Implementing Evidence-Based Practice in Residential Care - How Far Have We Come?

Reducing Behavioral Problems and Treatment Duration of Adolescents in Secure Residential Care: A Multiple Single-Case Experimental Design Study

Secure residential care (SRC) is criticized for several reasons. Therefore, in many countries, the general policy is to limit the length of stay of adolescents in SRC. However, research on length of stay and treatment effects of SRC on adolescents' behavioral problems is sparse. Using single case experimental designs with time-series, forty adolescents referred to SRC completed a questionnaire on behavioral and attention problems every two weeks during a baseline (A) and treatment period (B). Two-level regression analyses were used to investigate the effects of SRC on behavioral and attention problems. In addition, we tested whether length of stay moderated effectiveness. On the individual level, the treatment showed a positive statistically significant effect on the behavioral problems of 0%-8% of the adolescents and a statistically significant negative effect on behavioral problems was found in 3%-10% of the adolescents. On the group level, adolescents showed no significant decrease in problem behavior or attention problems from baseline to discharge. Length of stay did not moderate the results. Based on the results we conclude that most adolescents fail to improve. In addition, length of stay was not associated with effectiveness, nor could it be explained by adolescents' characteristics.

Identifying family engagement priorities in youth residential treatment settings: A group concept mapping study

Residential treatment (RT) settings serve youth with severe mental health challenges, often requiring more intensive intervention than outpatient services. Despite the recognized importance of family engagement in improving youth outcomes, there is limited understanding of which family engagement strategies are most valued within RT settings. This study aimed to develop a framework to enhance family engagement in RT by identifying and prioritizing strategies based on their importance and feasibility. Utilizing group concept mapping (GCM), the study gathered and analyzed data from 40 participants, including family members and RT staff across the United States. Participants brainstormed ideas, sorted them into thematic clusters, and rated them on importance and feasibility. The analysis revealed eight distinct clusters representing critical aspects of family engagement in RT, and 44 strategies were rated highly for both importance and feasibility, emphasizing areas like parent peer support, robust communication, and comprehensive discharge planning. The findings underscore the need for improved communication, greater family involvement as active team members, and extended support during and after discharge from RT. Notably, parent-peer support emerged as a critical component. This research provides a framework for understanding and implementing family engagement strategies in RT settings. The prioritized strategies can inform policy and practice to enhance family support and improve youth outcomes in RT. Future research should focus on the practical application of these strategies and the continued evaluation of their impact on families and youth in RT.

Mental disorders among adults formerly in out-of-home care: a systematic review and meta-analysis of longitudinal studies

While children and adolescents placed in child welfare or juvenile justice out-of-home care show higher prevalence rates of mental disorders compared to the general population, it remains unclear whether this pattern persists into adulthood. A quantitative synthesis of existing studies is lacking. The aim of this meta-analysis was to estimate the prevalence rates for mental disorders among adults with a foster or residential child welfare or juvenile justice care history, comparing them where possible to rates among the general population. PubMed, PsycInfo, EMBASE, and Web of Science were systematically searched for epidemiological studies published up to 28 October 2020. Nineteen studies, totaling 604,257 participants, met our inclusion criteria. Random-effects models were used for prevalence rates and odds ratios (OR) of mental disorders, and study quality was rated. A prevalence rate of 30% [95% CI (23.36, 37.36)] for any mental disorder in adults with a child welfare care history was found (3-17% for specific disorders). A prevalence rate of 45% [95% CI (42.38, 47.38)] for any mental disorder was found in adults with a juvenile justice care history (6-66% for specific disorders). For out-of-home placement history, adult mental disorders were significantly higher than in the general population (OR = 1.33-2.76). Studies differed in terms of methodology and the disorder groups considered, so heterogeneity between effect sizes ranged from low to high. Our findings suggest that the high risk that mental health issues will persist in adults with an out-of-home placement history needs to be taken seriously in the transition from adolescence to adulthood. The care systems involved need to collaborate and to be aware of these risks.

To Change or Not to Change? A Study regarding the Satisfaction of Care Workers and Adolescents with the Motivational Interviewing Based Residential Youth Care Training Program Up2U

Long-term behavioral change is often difficult to achieve with adolescents staying in residential youth care. To achieve long-term behavioral change, we developed the Up2U training program to enhance these adolescents' intrinsic motivation for change. Based on motivational interviewing and solution-focused therapy, Up2U is designed for conducting one-on-one conversations with adolescents in residential youth care. The aim of this study is to evaluate the experiences that adolescents and care workers have had with Up2U. The results of semi-structured interviews show that, in general, the care workers were satisfied with Up2U. They identified the clarity, conciseness, and sample questions as positive elements of Up2U. In contrast, the care workers regarded the extensiveness and the implementation of Up2U as less positive. The adolescents also seemed to be positive about the use of Up2U during one-on-one conversations. In conclusion, although both care workers and adolescents were generally satisfied, there is still room for improvement.

Evidence-based intervention on postoperative fear, compliance, and self-efficacy in elderly patients with hip fracture

BACKGROUND

Elderly patients tend to have poor self-efficacy and poor confidence in postoperative rehabilitation for hip fractures, and are prone to negative emotions, which affect treatment compliance.

