Mental Health Interventions for Children in Foster Care: A Systematic Review

Change in Child and Adolescent Needs and Strengths (CANS) scores over time among children and youth in out-of-home care: A latent growth curve analysis

BACKGROUND

Children and youth in out-of-home care (OOHC) have significant behavioral health needs and may not receive relevant treatment. While the literature has urged implementation of standardized assessment of behavioral health needs, and specifically mental, emotional and social wellbeing, for these children and youth, little is known about the extent to which these needs improve over time.

OBJECTIVE

The study purpose was to examine whether improvement in functioning was detected over time based on Child and Adolescent Needs and Strengths (CANS) scores, and how scores improved over time.

PARTICIPANTS AND SETTING

The study examined scores for 6104 children and youth in OOHC between 2016 and 2022 in one state.

METHODS

Total scores for six CANS domains (behavioral/emotional needs, risk behaviors, strengths, cultural factors, life functioning, caregiver resources and needs) were computed for children and youth at five timepoints at baseline and approximately every three months. To explore the trajectory of scores over time we used latent growth curve models and fit a series of increasingly complex models to identify the best fitting form.

RESULTS

While initial levels of CANS domain scores each varied significantly across children and youth, on average CANS domain scores significantly decreased over time between T1 and T3, demonstrating overall improvement. Children and youth with higher initial levels experienced a faster rate of change T1-T3, which tended to slow from T3-T5.

CONCLUSIONS

Understanding whether behavioral health services after the identification of higher initial behavioral health needs contribute to the faster rate of improvement for these youth is an important area of future research. Identifying factors that account for between-youth variability in initial levels and rate of change is important to identify groups of youth who may be more (or less) at risk and to inform intervention.

The effect of a low intensity intervention on the wellbeing of children in the juvenile justice system in India: Results from a pilot study

OBJECTIVE

Children in the Juvenile Justice System (JJS) face multiple adversities that may predispose them to developing mental health (MH) problems. Interventions that enhance the MH and well-being of these children while providing access to appropriate MH care are needed. This study examines the effect of a multipronged, low-intensity intervention on adolescents' well-being, stress levels, MH knowledge, and stigma perceptions in Childcare Institutions (CCIs) across Odisha and Tamil Nadu, India.

METHODS

Implemented in 7 CCIs, the intervention aimed to enhance the MH Literacy (MHL) and well-being of children in the CCIs through the Youth-Friendly Spaces (YFS) using experiential methods. It also sought to improve the MHL of the staff and administration within the JJS and provide access to MH care by linking CCIs to available local resources. Information using validated scales was obtained at baseline and six months.

RESULTS

Only 180 of the 310 children for whom baseline data was available remained in the CCI at six months. A statistically significant improvement in well-being (34.5 +13.7-55.9 +12.2, p < 0.001), stress (18.5 +6.8-17 +6.1, p = 0.044) and stigma (32 +11.9-29.4 +11.4, p = 0.023) scores were observed. Adjusted linear regression analysis showed significant differences across genders, sites, and child types.

DISCUSSION

This intervention, comprising YFS creation, MHL enhancement, and referral system development, is significantly associated with improved well-being of children in CCIs. The results underscore the need for tailored interventions based on gender, location, and child type. The study highlights the potential scalability of such programs in resource-constrained settings for vulnerable children.

A 15-year outcome study of children and young people in care attending a tertiary level specialist mental health service

BACKGROUND

Children and young people (C/YP) exposed to abuse and neglect can experience complex mental health problems. Examining interventions and outcomes for C/YP in care receiving mental health treatment could help optimise service delivery to this population.

OBJECTIVE

The aim of the study was to investigate functioning and mental health outcomes of C/YP in care attending a tertiary level specialist mental health service in Queensland, Australia. In addition, outcomes were explored with Aboriginal and/or Torres Strait Islander status, length of stay (LOS) and age as potential contributing factors.

PARTICIPANTS AND SETTING

This 15-year retrospective cohort study consisted of a sample of 1561C/YP with pre- and post-treatment data attending the mental health service.

METHODS

The Children's Global Assessment Scale (CGAS) and the Health of the Nations Outcome Scale for Children and Adolescents (HoNOSCA) were used to examine C/YP's functioning and mental health outcomes. Generalised linear mixed model, linear mixed model and McNemar's test were conducted.

RESULTS

Overall, C/YP improved in mental health concerns and functioning on all domains post-intervention (p < 0.001). Non-Aboriginal and/or Torres Strait Islander C/YP had a greater improvement post-intervention in disruptive/aggressive behaviour, scholastic/language skills, and poor school attendance compared to Aboriginal and/or Torres Strait Islander C/YP (p < 0.05). A reduced length of stay resulted in a greater improvement post-intervention in overall functioning, overactivity/attentional difficulties, peer relationships and poor school attendance (p < 0.05). Younger children had a greater improvement post-intervention in overall functioning, scholastic/language skills, emotional symptoms, peer relationships, self-care/independence and poor school attendance compared to older children (p < 0.05).

CONCLUSIONS

Findings from this study demonstrate that the tertiary level specialist mental health service is an effective treatment program for C/YP in care who have experienced severe and complex trauma. There were some differences in outcomes based on Aboriginal and/or Torres Strait Islander status, LOS and age that need to be considered to enhance service delivery for all C/YP. Implications and further research were explored.

Access to best-evidenced mental health support for care-experienced young people: Learnings from the implementation of cognitive therapy for PTSD

OBJECTIVES

Rates of PTSD are up to 12 times higher in care-experienced young people (CEYP) compared to their peers. Trauma-focused CBTs (tf-CBT) are the best-evidenced treatment for youth with PTSD, yet, in practice, CEYP often struggle to access this treatment. We worked alongside services to understand barriers and facilitators of the implementation of cognitive therapy for PTSD (a type of tf-CBT) to CEYP.

DESIGN

This was an active, open implementation trial.

METHODS

We recruited 28 mental health teams across England, including general CAMHS, targeted CAMHS for CEYP and social care-based teams. From these teams, participants were 243 mental health professionals, from a wide variety of professional backgrounds. Following recruitment/intervention training, teams participated in rolling three monthly focus groups and individual interviews, to understand what helped and hindered implementation. Data were analysed using a framework analysis conducted using CFIR 2.0.

RESULTS

Almost half of the teams were able to implement, but only approximately one quarter with CEYP, specifically. Universal barriers that were discussed by almost all teams particularly highlighted service structures and poor resourcing as major barriers to delivery to CEYP, as well as the complexities of the young person and their network. Unique factors that differentiated teams who did and did not implement included commissioning practices, the culture of the team, leadership engagement and style, and the development of supervision structures.

CONCLUSIONS

Findings offer key considerations for mental health teams, service leads, commissioners and policy-makers to enhance delivery of best-evidenced mental health treatments like CT-PTSD, for CEYP.

Special Challenges Working with Foster Care Youth in the Inpatient Setting

The inpatient treatment of youth in care with severe emotional or behavioral disorders is complicated by systemic factors unique to foster care, for example, placement shortages and relinquishment of custody, and clinically by factors more prevalent in these highly vulnerable youth such as in utero exposure to alcohol, exposure to domestic violence, neglect, and physical, sexual, and emotional abuse. The authors discuss prolonged lengths of stay and boarding in emergency rooms, medical units, government offices, and detention centers. We also discuss working with foster families, biological families, and the child welfare system.

