School readiness in children living in non-parental care: Impacts of Head Start

Interventions to improve mental health and well-being in care-experienced children and young people aged less than 25: the CHIMES systematic review

Background

Children and young people with experience of being in care (e.g. foster care, kinship care, residential care or at home with a supervision requirement order) are at higher risk of adverse mental health and well-being outcomes compared to the general population. Despite a range of policy recommendations and interventions, it is not clear what approaches are effective in the United Kingdom, or how context factors give rise to facilitators and inhibitors of implementation and acceptability.

Objectives

The CHIMES review is a complex-systems-informed mixed-method systematic review that aimed to synthesise the international evidence base for interventions addressing the mental health and well-being of care-experienced children and young people (age ≤ 25 years) and to assess the potential transportability of this evidence base to the United Kingdom context.

Data sources

We searched 16 electronic bibliographic databases and 22 websites from 1990 to May 2022. We conducted citation tracking, screened relevant systematic reviews and contacted international experts.

Method

We used a convergent synthesis design. We first constructed an evidence map to confirm review scope before undertaking method-level syntheses for outcome evaluations, process evaluations and economic evaluations. These elements were integrated into a review-level synthesis to identify potential evidence-based interventions that may progress to further development, adaptation and evaluation in the United Kingdom. We conducted stakeholder consultations to prioritise intervention theories, types and outcomes.

Results

We identified 64 interventions from 124 study reports. Interventions were primarily evaluated in the United States and targeted young people's competencies or carers' parenting practices. Meta-analysis reported limited evidence that interventions effectively improved mental health in the shorter term (0-6 months): total social, emotional and behavioural problems (d = -0.15, 95% confidence interval -0.28 to -0.02); internalising problem behaviours (d = -0.35, 95% confidence interval -0.61 to -0.08); externalising problem behaviours (d = -0.30, 95% confidence interval -0.53 to -0.08); depression and anxiety (d = -0.26, 95% confidence interval -0.40 to -0.13) and social-emotional functioning difficulties (d = -0.18, 95% confidence interval -0.31 to -0.05), but these impacts were not observed in the longer term (> 6 months). Five key context factors potentially explain challenges to implementation and acceptability: lack of system resources; the time, cognitive and emotional burden of delivery or participation; interprofessional tensions; the devaluing of young people, meaning that they felt unable to express dissatisfaction with interventions; and the devaluating of carers' expertise and needs. From the evidence, stakeholder consultation identified two priority interventions: (1) mentoring by individuals with knowledge and experience of care and (2) system and ethos change to create harmonisation between organisations and facilitate interprofessional relationships. Well-being and suicide-related behaviours are priority outcomes alongside mental health.

Limitations

The review was limited by a paucity of theory and economic evaluations, so it is unclear how interventions might function or their potential cost-effectiveness. Interventions were insufficiently described, making it challenging to map the evidence base. Outcome evaluations were poorly reported. Due to ongoing restrictions with COVID-19, stakeholder consultations were conducted later than intended with a smaller number of attendees.

Conclusions

The review identified some evidence for interventions impacting mental health in the short term. There is a lack of system-level interventions and approaches that target subjective well-being and suicide-related outcomes. Future intervention might prioritise mentoring and targeting system culture.

Study registration

This study is registered as PROSPERO CRD42020177478.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR129113) and is published in full in Public Health Research; Vol. 12, No. 14. See the NIHR Funding and Awards website for further award information.

Effectiveness of Mental Health and Wellbeing Interventions for Children and Young People in Foster, Kinship, and Residential Care: Systematic Review and Meta-Analysis