AIM

To evaluate the effects of evidence-based intervention on postoperative fear, compliance, and self-efficacy in elderly patients with hip fractures.

METHODS

A total of 120 patients with hip fracture surgically treated from June 2018 to June 2020 at the orthopedic department of our hospital were selected and divided into intervention and routine groups (n = 60 each) according to different nursing methods. The basic rehabilitation methods of the two groups were consistent, but patients in the intervention group received evidence-based nursing interventions at the same time. Differences between groups in the scores of motion phobia, pain fear, rehabilitation training compliance, self-efficacy, nursing satisfaction, and hip joint function were compared before and after the intervention.

RESULTS

Before the intervention, there were no statistically significant differences in motion phobia and pain fear scores between the groups (all P > 0.05). However, motion phobia scores at 1 wk after intervention initiation (P < 0.05), and pain fear scores at 1 wk and 2 wk after intervention initiation (all P < 0.05), were significantly lower in the intervention group than in the routine group. On the first day of intervention, there was no significant difference in rehabilitation treatment compliance between the groups (P > 0.05); however, at 2 wk after intervention initiation, rehabilitation compliance was significantly better in the intervention group than in the routine group (P < 0.05). Before the intervention, there were no statistically significant differences in the scores for the two self-efficacy dimensions (overcoming difficulties and rehabilitation exercise self-efficacy) and the total self-efficacy score between the groups (all P > 0.05). After 2 wk of intervention, the scores for these two dimensions of self-efficacy and the total self-efficacy score were significantly higher in the intervention group than in the routine group (all P < 0.05). At 3 and 6 mo after surgery, hip function as evaluated by the Harris hip score, was significantly better in the intervention group than in the routine group (P < 0.05). Additionally, overall nursing satisfaction was significantly higher in the intervention group than in the routine group (P < 0.05).

CONCLUSION

Evidence-based nursing intervention can alleviate fear of postoperative rehabilitation in elderly patients who underwent hip fracture surgery, and improve rehabilitation treatment compliance and patient self-efficacy, which promote hip function recovery.

Implementation of the Wolverine Mental Health Program, Part 1: Adoption Phase

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS's readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.

Implementation of the Wolverine Mental Health Program, Part 2: Implementation Phase

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic-community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).

Diverse trauma profiles of youth in group care settings: A cluster analysis

BACKGROUND

Many adolescents in group care have experienced higher rates of traumatic event exposure, behavior problems, and severe trauma sequelae compared to those outside of group care. Yet, little research has examined from a person-centered perspective their diverse trauma profiles and corresponding service needs.

OBJECTIVE

This exploratory study aimed to examine the heterogeneity of trauma-related profiles among youth in group care to highlight potential distinct service needs among subgroups.

METHOD

Data from the Maltreatment and Adolescent Pathways Study identified 96 randomly selected youth (14-17 years) in Canadian group care settings who completed a battery of self-report measures. Cluster analysis was employed to reveal common patterns of maltreatment and trauma symptoms among subgroups, further described and validated by externalizing behaviors (substance use, risky sexual behavior), internalizing symptoms (global mental health, anger), and personal/parental demographic factors.

RESULTS

Four distinct clusters emerged: (1) no/low maltreatment, low trauma; (2) moderate physical and emotional abuse, moderate trauma; (3) moderate-severe maltreatment, low trauma; and (4) severe maltreatment, high trauma. Clusters 1, 2, and 4 reflected 'dose-response' relationships between maltreatment and trauma symptoms; Cluster 3 was characterized as 'resilient'. Females were highly over-represented in Cluster 4, echoing previous research.

CONCLUSIONS

Findings align with previous research confirming high incidence of maltreatment, internalizing, and externalizing problems among youth in group care, but extends to emphasize the importance of providing trauma-informed services tailored to their variable, complex presentations. Limitations and suggestions for group care settings to provide this wide range of services at program and individual levels are discussed.

Feeling Better: Experiences and Needs of Adolescents and Professionals Regarding Their Mentoring Relationship in Residential Youth Care

Background

In residential youth care, group care workers and teachers often serve as a mentor for individual adolescents. Although favorable mentoring relationships are associated with positive adolescent outcomes, few studies examined the role of mentoring in residential youth care.

Objective

The present study aims to assess adolescents’, care workers’ and teachers’ mentoring relationship needs in terms of their one-on-one conversations during residential care.

Methods

We conducted structured interviews with eleven adolescents, ten group care workers and two teachers and content analysis to assess the data

Results

All respondents are rather satisfied with their conversations, which are often concerned with how the adolescent is doing. Adolescents mostly consider their family and home-situation as difficult topics, while care workers mostly consider sexuality as a difficult topic to talk about. Although ‘improvement’ with the youth is often the aim, most adolescents report that they do not (know if they) show changes because of these conversations. Moreover, only one of the twelve professionals thinks that it is his core task to achieve behavior change with the adolescents. According to the professionals, conversations often aim at building a good relationship, coaching, determining treatment goals, and gaining insight into the adolescent. Adolescents prefer a mentor who is calm, has respect, listens, and is reluctant in giving advice. Most professionals do not use a specific method and doubt whether they want to have conversations according to a manual or support tool.

Conclusions

Despite being rather satisfied, adolescents and professionals indicate several points for improvement of one-on-one conversations.