The Comprehensive Adversity Measure (CAM): A measure of early adversity and its severity

BACKGROUND

Early adversity scales often display insufficient content coverage and typically assess the presence of adversity, but not its severity.

OBJECTIVE

To address some of these limitations, we developed the 13-item Youth and Childhood Adversity Scale. We subsequently revised and expanded the scale regarding content coverage and item wording, resulting in a 22-item version, which we here describe.

METHODS

We conducted one cross-sectional (N = 1498; 43.9 % females; 24.42 years, SD = 3.72, range: 18-30 years) and one longitudinal study (N = 1084; 39.6 % females; 32 years, SD = 10.49, range: 18-75 years). To reflect the nature of the revised measure more accurately, it was named the Comprehensive Adversity Measure (CAM).

RESULTS

Exploratory factor analysis suggested a one-factor model for both the presence/absence and the severity facet, which both displayed good model fit in subsequent confirmatory factor analyses. Factor models demonstrated at least scalar measurement invariance across gender and country (US/UK). Correlations with psychological distress, depression, anxiety, substance use, posttraumatic stress symptoms, obsessive-compulsive symptoms, suicide attempts, rumination, social comparison, self-esteem, and quality of life provided evidence in support of construct validity - concurrently and prospectively.

CONCLUSIONS

The CAM offers a psychometrically-sound, content-wise comprehensive, and free to use assessment of early adversity.

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.

Sleep and adjustment in foster environments for toddlers and preschoolers (SAFE-T): Initial efficacy of a trauma-informed sleep intervention for young children in foster care

BACKGROUND

This study presents findings from a randomized controlled trial of Sleep and Adjustment in Foster Environments for Toddlers and Preschoolers (SAFE-T), a telehealth-delivered, trauma-informed sleep intervention for children in or adopted from foster care.

METHODS

N = 45 caregivers of children aged 2 to 5 years (M = 4.01; SD = 1.04) were randomized to SAFE-T or Sleep Education Support (SES), an active control condition. Assessments, including one-week parent-report sleep diaries, were completed at pre- intervention, post- intervention, and 3 months follow-up.

RESULTS

Results indicated improvements in multiple sleep outcomes at post-intervention and three months later, including nighttime sleep duration, nighttime awakenings, and overall sleep problems in the SAFE-T group only. Sleep-based improvements were largely maintained or strengthened over time. Several secondary outcomes, including child emotional and behavior problems and parenting stress, also improved considerably in the SAFE-T but not the SES group.

CONCLUSIONS

Findings suggest SAFE-T to be a promising intervention for improving sleep health among children currently or previously placed in foster care.

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.

Do weighted blankets improve sleep among children with a history of maltreatment? A randomized controlled crossover trial

STUDY OBJECTIVES

Sleep disruption is prevalent and persistent among children who experience maltreatment/interpersonal trauma. Weighted blankets have gained popularity in recent years as a potential nonpharmacological intervention for improving sleep in various populations, but their efficacy has not been examined among maltreated children. The current study used a randomized, within-subjects, crossover design to examine whether the use of a weighted blanket improves objective and/or subjective indices of sleep among 30 children, ages 6-15 years (mean = 9.7, standard deviation = 2.9) adopted from foster care.

METHODS

Participants used a weighted blanket for 2 weeks and their usual (unweighted) blanket for 2 weeks in a counterbalanced order. Sleep outcomes were measured using actigraphy and subjective sleep diaries.

RESULTS

No differences in actigraphy-based or subjective estimates of total sleep time, sleep onset latency, wake after sleep onset, or sleep quality ratings were found based on blanket type. Child age, biological sex, timing of participation (school year vs summer months), and maltreatment/trauma history did not impact outcomes.

CONCLUSIONS

Although we did not find evidence that weighted blankets improve sleep among children with a history of maltreatment/interpersonal trauma, additional well-controlled studies using larger samples of children are needed.

CITATION

Cifre AB, Vieira A, Baker C, et al. Do weighted blankets improve sleep among children with a history of maltreatment? A randomized controlled crossover trial. J Clin Sleep Med. 2024;20(9):1405-1413.

Long-term impact of the Fostering Healthy Futures for Preteens program on suicide-related thoughts and behaviors for youth in out-of-home care: A randomized controlled trial

Youth in out-of-home care are at high risk for suicide-related thoughts and behaviors (STB), yet there are no known efficacious interventions that reduce STB for this population. Fostering Healthy Futures for Preteens (FHF-P) is a 9-month community-based mentoring and skills training preventive intervention for children in out-of-home care. A randomized controlled trial enrolled 156 participants aged 9-11 years who were placed in out-of-home care over the prior year. Participants were 48.9% female, 54.1% Hispanic, 30.1% Black, and 27.1% American Indian. Follow-up interviews, conducted 7-12 years postintervention (85.2% retention rate), asked young adult participants, aged 18-22, to self-report lifetime STB as indexed by non-suicidal self-injury, suicidal thoughts, plans, and/or attempts. There was a nonsignificant reduction in the odds of STB for the intervention group at follow-up (OR = 0.74; CI, 0.32, 1.69). However, FHF-P significantly moderated the effect of baseline STB; control youth who reported baseline STB had 10 times the odds of young adult STB (OR = 10.44, CI, 2.28, 47.78), but there was no increase in the odds of adult-reported STB for intervention youth. Findings suggest that FHF-P buffers the impact of pre-existing STB on young adult STB for care-experienced youth. Further research is needed to identify mechanisms that may reduce STB in this population.

Discrepancies between Foster Care Entry and Mental Health Service Use for Black and Latinx Youth

Black and Latinx youth are more likely to be placed into foster care compared to non-Latinx white youth. Foster care placement can facilitate mental health service use, yet youth from marginalized and oppressed racial and ethnic groups in foster care are still less likely to receive mental health services compared to non-Latinx white youth. This study aims to examine this discrepancy Black and Latinx youth face by testing (a) whether mental health need moderates the relationship between race or ethnicity and foster care placement and (b) whether race or ethnicity moderates the relationship between foster care placement and mental health service use. Data come from the National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal national probability study of youth in contact with the child welfare system. Internalizing need was associated with a decreased likelihood of foster care placement for non-Latinx white youth compared to those with no need; findings showed the opposite for Latinx youth. Race and ethnicity did not significantly moderate the relationship between foster care placement and mental health service use, although predicted probabilities suggest that differences in mental health service use were more pronounced for Black and Latinx youth in in-home and kinship care compared to non-kinship foster care. Results suggest that despite main effects of race and ethnicity on foster care placement and mental health service use, discrepancies across these outcomes are not explained by race and ethnicity alone. Findings highlight the need to comprehensively examine predictors together, rather than separately, when assessing foster care care placement and mental health service use. A multi-pronged approach is outlined for child welfare reform.