The mental health and wellbeing of children and young people who have been in care, primarily foster care, kinship care or residential care, remains a public health priority. The Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) synthesized evidence for the effectiveness of interventions targeting: subjective wellbeing; mental, behavioral and neurodevelopmental disorders; and suicide-related outcomes. Searches were conducted in 16 bibliographic databases and 22 websites between 1990 and 2022. This was supplemented by citation tracking, screening of relevant systematic reviews, and expert recommendation. We identified 35 interventions, with 44 evaluations via randomized controlled trials. Through meta-analyses, we found that interventions have a small beneficial impact on a variety of mental health outcomes in the short term (0-6 months). Interventions improved total social, emotional, and behavioral problems (d = -0.15, 95% CI [-0.28, -0.02]), social-emotional functioning difficulties (d = -0.18, 95% CI [-0.31, -0.05]), externalizing problem behaviors (d = -0.30, 95% CI [-0.53, -0.08]), internalizing problem behaviors (d = -0.35, 95% CI [-0.61, -0.08]); and depression and anxiety (d = -0.26, 95% CI [-0.40, -0.13]). Interventions did not demonstrate any effectiveness for outcomes assessed in the longer term (>6 months). Certainty of effectiveness was limited by risk of bias and imprecision. There was limited available evidence for interventions targeting subjective wellbeing and suicide-related outcomes. Future intervention design and delivery must ensure that programs are sufficient to activate causal mechanisms and facilitate change. Evaluation research should use a robust methodology.PROSPERO Registration: CRD42020177478.

Interventions targeting the mental health and wellbeing of care-experienced children and young people in higher-income countries: Evidence map and systematic review

BACKGROUND

The mental health and wellbeing of care-experienced children and young people (i.e. foster care, kinship care, residential care) is poorer than non-care-experienced populations. The Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) aimed to synthesise the international evidence base for interventions targeting subjective wellbeing, mental health and suicide amongst care-experienced young people aged ≤ 25 years.

METHODS

For the first phase of the review, we constructed an evidence map identifying key clusters and gaps in interventions and evaluations. Studies were identified through 16 electronic databases and 22 health and social care websites, in addition to expert recommendations, citation tracking and screening of relevant systematic reviews. We charted interventions and evaluations with a summary narrative, tables and infographics.

RESULTS

In total, 64 interventions with 124 associated study reports were eligible. The majority of study reports were from the USA (n = 77). Interventions primarily targeted children and young people's skills and competencies (n = 9 interventions), the parental functioning and practices of carers (n = 26), or a combination of the two (n = 15). While theoretically under-specified, interventions were largely informed by theories of Attachment, Positive Youth Development, and Social Learning Theory. Current evaluations prioritised outcomes (n = 86) and processes (n = 50), with a paucity of study reports including theoretical descriptions (n = 24) or economic evaluations (n = 1). Interventions most frequently targeted outcomes related to mental, behavioural or neurodevelopmental disorders, notably total social, emotional and behavioural problems (n = 48 interventions) and externalising problem behaviours (n = 26). There were a limited number of interventions targeting subjective wellbeing or suicide-related outcomes.

CONCLUSIONS

Future intervention development might focus on structural-level intervention theories and components, and target outcomes related to subjective wellbeing and suicide. In accordance with current methodological guidance for intervention development and evaluation, research needs to integrate theoretical, outcome, process and economic evaluation in order to strengthen the evidence base.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020177478.

Effects of formal center-based care and positive parenting practices on children in foster care

BACKGROUND

The current study examined whether children in foster care have better cognitive and social-emotional outcomes at kindergarten age when they enroll in formal center-based care and when they receive positive parenting practices at home.

OBJECTIVE

Two primary questions were addressed: (1) Do children in foster care who attended formal center-based care (including Head Start) have higher cognitive and socio-emotional outcomes than children in foster care who did not attend formal center-based care? (2) Does positive parenting practice promote better cognitive and socio-emotional outcomes?

PARTICIPANTS AND SETTING

Based on the Early Childhood Longitudinal Study-K: 2011 data, 299 children in foster care were selected.

METHODS

Regression analyses were conducted on children's cognitive and social-emotional scores by types of children's childcare arrangements (formal vs informal care) and positive parenting practices. Active parental involvement was measured based on how frequently parents read books with their children, and authoritarian parenting discipline was measured based on whether parents spanked their children.

RESULTS

Children in foster care who enrolled in formal center-based childcare at pre-school age have higher cognitive and socio-emotional scores at kindergarten age. Positive parenting practice also promotes children's outcomes. Children in foster care who are both enrolled in formal center-based care and experience positive parenting practice had the most positive outcomes.

CONCLUSIONS

Parents raising children in foster care should be informed about the positive impacts of certain parenting practices on their children. Foster parents should be connected to available community resources, including formal-center-based preschool programs and required to continuously attend parenting classes to sustain positive impact of parenting practice on foster children.

