Decrease in Behavioral Problems and Trauma Symptoms Among At-Risk Adopted Children Following Web-Based Trauma-Informed Parent Training Intervention

Trauma-informed care beliefs scale-comprehensive for child welfare carers using Rasch analysis

BACKGROUND

The literature on trauma-informed care practices (TIC) indicates that this framework is beneficial for young people, carers, and staff. However, a significant gap in the literature and practice is the absence of psychometrically sound scales to measure carer adherence to TIC principles. Emerging evidence suggests that TIC practices shift carer attitudes and beliefs, which mediate positive outcomes for both carers and young people.

OBJECTIVE

To develop a theoretically comprehensive and psychometrically sound measure of carer TIC beliefs using Rasch methodology.

PARTICIPANTS AND SETTING

Active carers (N = 719, M = 43 years, SD = 10.7 years) from online support groups in Australia, Canada, the United States of America, the United Kingdom, and the Republic of Ireland completed the questionnaire online.

METHODS

Based on previous research (e.g., limitations of the Trauma-Informed Belief Scale-Brief [TIBS-B]; Beehag, Dryer, et al., 2023a) and a scoping review of the TIC literature (Beehag, 2023), 61 candidate items were created that covered the three main characteristics of carer-related TIC theory (i.e., beliefs on TIC strategies to manage trauma symptoms, beliefs on the impact of adverse childhood experiences (ACE), and beliefs on the importance of self-care/reflection). The resulting data was subjected to Rasch analyses.

RESULTS

Following analyses and minor modifications, a 35-item version of the questionnaire was confirmed, which fitted the Rasch model and demonstrated unidimensionality, reasonable targeting, and sound internal consistency reliability (Person Separation Index = 0.81).

CONCLUSIONS

The TIBS-C is a psychometrically sound measure of child welfare carer TIC beliefs. Future studies are needed to provide further evidence of its validity (e.g., predictive validity), reliability (e.g., test-retest reliability) and clinical utility.

Feasibility and Acceptability of a Trauma-informed Intervention to Leverage Caregivers in Preventing Opioid Use Among Youth Involved in the Legal System

Youth in the legal system (YILS) report high rates of substance use (SU), complex family/social relationships, and chronic trauma. The current study tested the feasibility of a prevention intervention, Trust-based Relational Intervention® (TBRI®), that leverages family systems by strengthening connection and providing emotional and instrumental guidance and support. TBRI includes the primary TBRI Intervention, comprised of Caregiver Training, Youth Training, and joint youth-caregiver Nurture Groups, and TBRI Family Coaching. With a sample of eight youth-caregiver dyads, the study adopted a mixed-methods design with a multi-informant approach to fulfill two goals: (1) testing TBRI as a prevention intervention for opioid use (OU), other SU, and related issues, and (2) testing the feasibility and acceptability of the TBRI Intervention by virtual delivery. Session attendance and completion rates demonstrated feasibility of recruiting and retaining participants and intervention fidelity. Preliminary results were reported on intervention outcomes, including OU and other SU, illegal activities, and educational attainment. Pre- and post-intervention comparisons showed decreases in youth negative urgency, conduct problems, and hyperactivity. Caregiver and staff participants responded favorably to TBRI and its virtual delivery; youth were more capable of expressing their needs and acknowledged the importance of families in preventing problems after discharge from secure facilities. While acknowledging sufficiency of intervention content, caregivers expressed the desire for more sessions. Results demonstrate the feasibility and acceptability of a trauma-informed, attachment-based prevention intervention for youth and families in contact with the legal system. TBRI is a promising approach for preventing the initiation or escalation of OU among YILS.

Adaptation of a trauma-informed intervention to prevent opioid use among youth in the legal system

INTRODUCTION

Youth in the legal system are at high risk for opioid and other substance use problems and exhibit high rates of trauma exposure. Trauma-focused therapeutic approaches to prevent substance use show promise, but few evidence-based interventions are designed with justice-involved youth in mind. Consequently, implementing trauma-informed, evidence-based interventions within juvenile justice systems is challenging. The current paper describes the systematic adaptation of Trust-Based Relational Intervention (TBRI) as a family-centered substance use prevention program for youth transitioning from secure residential facilities.

METHODS

The study utilized the ADAPT-ITT methodological framework to adapt TBRI Caregiver Training, an evidence-based, trauma-informed intervention designed to help caregivers support children and youth with histories of trauma. Phases of adaptation included (1) Assessment, (2) Decision, (3) Prototype Development, and (4) Testing and Integration. The adaptation process explored contextual factors (e.g., systems, facilities, and staff) and the needs of the new target population (i.e., youth in the legal system and their caregivers). Adaptations were made to both content (e.g., terminology and activities) and structure (e.g., session duration and delivery setting) with input from participants from the target population, key stakeholders, and content experts.