The Effectiveness of Preventative Interventions to Reduce Mental Health Problems in at-risk Children and Young People: A Systematic Review of Reviews

Mental health problems are the leading cause of childhood disability worldwide, resulting in poor outcomes for children and young people that persist into adulthood. It is essential that those young people most at risk of developing mental health problems receive effective preventative interventions. Whilst there have been a number of systematic reviews which have examined the effectiveness of secondary prevention interventions for specific groups of children and young people, or to address identified mental health concerns, no review has engaged with the breadth of this literature. We conducted a systematic review of systematic reviews to map this complex field of secondary preventative interventions and identify effective interventions to prevent mental health problems in children and adolescents aged 3-17 years. The review protocol was registered on PROSPERO. We searched five electronic databases from inception to February 2023. The certainty of the evidence was appraised using the AMSTAR 2. We included 49 unique systematic reviews each including between 2 and 249 (mean 34) unique studies; the majority of which were reviews which included only or mostly randomised controlled trials (70%). The reviews examined selective interventions (defined as interventions which are delivered to sub-group populations of young people at increased risk of mental health problems) (n = 22), indicated interventions (defined as interventions which target young people who are found to have pre-clinical symptoms) (n = 15) or a synthesis of both (n = 12). The certainty of the evidence in the reviews was rated as high, (n = 12) moderate (n = 5), low (n = 9) and critically low (n = 23). We found evidence to support both selective and indicated interventions in a range of populations and settings, with most of this evidence available for children and young people in their mid-years (6-10 years) and early adolescence (11-13 years). There was a large body of evidence suggesting that resilience enhancing, cognitive behaviour therapy-based and psychoeducational interventions for children who experience adversity, or those with subclinical externalising problems may offer promise. Early selective interventions for a subpopulation of children and young people who have experienced adversity which combines risk reduction and resilience enhancing approaches directed at children and their families may be effective at reducing mental health problems.

First evaluation of Eyberg Child Behavior Inventory for foster children in Japan

BACKGROUND

Behavioral problems of foster children are an important issue for the maintenance of the foster care system, but they have not been adequately studied in Japan. We used the Eyberg Child Behavior Inventory (ECBI) to investigate behavioral problems among foster children and to examine associated factors.

METHODS

Twenty-nine foster children and their foster parents and 479 non-foster children and parents were recruited for the foster and control groups, respectively. Both groups underwent statistical comparative analyses using data from their ECBI assessments. The ECBI has two scales: the Intensity Scale quantifies the severity of child behavioral problems, and the Problem Scale captures the caregiver's perceived difficulties handling each behavior. We conducted a retrospective investigation of the background of the foster parent-child pairs to explore potential causal relationships with behavioral problems.

RESULTS

The mean intensity score for the foster group was significantly higher than that for the control group (p = 0.001). The mean problem scores for the foster group and the control group were not significantly different (p = 0.79). In the foster group, the retrospective investigation revealed two children with neurological or neurodevelopmental disorders, 17 with histories of abuse, and 10 with other issues.

CONCLUSION

Intensity scores showed severe behavioral problems among foster children, perhaps caused by neurological disorders, abuse, parental mental health, or economic hardship. Problem scores showed no significant differences between groups. It can therefore be posited that foster parents might exhibit a more lenient parenting style when dealing with children who have a history of abuse by their biological parents.

Maneuvering through Life with Positivity: Estimating the Effects of Foster Youth's Appraisal on Coping Styles

Youth in foster care tend to experience a disproportional number of adverse life experiences and demonstrate high rates of emotional and behavioral difficulties. According to the transactional model of stress and coping, how youth appraise their experiences influences the type of coping strategies they use in response to adversity, and these relations are key components to understanding later adjustment. However, few studies have examined potential effects of appraisal on coping for youth in foster care. Furthermore, it is not well understood if or how such interaction may vary across age. To address this gap, this study examined potential age moderation of contemporaneous primary, threat-based appraisal effects on coping in a large sample of 490 youth in foster care (48% female, ages 8 to 18) using a series of statistical models which were capable of detecting very general forms of effect moderation. Results indicated that primary appraisal positively predicted direct and prosocial coping, and negatively predicted asocial coping. The linear effects of appraisal on coping did not vary based on age of the youth. The findings suggest that primary appraisals of life events for youth in foster care does have a unique influence on certain coping styles, suggesting perhaps new directions for research on youth exposed to multiple adversities. To promote wider use of the non-parametric time-varying effect model in R, the analysis syntax is also included in the appendix.

A qualitative study on the implementation of a transdiagnostic cognitive behavioral therapy for children in a child welfare residential treatment program

BACKGROUND

Youth with severe emotional or behavioral issues who are involved with child welfare authorities are sometimes placed in intensive care services in a residential treatment program. Evidence-based psychotherapies are often used in residential treatments, but there is very little research on how to adapt psychotherapy for residential treatment.

OBJECTIVE

To describe the implementation of a transdiagnostic cognitive behavioral therapy (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children) in a residential treatment program for children.

PARTICIPANTS AND SETTING

Staff (n = 20) at a residential facility in Calgary, Canada.

METHODS

A combination of qualitative interviews and focus groups were conducted before and after therapy to identify barriers and facilitators to implementation. Data were analyzed and reported using the Consolidated Framework for Implementation Research and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies.

RESULTS

Modifications were made to the program including creating inclusive language, integrating relevant content targeting pediatric irritability, delivering sessions online for caregivers, and using additional staff to support youth to learn and practice the application of the content and behavioral interventions. Key barriers to implementation of the Unified Protocol included staff turnover and the difficulty of sustaining a critical mass of knowledge surrounding the Unified Protocol. The major facilitators to implementation were the perceived quality of the program and advantages of the program to children and their caregivers.

CONCLUSIONS

This study supports the feasibility and acceptability of providing transdiagnostic cognitive behavioral therapies for children in residential treatment and provides a template for how to implement evidence-based practice in residential treatment.

A social network analysis of perpetrators of child maltreatment reported by youth in foster care

OBJECTIVE

Prior research on child maltreatment has focused on distinct features of maltreatment (type, severity, chronicity) important for youth outcomes, yet perpetrators of child maltreatment reported by youth have gone largely unstudied. The present study examines connections between perpetrators, the total number and type of perpetrators reported, and the frequency at which each type of perpetrator was reported across 24 relationship types to provide a foundation for future research seeking to provide comprehensive measurement of perpetrator profiles.

METHODS

Data from 503 youth in foster care (8-21 years old) were collected through the Studying Pathways to Adjustment and Resilience in Kids (SPARK) Project. Youth reported on their history of physical, sexual, and psychological maltreatment. Social Network Analysis (SNA) was used to visualize links between perpetrators within maltreatment type and paired samples t-tests were used to compare differences between network edge weights.

RESULTS

Full sample SNA results were highly interconnected and variable across maltreatment types. Biological parents and peers were the most common perpetrators of physical and psychological abuse with peers and non-family adults being most common for sexual abuse. Family and community member groupings were most distinct in the physical and psychological abuse networks whereas in the sexual abuse network, ties between perpetrators were more equidistant.

CONCLUSIONS

Differences exist in perpetrator profiles across maltreatment types, adding a layer of complexity to how maltreatment experiences are captured, and variability in profiles might provide insight to differing youth outcomes. Understanding individual youth perpetrator profiles could be used to inform foster care placements and reduce the risk of revictimization.