Can early childhood education be compensatory? Examining the benefits of child care among children who experience neglect

Children that experience neglect are at risk for maladaptive outcomes. One potential resource for these children is early childhood education (ECE), but there is currently limited evidence which is compounded by data limitations. This study used data from the National Study of Child and Adolescent Well-being II (N = 1,385) to compare children's cognitive and social-emotional outcomes among children involved in child protective services that experienced either no care, informal care, or formal care, as well as moderation by type of neglect. Results suggest that ECE was related to increased cognitive and social skills and decreased behavior problems, depending on whether the child attended informal or formal care, with some associations being stronger for children that experienced neglect. These findings have implications for practitioners and policymakers in the intersection of ECE and child protective services.

Assessment of the predictive power of a causal variable: An application to the Head Start impact study

In a study attempting to estimate a causal effect of a causal variable, an assessment of the predictive power of the causal variable can shed light on the heterogeneity around its average effect. Using data from the Head Start Impact Study, a randomized controlled trial of the Head Start, a nation-wide early childhood education program in the United States, we provide a parallel comparison between measures of average effect and predictive power of the Head Start on five cognitive outcomes. We observed that one year of the Head Start increased scores for all five outcomes, with effect sizes ranging from 0.12 to 0.19 standard deviations. Percent variation explained by the Head Start ranged from 0.56 to 1.62%. For binary versions of the outcomes, the overall pattern remained; the Head Start on average improved the outcomes by meaningful magnitudes. In contrast, in a fully adjusted model, the Head Start only improved area under the curve (AUC) by less than 1% and its influence on the variance of predicted probabilities was negligible. The Head-Start-only model only achieved AUC ranging from 50.22 to 55.24%. Negligible predictive power despite the significant average effect suggests that the heterogeneity in effects may be large. The average effect estimates may not generalize well to different populations or different Head Start program settings. Assessment of the predictive power of a causal variable in randomized data should be a routine practice as it can provide helpful information on the causal effect and especially its heterogeneity.

Distributional effects on children's cognitive and social-emotional outcomes in the Head Start Impact Study: A quantile regression approach

Heterogeneity in treatment effects of the Head Start, a federally funded early childhood development program in the United States, has previously been found in the Head Start Impact Study (HSIS), a nationally representative randomized controlled trial. While individual characteristics have been extensively examined as sources of effect heterogeneity, treatment effects may vary as a function of outcome distribution (i.e., distributional effect). Using quantile regressions, we investigated distributional effects of the Head Start on eight child developmental outcomes for first year, second year, third year, and the 3rd grade year follow-up in the HSIS data. For PPVT and Applied Problems, the effects varied substantially across quantiles in the first follow-up, but they were positive overall. The effects at the lower quantiles were larger and were sustained beyond the first follow-up (PPVT [95% CI] at 10th and 90th quantiles: 8.74 [6.22, 11.27], 3.32 [0.82, 5.81]) in the first follow-up and 5.72 [2.66, 8.77], −1.66 [-3.69, 0.37] in the second follow-up). For Behavior Problems, the effects were only positive for the lower quantiles in the first follow-up, but they became null in the latter follow-ups. For Letter-Word Identification, Spelling, and Pre-Academic, the effects were positive in the first follow-up with moderate variation across quantiles. In the second follow-up, only the effects at the lower quantiles were statistically significant, although they faded in the latter follow-ups. For Oral Comprehension and Social Skills, effects were null for all follow-ups. The Head Start had meaningful distributional effects for a range of child developmental outcomes, and distributional effects should be routinely assessed for better understanding of child developmental programs.

•

The Head Start effects on children’s cognitive and social-emotional outcomes were estimated using quantile regressions.

•

The Head Start effects were more beneficial at the worse-performing part of the outcome distribution.

•

A substantial variation in treatment effects was found along the outcome distribution.

