borderline range of functioning. This
finding of extremely high levels of social competence problems in school
age foster care populations has not been reported previously. These results
clearly implicate the need to provide mental health services for children
in foster care which address not only behavior problems but also deficits
Mental Health Problems of Foster Children 293
294 Clausen, Landsverk, Ganger, Chadwick, and Litrownik

in social competencies. Mental health services specifically designed to tar-

get deficits in social competency and adaptive behavior, such as group
psychotherapy, recreational interventions, and social skills building, should
be utilized. Finally, these results confirm the high rate of adaptive behavior
problems found in a prior study of children entering foster care in the state
of Illinois (Hochstadt et al., 1987).
This multi-site study of children placed in non-relative foster family
homes found that children in foster care from three different foster care
systems are similar in their profiles of mental health problems. The in-
stances of statistically significant differences between the three study sites
were far fewer than would have been expected by chance, particularly since
the alpha level was not adjusted for the large number of comparisons.
Given the substantial demographic differences between the three counties
in terms of geographic size, population density, and racial/ethnic distribu-
tions, this commonality is notable. This finding is strengthened by its
persistence across two different types of analyses, namely, differences in
mean scores, and differences in the percent of children reaching clinically
related cut-points. The finding is further strengthened by its persistence
across three different domains (behavior problems, social competence, and
self-concept) which are measured by two different instruments (CBCL PRF
and Piers-Harris SCS), using two different types of informants (foster par-
ent and foster child).
The common profile of mental health and adaptive behavior problems
among children in foster care across three California counties suggests that
the children entering foster care in these counties appear to have been
drawn from the same population. It is likely that children coming into foster
care share common elements in their backgrounds which may generate the
development of mental health problems. These common elements cluster
in the traumatic conditions which they have experienced due to the mal-
treatment in their family life as well as the poverty in their communities.
There are several limitations of this study which should be noted. The
data were collected in California and may not be generalizable to children
in foster care in other states. Children placed with relatives or in group
and institutional settings were excluded, limiting the generalizability to
these types of children in foster care. We were unable to compare the three
county foster care populations by the important domain of type of mal-
treatment because these data were not recorded in a comparable way
between counties. However, the issue of impact of type of maltreatment
on mental health status of children in foster care is being examined in a
larger ongoing study and will be reported separately. In addition, due to
limited sample size, examination of differences in self-report and parent
report of mental health problems is not possible. However, this parent/child
Mental Health Problems of Foster Children 295

concordance issue is being examined in a larger data set (Clausen,

Landsverk, Newton, & Ganger, 1995). Finally, this profile of mental health
problems reflects only problems assessed relatively early in an episode of
foster care placement. Longitudinal studies are required to profile the pat-
terns of mental health problems over the longer course of a child's stay in
foster care.

ACKNOWLEDGMENTS

Support for this research was provided by the David and Lucille
Packard Foundation and by the Sam and Rose Stein Foundation. Special
thanks are expressed to Diana Gomby, Ph.D., Program Officer of the David
and Lucille Packard Foundation, Janet Reed, M.S.W., Program Manager,
Child Welfare Services for Santa Cruz County, M. Sue Campbell, M.S.W.,
Deputy Director, Office for Community Services and Children's Services
for Monterey County, and Cynthia Zook, M.S.W., Program Specialist, Chil-
dren's Services Bureau, Department of Social Services for San Diego
County.

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