Predisposing, Enabling, and Need Factors Associated with Psychotropic Medication and Mental Health Service Use among Children in Out-of-Home Care in the United States: A Scoping Review

This scoping review aimed to identify predisposing, enabling, and need factors associated with the use of mental health services, including psychotropic medications, among children in out-of-home care in the United States. We searched the PsycInfo, SocINDEX, Medline, and Scopus databases, and 22 studies met inclusion criteria and were systematically analyzed. Among the included studies, 7 studies examined predictors associated with taking psychotropic medications, and 16 examined factors associated with using other mental health services. Significant predisposing, enabling, and need factors associated with greater use of mental health services, including psychotropic medications, were identified. The most frequently identified predisposing factors were child race/ethnicity, age, gender, and maltreatment. Important enabling factors were out-of-home placement type and length of care, and need factors included children's mental/behavioral problems. The results provide insight into maximizing factors facilitating children's use of mental health services to address mental health problems of children in out-of-home care. Further, the results imply the importance of the appropriate use of psychotropic medication (e.g., the type and dosage of medications) among children in out-of-home care. The identified factors can inform child welfare agencies and stakeholders on ways to improve access to mental health services and the appropriate use of psychotropic medications among children in out-of-home care in the United States.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

Co-Regulation as a Support for Older Youth in the Context of Foster Care: a Scoping Review of the Literature

Co-regulation is a relatively new theoretical framework for interventions that connects developmental science to adolescent needs and provides strategies that can be applied across contexts. It also has value in shifting the focus of interventions to the role of relationships and interactions with caring adults, as well as supportive environments. This framework may be particularly salient for older youth with foster care experience whose relationships with adults and availability of developmental supports are disrupted. To understand how co-regulation aligns with current understanding of needs and supports for this population, we conducted a scoping review that involved systematically searching four databases, coding and charting relevant information, and actively engaging expert consultants and other stakeholders. Across 46 primarily descriptive articles, co-regulation was discussed most often in relation to relationships, as expected (89% of articles). Despite theoretical and empirical evidence of the benefits of supportive environments and intentional day-to-day interactions in promoting developmental skills and competencies, these two domains of co-regulation were referenced much less (39% and 28%, respectively). Results highlight opportunities for co-regulation supports that can be provided to older youth with foster care experience by caring adults and near-aged peers in a wide range of roles. Notable limitations in the literature were identified in applying co-regulation within the context of employment and career readiness, healthy relationships, and teen parenting. Also under-researched is the role of adult self-regulation skills and co-regulation approaches for youth from diverse backgrounds, including those who identify as LGBTQ or have disabilities. Considerations for practice and future research are provided.

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.

Meeting the Mental Health Needs of College Students with a Background in Foster Care

Many colleges and universities are creating campus-based programs to support students with a background in foster care. When considering the histories of trauma experienced by these young people, meeting mental health needs is an important part of a portfolio of services. ASuPIRE is a strengths-based, trauma-informed counseling program that was designed to respond to the unique needs of college students who aged-out and/or experienced foster care at any point across their development. This program can stand alone or can be used to supplement campus-based support programs. This approach, including its theoretical framework and related interventions, will be described. A case study is also provided to illustrate the model for other post-secondary institutions interested in adopting this approach.

Adaptations of evidence-based trauma-focused interventions for children and adolescents: a systematic review

BACKGROUND

Rates of potentially traumatic events (PTEs) and other forms of adversity among children are high globally, resulting in the development of a number of evidence-based interventions (EBIs) to address the adverse outcomes stemming from these experiences. Though EBIs are intended to be delivered according to set parameters, these EBIs are frequently adapted. However, little is known about existing adaptations of EBIs for children who experienced PTEs or other adversities. As such, this review aimed to determine: (1) why existing EBIs designed to address PTEs and other adversities experienced by children are adapted, (2) what processes are used to determine what elements should be adapted, and (3) what components of the intervention are adapted.

METHODS

Nine academic databases and publicly available search engines were used to identify academic and grey literature. Initial screening, full-text review, data extraction, and quality determinations were completed by two members of the research team. Data were synthesized narratively for each adapted EBI by research question.

RESULTS

Forty-two studies examining the adaptations of nine different EBIs were located, with Trauma-Focused Cognitive Behavioral Therapy and Cognitive Behavioral Intervention for Trauma in Schools being the most commonly adapted EBIs. Most frequently, EBIs were adapted to improve fit with a new population and to address cultural factors. Most commonly, researchers in combination with others made decisions about adapting interventions, though frequently who was involved in these decisions was not described. Common content adaptations included the addition of intervention elements and the tailoring/tweaking/refining of intervention materials. Common contextual adaptations included changes to the intended population, changes to the channel of treatment delivery, and changes to who administered the intervention.

CONCLUSIONS

Most published studies of EBI adaptions have been developed to improve fit and address cultural factors, but little research is available about adaptations made by clinicians in day-to-day practice. Efforts should be made to evaluate the various types of adaptations and especially whether adaptations improve access to services or improve child outcomes in order to ensure that all children exposed to trauma can access effective treatment.

TRIAL REGISTRATION

The protocol for this systematic review was published with PROSPERO (CRD42020149536).

Physical health of care-experienced young children in high-income countries: a scoping review protocol

INTRODUCTION

Care-experienced children have poorer health, developmental, and quality of life outcomes across the lifespan compared to children who are not in care. These inequities begin to manifest in the early years. The purpose of the proposed scoping review is to collate and synthesise studies of the physical health of young care-experienced children. The results of the review will help map the distribution of health outcomes, identify potential targets for intervention, and assess gaps in the literature relating to this group.

METHODS AND ANALYSIS

We will carry out a scoping review of the literature to identify studies of physical health outcomes in care-experienced children. Systematic literature searches will be carried out on the MEDLINE, CINAHL and Web of Science Core Collection databases for items indexed on or before 31 August 2022. Studies will be included where the participants are aged 3 months or greater and less than 6 years. Data elements extracted from included studies will include study objectives, health outcomes, participant demographics, care setting characteristics and bibliographic information. The results of the review will be synthesised and reported using a critical narrative approach. Comparisons between care and non-care populations will be reported if sufficient studies are identified.

ETHICS AND DISSEMINATION

Data will be extracted from publicly available sources, so no additional ethical approval is required. Results will be published in a peer-reviewed journal article. Furthermore, they will be shared in summary reports and presented to local authorities, care organisations and other relevant stakeholders that can influence healthcare policy and procedure relating to young children in care.

Using Time-out for Child Conduct Problems in the Context of Trauma and Adversity: A Nonrandomized Controlled Trial

Importance

Exposure to adverse childhood experiences substantially increases the risk of chronic health problems. Originally designed to treat child conduct problems, parent management training programs have been shown to be effective in preventing children from being exposed to further adversity and supporting children's recovery from adversity; however, there are increasing concerns that a core component of these programs, the discipline strategy time-out, may be harmful for children with a history of exposure to adversity.

Objective

To investigate the comparative benefits and potential harms to children exposed to adversity that are associated with parenting programs that include time-out.