Assessment of heterogeneous Head Start treatment effects on cognitive and social-emotional outcomes

Head Start is a federally funded, nation-wide program in the U.S. for enhancing school readiness of children aged 3–5 from low-income families. Understanding heterogeneity in treatment effects (HTE) is an important task when evaluating programs, but most attempts to explore HTE in Head Start have been limited to subgroup analyses that rely on average treatment effects by subgroups. This study applies an extension of multilevel modelling, complex variance modelling, to data from a randomized controlled trial of Head Start, Head Start Impact Study (HSIS). The treatment effects on the variance, in addition to the mean, of nine cognitive and social-emotional outcomes were assessed for 4,442 children aged 3–4 years who were followed until their 3rd grade year. Head Start had positive short-term effects on the means of multiple cognitive outcomes while having no effect on the means of social-emotional outcomes. Head Start reduced the variances of multiple cognitive and one social-emotional outcomes, meaning that substantial HTE exists. In particular, the increased mean and decreased variance reflect the ability of Head Start to improve the outcomes and reduce their variability. Exploratory secondary analyses suggested that larger benefits for children with Spanish as a primary language and low parental educational level partly explained the reduced variability, but the HTE remained and the variability was reduced even within these subgroups. Routinely monitoring the treatment effects on the variance, in addition to the mean, would lead to a more comprehensive program evaluation that describes how a program performs on average and on the entire distribution.

Treatment effect heterogeneity in the head start impact study: A systematic review of study characteristics and findings

There have been consistent efforts to assess treatment effect heterogeneity (TEH) of Head Start using the data from the Head Start Impact Study (HSIS), a randomized controlled trial of a federally funded child development program for a nationally representative sample of low-income parents and their 3- and 4-year-old children in the United States. Including 28 studies on TEH of Head Start, this review found that multiple high-risk subgroups (e.g., children with lower cognitive abilities, Spanish-speaking dual language learners) experienced larger gains across a range of developmental and parental outcomes, but mixed results for several subgroups. Most studies focused on subgroup analyses, cognitive and social-emotional outcomes, and short-term effects. Further studies on distributional effects, health and parental outcomes, and long-term effects are warranted. Finally, suggestions for future research on TEH of Head Start are discussed, which are applicable to other child development programs and policy evaluations.

The role of early care and education in addressing early childhood trauma

Young children's experience of trauma is associated with a wide range of adverse events and circumstances, including abuse and neglect, domestic violence, loss of a parent, and community violence. Policymakers and practitioners are increasingly aware that trauma during the first few years of life is especially widespread, and there is growing interest in new ways to support these young children and their families. Many young children who experience trauma attend early care and education (ECE) programs, and these settings offer important opportunities to promote their well-being. This paper examines strategies currently being implemented in ECE to address early childhood trauma. The paper first examines research on how trauma affects young children's development, ECE environments, and society. We then describe the unique needs of young, traumatized children and features of trauma-informed care that can address their needs, along with emerging interventions and supports that can be incorporated into or linked with ECE settings as part of a trauma-informed approach. We conclude with a discussion of future directions for ECE and trauma research, policy, and practice, bearing in mind both the promise of new approaches and a limited evidence base to date.

The benefits of early care and education for child welfare-involved children: Perspectives from the field

Increasing access to early care and education (ECE) for children in the child welfare system (CWS) remains a critical issue in the United States, as the numbers of young children entering this system steadily increases. Mounting evidence suggests that participation in at least some types of ECE can mitigate the need for child welfare supervision. Moreover, ECE participation has been linked to positive developmental and school readiness outcomes, lower rates of foster placement, and greater placement stability for children in the CWS. Despite this research, ECE is not widely used by this population. This study informs recent local and federal efforts to increase ECE utilization among children in the CWS by exploring the perspectives of three stakeholder groups (child welfare caseworkers, ECE providers, and parents/caregivers) regarding the benefits of CWS-supervised children's participation in ECE for 1) the children themselves, 2) their parents/caregivers, and 3) their caseworkers. A total of ten focus groups were conducted with these stakeholders in a large urban area in the western U.S. (n = 79). Meeting transcripts were analyzed with Atlas TI software to identify themes. Results highlight multiple ways in which participants perceived ECE as being beneficial for CWS-supervised children, as well as for their parents/caregivers, and caseworkers. These findings offer suggestions for ways to motivate caseworkers and parents/caregivers to enroll CWS-supervised children in ECE by educating them about benefits, not only for the children, but also for themselves.