Design, Setting, and Participants

This nonrandomized waiting list-controlled clinical study was conducted at a specialist clinic for the treatment of conduct problems in Sydney, Australia. The self-referred sample included children with conduct problems and their caregivers. Eligibility was confirmed through clinician-administered interviews. Data were collected between February 14, 2018, and February 1, 2021.

Interventions

Caregivers participated in a 10-session, social learning-based parent management training program. Caregivers were provided with parenting strategies aimed at encouraging desired behaviors through effective reinforcement and managing misbehavior through consistent limit setting, including the use of time-outs.

Main Outcomes and Measures

The primary outcome was the parent-reported Strengths and Difficulties Questionnaire score, and secondary outcomes included subscale scores from the clinician-administered Diagnostic Interview Schedule for Children, Adolescents, and Parents. Multi-informant measures of child adversity were collected using the parent-reported Adverse Life Experiences Scale and the clinician-rated Maltreatment Index.

Results

A total of 205 children were included in analysis (156 in the full intervention and 49 in the control condition; 158 boys [77.1%]; mean [SD] age, 5.6 [1.8] years [range, 2-9 years]). Compared with children with low adversity exposure, children with high adversity exposure showed greater reductions in the Strengths and Difficulties Questionnaire score from baseline (mean difference, 3.46 [95% CI, 1.51-5.41]; P < .001) to after treatment (mean difference, 1.49 [95% CI, -0.46 to 3.44]; P = .13) and in the internalizing symptom subscale score (baseline mean difference, 1.00 [95% CI, -2,00 to 0.00]; P = .50; posttreatment mean difference, 0.06 [95% CI, -0.82 to 0.94]; P = .90). No significant differences in the externalizing symptom subscale score were found.

Conclusions and Relevance

In this nonrandomized clinical study, children with high exposure to adversity experienced equivalent, if not greater, benefits associated with parenting programs that include time-out compared with children with low exposure to adversity. Results suggest that time-out was an effective component of parenting programs for children exposed to adversity.

Trial Registration

anzctr.org.au Identifier: ACTRN12617001472369.

Internet-Based Prevention Program of Victimization for Youth in Care and Care Leavers (EMPOWER YOUTH): Protocol for a Randomized Controlled Trial

BACKGROUND

The global estimate of the number of children in institutional care is around 5 million, with around 1 million of these children living in Europe. In Germany, about 75,000 children and adolescents find themselves in the foster care system and about 93,000 additional children and adolescents are living in institutions. Traumatic experiences and neglect in childhood are highly prevalent among these youth in care and are related to severe long-term effects. Childhood maltreatment and abuse can increase the risk of future victimization experiences. Although youth in care are at risk of victimization or revictimization, no specific evidence-based prevention program has been designed to address these specific needs.

OBJECTIVE

This study aims to evaluate the efficacy of a newly developed 6-module internet-based prevention program of victimization for youth in care, named EMPOWER YOUTH.

METHODS

In a randomized controlled trial, the intervention group will be compared to a waiting-list control group with an unblinded 1:1 allocation ratio. Assessments will take place before randomization (baseline) and at follow-up 18 weeks after baseline (ie, 12 weeks after finishing the last module of the program). The primary endpoint is the number of victimization, and online and offline bullying experiences (composite score) at the 18-week follow-up. Secondary endpoints are risk-taking behavior, aggressive tendencies, empathy, prosocial behavior, depressiveness, and loneliness at follow-up. The expected outcome requires a sample size of 156 subjects to achieve a power of 80%. Assuming a 30% dropout rate at follow-up, we require 225 participants to be allocated to the trial. Participants are youth in care, that is, adolescents in foster care, adopted adolescents, or young care leavers aged 14 to 21 years.

RESULTS

Ethical approval was granted by the Ethics Committee of the Medical School Berlin in March 2021 (MSB-2021/55). Recruitment started in September 2021 and is planned until November 2022. The results are expected to be published in January 2023.

CONCLUSIONS

Given the increased likelihood for future victimization experiences among youth in care, there is a strong need for a low-threshold intervention specifically for this high-risk age group. There are no existing nationwide mental health programs exclusively for youth in care in Germany.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024749; https://tinyurl.com/tjaahayw.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34706.

Trajectories of adolescent psychopathology among youth who were maltreated and placed in out-of-home care

BACKGROUND

Although researchers have found an increased risk for psychopathology among maltreated adolescents placed in out-of-home care, different trajectories of psychopathology by out-of-home placements have not been previously studied.

OBJECTIVE

The current study is built on previous investigation of youth in different long-term out-of-home placements and examined the trajectories of adolescent psychopathology by out-of-home placement classes.

PARTICIPANTS AND SETTING

We leveraged data from the Southwestern site of the Longitudinal Studies of Child Abuse and Neglect. Participants included caregiver-youth dyads (N = 273), who had substantiated reports of child maltreatment (CM) prior to children's age four and were placed in out-of-home care.

METHODS

Five out-of-home placement classes from ages 4 to 12 (i.e., stable adopted, stable reunified, stable kinship care, stable non-kin foster care, and unstable placement) were identified from previous study and participants were interviewed at youth ages 12, 14, and 16 to assess adolescent psychopathology. Latent Growth Curve Analysis was used to examine trajectories of psychopathology by placement classes.

RESULTS

Adolescents in unstable placement and stable adopted classes had higher intercepts and more positive or less negative slopes for psychopathology compared to those in stable kinship care and stable reunified classes.

CONCLUSIONS

Adolescents in unstable placement and stable adopted classes were at similarly elevated risk for psychopathology, whereas adolescents in stable kinship care and stable reunified classes were at lower risk for psychopathology. We discuss the clinical implication to preventing and intervening risks for psychopathology among maltreated youth in unstable and adopted placements.

Ontogeny of the Dyad: the Relationship Between Maternal and Offspring Neuroendocrine Function

PURPOSE OF REVIEW

We review ontogeny of the maternal-offspring neuroendocrine relationship in human pregnancy. We present bidirectional genetic, physiological, and behavioral influences that enhance or disrupt HPA activity and its end product cortisol at the individual level and within the dyad.

RECENT FINDINGS

Consistent evidence supports that maternal mood and caregiving behavior are associated with maternal and offspring cortisol levels. Select studies support the buffering effects of antidepressant use and maternal positive affect on offspring cortisol. Growing research highlights evocative effects of fetal neuroendocrine activity, antenatal gene transfer, and infant behavioral distress and risk characteristics on maternal cortisol levels and dyadic attunement. There is potential to advance our understanding of the mother-offspring neuroendocrine relationship by consideration of other neuroactive steroids in addition to cortisol, and to consider developmental timing and measurement source in study design. Future study should emphasize in what context or for whom neuroendocrine attunement is adaptive versus maladaptive for mother and child.

Associations between out-of-home care and mental health disorders within and across generations in a Swedish birth cohort

Previous studies have shown that mental health disorders (MHD) among parents might be an important mechanism in the intergenerational transmission of out-of-home care (OHC). The current study aimed to further study this interplay by investigating the associations between OHC and MHD within and across generations. We used prospective data from the Stockholm Birth Cohort Multigenerational Study (SBC Multigen) on 9033 cohort members (Generation 1; G1) and their 15,305 sons and daughters (Generation 2; G2). By odds ratios of generalised structural equation modelling, we investigated the intergenerational transmission of OHC and MHD, respectively, as well as the association between OHC and MHD within each generation. Second, we examined the associations between OHC and MHD across the two generations. In order to explore possible sex differences, we performed the analyses stratified by the sex of G2. The results showed an intergenerational transmission of OHC, irrespective of sex. Regarding the intergenerational transmission of MHD, it was shown for both sexes although only statistically significant among G2 males. OHC was associated with MHD within both generations; in G2, this association was stronger among the males. While we found no direct association between OHC in G1 and MHD in G2, there was a significant association between MHD in G1 and OHC in G2. The latter was more evident among G2 females than G2 males. We conclude that OHC and MHD seem to be processes intertwined both within and across generations, with some variation according to sex. Although there did not seem to be any direct influences of OHC in one generation on MHD in the next generation, there was some indication of indirect paths going via parental MHD and child OHC.

•

Mental health disorders (MHD) (G1) was directly associated with out-of-home care (G2) among females.

•

There were no direct influences of OHC in one generation on MHP in the next generation.

•

There was some indication of indirect paths going via parental MHD and child OHC.

[Interventions for Children and Adolescents Living in Foster or Institutional Care - A Systematic Review]

Children or adolescents living in foster or institutional care received so far insufficient consideration in therapy intervention research. At the same time, they are a high-risk group for developing mental illness. The aim of this systematic review is to record evidence-based psychotherapeutic interventions of the past 15 years on a national and international level that address children and young people living in foster care and youth welfare institutions and their mental health. Through a systematic literature research, interventions for the target group described were identified and analyzed about their specificity and evidence. From 170 publications, ten interventions with sufficient evidence could be included in the present analysis. The result of the current literature research shows that further specialized psychiatric-psychotherapeutic interventions for children in foster care and youth welfare institutions are necessary. Regarding the transferability to the German youth welfare and health system, cross-system and interdisciplinary cooperation is needed. Hereafter further research is required to establish specific and evidence-based intervention approaches.

Promoting mental health in out of home care in Australia

Young people in out of home care (OoHC) typically have worse mental health outcomes than peers who grow up within a family of origin. Innovations to improve the mental health of this group have tended to focus on pathology rather than mental health promotion and prevention of mental illnesses, and are often costly and challenging to implement. This qualitative study explored perspectives from young people with experience of OoHC in Melbourne, Australia regarding the promotion of mental health in OoHC. The study informed the subsequent development of a system-level intervention to support workers and carers in OoHC and evaluation of its implementation, the Ripple study. We conducted thematic analysis of data from interviews and focus groups with 14 young people aged 18-24 years with diverse identities and experiences of foster, kinship and residential care. We identified four key themes. These were providing a home-like environment; having someone to talk to; connecting to the wider community and having opportunities to become an active citizen. There is a need for both mental health promotion and treatment approaches in interventions to support workers and carers and young people in OoHC. Mental health promotion strategies should include a focus on enhancing existing capacities of carers and workers. Mental health promotion for young people in OoHC depends on strong intersectoral collaboration and youth participation.

Intergenerational transmission of out-of-home care and the role of mental health problems: Findings from Stockholm birth cohort multigenerational study

Out-of-home care (OHC) experiences are associated with poor long-term outcomes throughout life. However, the continuity of OHC over generations is not fully explored, and the influence of mental health problems (MHP) and socioeconomic conditions on such transmission is still unclear. We therefore assessed the extent to which MHP affect the intergenerational transmissions of OHC as well as whether there are differential patterns depending on the socioeconomic conditions of the family of origin. We used a prospective data from the Stockholm Birth Cohort Multigenerational Study (SBC Multigen) on 11,333 cohort members (Generation 1; G1), their parents (Generation 0; G0), and 24,905 children (Generation 2; G2). Multivariate regressions and path models were used to examine the associations between OHC and MHP across generations; stratified analysis by occupational class in G0 was performed to explore potentially differential patterns. Our findings support the existence of an intergenerational transmission of OHC, particularly in the working class group (OR 4.70); MHP was only transmitted across generations in this group (OR 1.51). While the results indicated a stronger role of MHP among the middle/upper class (OR 5.59) compared to working class (OR 3.52) in part of the pathway (MHP G1→OHC G2), this patter was not consistent throughout the whole pathway (e.g. OHC G1→MHP G1). We conclude that there is a tendency for OHC and MHP experiences to continue across generations, particularly among families with more disadvantageous socioeconomic conditions. MHP seem to play an important role in the transmission of OHC irrespective of socioeconomic conditions.

Interventions that address institutional child maltreatment: An evidence and gap map

Background

Child maltreatment has serious short and long-term negative impacts for those experiencing it. Child maltreatment occurring in institutional settings has recently received substantial attention. However, evidence about the effectiveness of interventions that prevent, disclose, respond to, or treat maltreatment that has occurred in these environments is fragmented and can be difficult to access. This evidence and gap map (EGM) collates this research evidence. It was developed as a resource for stakeholders operating in the child health, welfare and protection sectors, including practitioners, organisational leaders, policy developers and researchers, wanting to access high quality evidence on interventions addressing institutional child maltreatment.

Objectives

The objectives of this EGM were twofold: (a) To provide a structured and accessible collection of existing evidence from finalised and ongoing overviews of systematic reviews, systematic reviews and effectiveness studies of interventions addressing institutional child maltreatment-for those who work to fund, develop, implement and evaluate interventions aimed at ensuring children's safety in institutional settings; (b) to identify gaps in the available evidence on interventions addressing institutional child maltreatment-thereby helping to inform the research agendas of funders and other organisations.

Search Methods

A comprehensive search strategy identified relevant studies from published and grey literature, comprising: (1) 10 electronic academic databases; (2) five trial and systematic review registries; (3) nine organisational websites; (4) websites and reference lists of inquiry reports associated with seven international inquiries into child abuse and (4) the lists of included studies within systematic reviews identified by the search strategy. Members of this EGM's Subject Matter Experts group were also invited to forward relevant unpublished studies or grey literature.

Selection Criteria

The selection criteria were developed to identify finalised and ongoing overviews of reviews, systematic reviews and primary studies that reported on the effectiveness of interventions addressing child maltreatment (including sexual abuse, physical abuse, neglect and emotional abuse) within institutional settings. Eligible effectiveness study designs included: randomised controlled trials (RCTs), nonrandomised trials, controlled before-and-after studies and quasi-experimental studies. Reviews were eligible if they reported a systematic literature search strategy.

Data Collection and Analysis

All screening, data extraction, coding and critical appraisals were undertaken by two or more reviewers working independently, with discrepancies resolved via consensus or by a third reviewer. The titles and abstracts of studies identified by the search strategy were screened, and each full text of potentially relevant studies was further assessed for inclusion. Key data were extracted from all included studies and reviews. This included information about: publication details (e.g., year, author, country), inclusion/exclusion criteria (for reviews), study design, institutional setting, target population, type of maltreatment, intervention type and outcomes. Critical appraisal of included systematic reviews was achieved using the AMSTAR 2 tool, and completed RCTs were assessed using the updated Cochrane Risk of Bias 2.0 tool.