Systematic review of educational interventions for looked-after children and young people: Recommendations for intervention development and evaluation

Looked-after children and young people (LACYP) are educationally disadvantaged compared to the general population. A systematic review was conducted of randomised controlled trials evaluating interventions aimed at LACYP aged ≤18 years. Restrictions were not placed on delivery setting or delivery agent. Intervention outcomes were: academic skills; academic achievement and grade completion; special education status; homework completion; school attendance, suspension, and drop-out; number of school placements; teacher-student relationships; school behaviour; and academic attitudes. Fifteen studies reporting on 12 interventions met the inclusion criteria. Nine interventions demonstrated tentative impacts. However, evidence of effectiveness could not be ascertained due to variable methodological quality, as appraised by the Cochrane risk of bias tool. Theoretical and methodological recommendations are provided to enhance the development and evaluation of educational interventions.

Parental Book Reading and Social-Emotional Outcomes for Head Start Children in Foster Care

This study examines the associations between parental book reading and social-emotional outcomes for Head Start children in foster care. Despite no main Head Start impact on parental book reading, subgroup effects were found. Foster parents in Head Start provided more book reading for children with disabilities but less for children with low preacademic scores. Head Start enhanced social-emotional outcomes for children in foster care. The positive impacts of Head Start on children's social-emotional outcomes were greater when parents read books frequently. Head Start should include more foster families and provided parenting skills to enhance social-emotional outcomes for children in foster care.

Do early care and education services improve language development for maltreated children? Evidence from a national child welfare sample

Young children under 6 years old are over-represented in the U.S. child welfare system (CWS). Due to their exposure to early deprivation and trauma, they are also highly vulnerable to developmental problems, including language delays. High quality early care and education (ECE) programs (e.g. preschool, Head Start) can improve children's development and so policymakers have begun calling for increased enrollment of CWS-supervised children in these programs. However, it is not a given that ECE will benefit all children who experience maltreatment. Some types of maltreatment may result in trauma-related learning and behavior challenges or developmental deficits that cause children to respond to ECE settings differently. The current study uses data from a nationally representative survey of children in the U.S. child welfare system, the National Survey of Child and Adolescent Well-Being II, to assess whether young CWS-supervised children (N=1,652) who were enrolled in ECE had better language development outcomes 18 months later than those not enrolled in ECE. We also explore whether the type of maltreatment that brought children to the CWS' attention moderates the relationship between ECE and children's language development. After controlling for children's initial scores on the Preschool Language Scale (PLS-3), type(s) of maltreatment experienced, and child and caregiver demographics, we found that ECE participation predicted better PLS-3 scores at follow-up, with a positive interaction between ECE participation and supervisory neglect. ECE seems to be beneficial for CWS-involved children's early language development, especially for children referred to the CWS because they lack appropriate parent supervision at home.

Specific learning difficulties: a retrospective study of their co morbidity and continuity as early indicators of mental disorders

BACKGROUND

Specific Learning difficulties constitute a continuity of complex disorders, which unfold across the lifespan and are associated with a wide range of mental disorders. In order to determine the importance of specific learning difficulties as an underlying factor in various mental disorders, we investigated associations between mental disorders and factors related to learning difficulties, poor family and school environment, and social and psycho-emotional disorders.

METHODS

This retrospective study is based on data from 835 case histories of adults who were treated at the Psychiatric Clinic of the University Hospital in Ioannina, Greece, between 1992 and 2008. The examination of the early (co-)occurrence of specific disorders was based on the ICD-10 classification of mental disorders. LogLinear analysis showed that all models retained 2nd or 3rd order effects with p-values >0.8 for all estimated likelihood ratios.

RESULTS

Patients with specific learning difficulties, who grew up in a socially disturbed environment, and manifested behavioral problems (aggression, alcoholism, and isolation or running away from home) were found to be more frequently diagnosed with schizophrenia than with any other mental disorder. In some cases, the profiles of these patients also included family problems such as parental loss or alcoholism.

CONCLUSIONS

Significant association between learning and other disorders in adult psychiatric patients' developmental profile has been indicated. Furthermore, a specific association between specific learning difficulties, environmental problems, and schizophrenia corroborates the continuity and complexity of these disorders at higher developmental stages. The results from this study can be utilized in the study of mental disorder etiology, raising the possibility that the early treatment of the learning or other disorders could reduce children's likelihood of developing mental disorders in adulthood.