Main Results

Number of studies The electronic database search yielded 6318 citations, and a further 2375 records were identified from additional sources. Following deduplication and title/abstract screening, 256 studies remained for full text review. A total of 73 eligible studies (reported across 84 publications) met the inclusion criteria, including: 11 systematic reviews (plus, one update); 62 primary studies (including, three protocols for primary studies). Study characteristics The studies were conducted across 18 countries, however more than half (52%) were undertaken in the United States. Overall, most studies evaluated curriculum-based interventions delivered in educational settings, primarily aimed at the prevention of sexual abuse. Institutional setting: Most studies evaluated interventions in school or early learning environments (n = 8 systematic reviews; n = 58 primary studies). Far fewer studies examined other organisational settings. Out of home care (including foster care, residential care and orphanages), and social service organisations servicing children were minimally represented. No studies were identified where the primary setting was sports clubs, churches/religious organisations, summer/vacation camps, detention centres/juvenile justice settings, or primary/secondary health care facilities. Target population: Most interventions targeted children rather than adults (n = 7 systematic reviews; n = 47 primary studies) from the general population. Fewer studies included populations known to be at an increased risk, or those already exposed to maltreatment. Just over a third of the primary studies conducted an analysis to ascertain differences in the effect of an intervention between the genders. Intervention type: Prevention interventions were the most studied (n = 5 systematic reviews; n = 57 primary studies), with additional studies including prevention approaches alongside other intervention types. Fewer studies evaluated interventions targeting disclosure, institutional responses, or treatment interventions. Type of maltreatment: The vast majority of the studies assessed interventions solely addressing the sexual abuse of children (n = 8 systematic reviews; n = 45 primary studies). The remaining studies addressed other forms of maltreatment, including physical and emotional abuse, or neglect, either in combination or as a sole focus. Outcomes: Primary reported outcomes reflected the bias toward child targeted interventions. Outcome measures captured child wellbeing and knowledge outcomes, including measures of mental health, children's knowledge retention and/or self-protective skills. Measures of maltreatment disclosure or maltreatment occurrence/reoccurrence were less common, and all other outcome categories included in the EGM were minimally or not reported. A third of studies reported on some measure of implementation. Study quality The overall quality of the studies was low to moderate. Most systematic reviews were low-quality (n = 10), with only one high quality review (and update) identified. Most completed RCTs had some concerns relating to the risk of bias (n = 30), and the remainder were considered to be at a high risk of bias (n = 19).

Authors' Conclusions

This EGM has highlighted a substantial need for more high quality studies that evaluate interventions across a broader range of institutional contexts and maltreatment types. The current evidence base does not represent countries with large populations and the greatest incidence of child maltreatment. Few studies focussed on perpetrators or the organisational environment. Further evidence gaps were identified for interventions relating to disclosure, organisational responses and treatment, and few studies assessed interventions targeting perpetrators' maltreatment behaviours, recidivism or desistence. Future studies should also include measure of programme implementation.

Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes: Systematic review (CHIMES) protocol

INTRODUCTION

The mental health and well-being of children and young people who have been in care (ie, care-experienced) are a priority. There are a range of interventions aimed at addressing these outcomes, but the international evidence-base remains ambiguous. There is a paucity of methodologically robust systematic reviews of intervention effectiveness, with few considering the contextual conditions under which evaluations were conducted. This is important in understanding the potential transferability of the evidence-base across contexts. The present systematic review will adopt a complex systems perspective to synthesise evidence reporting evaluations of mental health and well-being interventions for care-experienced children and young people. It will address impact, equity, cost-effectiveness, context, implementation and acceptability. Stakeholder consultation will prioritise a programme theory, and associated intervention, that may progress to further development and evaluation in the UK.

METHODS AND ANALYSIS

We will search 16 bibliographic databases from 1990 to June 2020. Supplementary searching will include citation tracking, author recommendation, and identification of evidence clusters relevant to included evaluations. The eligible population is children and young people (aged ≤25 years) with experience of being in care. Outcomes are (1) mental, behavioural or neurodevelopmental disorders; (2) subjective well-being; (3) self-harm; suicidal ideation; suicide. Study quality will be appraised with methodologically appropriate tools. We will construct a taxonomy of programme theories and intervention types. Thematic synthesis will be used for qualitative data reporting context, implementation and acceptability. If appropriate, meta-analysis will be conducted with outcome and economic data. Convergent synthesis will be used to integrate syntheses of qualitative and quantitative data.

ETHICS AND DISSEMINATION

We have a comprehensive strategy for engagement with care-experienced children and young people, carers and social care professionals. Dissemination will include academic and non-academic publications and conference presentations. Ethical approval from Cardiff University's School of Social Sciences REC will be obtained if necessary.

PROSPERO REGISTRATION NUMBER

CRD42020177478.

Long-term mental health services use in children referred to a clinical intervention

BACKGROUND

Recent advancements in pediatric mental health (MH) increased accessibility of evidence-based interventions. Yet, accessibility alone does not explain the rise in MH services use (MHSU). Maltreatment-related adversity, symptom severity, and access to early interventions have been linked to ongoing need for services, yet their joint contributions to continuities in MHSU remain unclear.

OBJECTIVE

The study examines the role of maltreatment, externalizing symptom severity, and referral for early intervention in pediatric MHSU across five years. To evaluate engagement in treatment, we accounted for treatment progress and referral type, comparing MHSU in court-mandated and voluntary participants.

PARTICIPANTS AND SETTING

Participants were 321 children (M = 4.3 years; 58.9 % boys) referred to parent-child interaction therapy (PCIT), an evidence-based intervention for families struggling with child disruptive behaviors and maltreating families involved with child welfare. Services were provided at a university-affiliated clinic in a metropolitan county.

METHOD

Symptom severity was assessed with standardized questionnaires; maltreatment history and referral type were obtained from casefile reviews. MHSU was tracked through county behavioral health diagnostic reports. The data were analyzed using structural equation modeling.

RESULTS

Results indicated that for the 44.9 % of children with onward referrals, the frequency of service use, but not progress in treatment, predicted ongoing services. Maltreatment emerged as a universal predictor, while externalizing predicted MHSU only in court-mandated participants, suggesting referral type contributes to quantifiable differences in MH needs.

CONCLUSIONS

Findings emphasize importance of ongoing funding for pediatric MH services, and the need to explore mechanisms underlying continuous MHSU in vulnerable children.

Integrative review of the evaluation of additional support programs for care leavers making the transition to adulthood

PROBLEM

Care leavers face many challenges during their transition to adulthood, such as educational attainment, financial instability, housing problems and relationship problems. Various structured programs and additional support exist to help them make this transition and these provide help before or after they have left care. However, the outcomes of such support programs are fragmented. The aim of this study was to synthesize the empirical evidence of studies that evaluated additional support programs that facilitated the transition of care leavers to adulthood.

ELIGIBILITY CRITERIA

Six databases were searched that were published in English in peer-review journals from 2010 to 2019. We reviewed 16 studies related to additional support programs with different methodological designs.

SAMPLE

Care leavers' who have left the foster care.

RESULTS

There were two different types of programs: single-focused and multiple-focused programs. Half of them provided holistic support. Feedback from care leavers provided practical suggestions for the development of relationships with the staffs and peers, for the development of programs and care leavers own involvement in decision-making. The evaluations showed weak evidence of the effectiveness of housing, employment and educational programs.

CONCLUSIONS

The programs were poorly described and heterogenous so that the outcomes could not be compared. It was not possible to provide robust information about their effectiveness.

IMPLICATIONS

We need holistic programs which consider care leavers needs and views, and evaluate rigorously the programs by strong study designs, to determine their effectiveness.

Advancing Research in Child Suicide: A Call to Action

OBJECTIVE

To highlight the problem of child suicide, summarize what is known and not known about the problem in the empirical literature, and provide recommendations with ethical considerations for future research and practice.

METHOD

The development of this paper was informed by a meeting of national experts on the topic hosted by the National Institute of Mental Health, as well as by a review of the empirical literature.

RESULTS

We know something about demographic characteristics that are related to higher child suicide rates, but beyond that we know relatively little about risk factors, prevention, and intervention for suicide risk in children <12 years. It is important for child suicide researchers and practitioners to pay particular attention to ethical issues that may be likely to arise in doing this type of work.

CONCLUSION

Much more research is needed on child suicide in the areas of measurement, prevention, and intervention in order to advance the field and provide practitioners with the tools that they critically need.

Using Positive Emotion Training With Maltreated Youths to Reduce Anger Bias and Physical Aggression

Maltreated youths often overinterpret anger in others' emotional expressions, particularly expressions that are ambiguous, and this "anger bias" is associated with aggressive behavior. In the current experiment, we tested the effect of an emotion-training intervention on anger bias and subsequent aggression. Eighty-four youths, ages 8 to 17, who had been removed from home because of maltreatment and had screened positive for aggressive tendencies, served as participants. Over 4 days, youths completed positive emotion training, a computerized program in which youths classify emotional expressions. Youths in the treatment condition received feedback to encourage their recognition of happiness over anger in ambiguous expressions. Physical aggression up to 1 week posttraining was assessed on the basis of self- and staff reports. The intervention was effective in reducing youths' anger bias and somewhat so in reducing aggression-the latter of-which occurred infrequently, limiting power. Results offer direction for developmental research and cost-effective interventions for maltreated youths at risk for aggression and future justice-system involvement.

Effects of an Urban Forest-Based Health Promotion Program on Children Living in Group Homes

Children living in foster care group homes are more likely to have physical, mental, and social health problems due to parental abuse, neglect, and family breakdown. The purpose of the current study was to develop and apply the urban forest-based health promotion program on children living in group homes in Korea to investigate its effects on perceived health, psychological health, and connectedness to nature. Eight children (mean age = 12.13 [SD = 1.25] years) from three group homes participated in the study. The intervention was conducted individually for each group home once per week for 8 weeks. Quantitative and qualitative data were collected and analyzed. Participants showed significant improvement in restoration. Six themes were identified that reflect participants' experience and the effectiveness of the urban forest-based health promotion program. This program may be considered a possible intervention to promote children's psychosocial health and connectedness to nature. Continuous efforts are needed to further examine the program's effectiveness. [Journal of Psychosocial Nursing and Mental Health Services, 58(6), 18-29.].

A Positive Youth Development Approach to Improving Mental Health Outcomes for Maltreated Children in Foster Care: Replication and Extension of an RCT of the Fostering Healthy Futures Program

Preventing the negative impact of maltreatment on children's mental health requires interventions to be contextually sensitive, grounded in theory and research, and effective in reaching and retaining children and families. This study replicates and extends previous findings of the Fostering Healthy Futures (FHF) program, a 30-week mentoring and skills group intervention for preadolescent maltreated children in foster care. Participants included 426 children recently placed in out-of-home care who were randomized to intervention or control conditions. Outcomes measured 6-10 months postintervention included a multi-informant (child, caregiver, teacher) index of mental health problems as well as measures of posttraumatic stress symptoms, dissociative symptoms, quality of life, and use of mental health services and psychotropic medications. There were high rates of program initiation, retention, and engagement; 95% of those randomized to FHF started the program, 92% completed it, and over 85% of the mentoring visits and skills groups were attended. The FHF program demonstrated significant impact in reducing mental health symptomatology, especially trauma symptoms, and mental health service utilization. These program effects were consistent across almost all subgroups, suggesting that FHF confers benefit for diverse children. Results indicate that positive youth development programming is highly acceptable to children and families and that it can positively impact trauma and its sequelae.

Depression in Children and Adolescents Involved in the Child Welfare System

Child maltreatment presents a significant public health challenge and is strongly associated with development of depression during childhood and adolescence. Not all abused or neglected children are in the child welfare system, but most children in the foster care system have a history of maltreatment. Involvement with the child welfare system presents an additional risk for psychopathology. The role of child maltreatment and child welfare involvement in development of depression in children and adolescents is reviewed and effective treatments are discussed. Clinicians working with foster children must collaborate with care providers and other stakeholders to enhance the child's placement permanence.

The relation between dimensions of maltreatment, placement instability, and mental health among youth in foster care

Youth in foster care with maltreatment experiences often demonstrate higher rates of mental and behavioral health problems compared to youth in the general population as well as maltreated youth who remain at home. Previous research has demonstrated that dimensions of maltreatment (type, frequency, and severity) and placement instability are two prominent factors that account for high rates of psychopathology (e.g., depression, anxiety, and disruptive behavior disorders). The present study sought to clarify the relation between maltreatment and mental health among youth in foster care by studying both the isolated dimensions of maltreatment and cumulative maltreatment, and to determine whether the effects of maltreatment on mental health operated indirectly through placement instability. Information on youth in foster care's (N = 496, Mage = 13.14) mental and behavioral health, maltreatment history, and placement changes were obtained from state records and primary caregivers. Using a SEM framework, the results suggest that maltreatment and placement instability each independently relate to mental and behavioral health problems. Further, none of the maltreatment types predicted greater placement instability in the current models. These findings suggest that placement stability is critical for mental health for youth in foster care, regardless of the type, severity, or frequency of their maltreatment experiences. Results also indicated that, although cumulative maltreatment predicted both internalizing and externalizing symptoms, maltreatment frequency and severity had direct relations to externalizing symptoms only. These findings underscore the utility of comprehensive maltreatment assessment, encouraging researchers and clinicians to assess and carefully consider the relation between maltreatment dimensions and outcomes.

The grip of trauma: How trauma disrupts the academic aspirations of foster youth

The academic challenges foster youth encounter during their P-12 education have been widely reported. Yet, despite these challenges, the majority of foster youth desire postsecondary education. What is less known is the reason why so few foster youth alumni who desire a four-year college degree, achieve this goal. For the participants in this four-year longitudinal study, maltreatment, resulting in foster care placement, and the ensuing exposure to the foster care system, resulted in trauma histories and mental health diagnoses. Anxiety, depression, and posttraumatic stress disorder (PTSD), were the most common diagnosis. The participants shared the ways in which these mental health challenges manifested throughout their college education. Of those in the study, almost half successfully graduated from college, a third dropped out, and only two remain enrolled. This study provides a unique and critical insight into the experiences of foster youth, enrolled in a four-year university, by sharing their stories.