RESULTS

The systematic adaptation of the intervention model resulted in a two-phase, four-component intervention package that can be implemented in juvenile justice settings as part of youth reentry services. The primary intervention, delivered while youth are in residential facilities, includes the TBRI Caregiver Curriculum, TBRI Youth & Young Adult Curriculum, and TBRI Nurture Groups. The secondary intervention, delivered after youth transition home, includes the TBRI Family Coaching Curriculum.

CONCLUSIONS

Utilizing a systematic methodological framework to guide adaptation has implications for developing accessible, culturally relevant, and contextually appropriate interventions. Accounting for contextual factors and population needs can improve the fit of evidence-based interventions for youth in the legal system, facilitating uptake and ultimately improving outcomes for youth at risk for substance use problems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04678960.

Trust-Based Relational Intervention® (TBRI®) Impact for Traumatized Children-Meaningful Change on Attachment Security and Mental Health after One Year

Children from vulnerable backgrounds often have insecure attachment or disorganized attachment, which are related to psychological troubles, and such children need interventions to help them heal. The attachment system reorganizes in middle childhood, and other important adults play a considerable role in children's lives. Thus, it is essential to weigh the impact of psychosocial interventions, while the main focus of the intervention is the staff member's direct work with the child through a trusting relationship. The primary purpose of this study is to investigate whether children's attachment security and mental health outcomes change after participating in a trauma-informed, attachment-based, Trust-Based Relational Intervention (TBRI) provided in a daycare center. It was a case-series study involving twelve children aged 8-11 years. The child attachment interview (CAI), CBCL/6-18, TRF/6-18, and clinical interviews for parents and children were used, measuring the change between the TBRI implementation in the daycare center and after one year. For ten participants, we noticed an improvement in mental health; for seven participants, security scales improved; for two participants, their disorganized attachment changed into insecure-dismissing. We have preliminary evidence that vulnerable children may benefit in terms of attachment security and mental health from the trusting relationship that staff build using the TBRI.

Engaging Parents in Technology-Assisted Interventions for Childhood Adversity: Systematic Review

BACKGROUND

Youth mental health problems are a major public health concern and are strongly associated with adverse childhood experiences (ACEs). Technology-assisted parenting programs can intervene with ACEs that are within a parent's capacity to modify. However, engagement with such programs is suboptimal.

OBJECTIVE

This review aims to describe and appraise the efficacy of strategies used to engage parents in technology-assisted parenting programs targeting ACEs on the behavioral and subjective outcomes of engagement.

METHODS

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines, we conducted a systematic review of peer-reviewed papers that described the use of at least 1 engagement strategy in a technology-assisted parenting program targeting ACEs that are within a parent's capacity to modify. A total of 8 interdisciplinary bibliographic databases (CENTRAL, CINAHL, Embase, OVID MEDLINE, OVID PsycINFO, Scopus, ACM, and IEEE Xplore) and gray literature were searched. The use of engagement strategies and measures was narratively synthesized. Associations between specific engagement strategies and engagement outcomes were quantitatively synthesized using the Stouffer method of combining P values.

RESULTS

We identified 13,973 articles for screening. Of these, 156 (1.12%) articles were eligible for inclusion, and 29 (18.2%) of the 156 were associated with another article; thus, 127 studies were analyzed. Preliminary evidence for a reliable association between 5 engagement strategies (involving parents in a program's design, delivering a program on the web compared to face-to-face, use of personalization or tailoring features, user control features, and provision of practical support) and greater engagement was found. Three engagement strategies (professional support features, use of videos, and behavior change techniques) were not found to have a reliable association with engagement outcomes.

CONCLUSIONS

This review provides a comprehensive assessment and description of the use of engagement strategies and engagement measures in technology-assisted parenting programs targeting parenting-related ACEs and extends the current evidence with preliminary quantitative findings. Heterogeneous definition and measurement of engagement and insufficient engagement outcome data were caveats to this synthesis. Future research could use integrated definitions and measures of engagement to support robust systematic evaluations of engagement in this context.

TRIAL REGISTRATION

PROSPERO CRD42020209819; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=209819.

Protocol for evaluation of effects of a psychoeducational trauma-informed intervention directed at schools

Background: Adverse childhood experiences (ACE) can have negative effects on cognitive, social and emotion regulation abilities, which can threaten the child's school integration and capacity to learn. While steady relations to sensitive, understanding adults may moderate these negative outcomes, the difficulties of children with ACEs pose a major challenge for teachers, whose insufficient preparation may lead to career attrition.Objective: Psychoeducational trauma-informed care (TIC) interventions targeting teachers may strengthen teacher preparation and buffer the deleterious outcomes of ACEs, yet the evidence-base for these interventions is limited. Importantly, while minority groups are overrepresented among those with ACEs and additionally risk exposure to ethno-racial trauma, TIC interventions lack a social disadvantage/discrimination perspective. The Present trial addresses these issues.Method: The study protocol employs a quasi-experimental design for assessing effects of a psychoeducational TIC intervention carried out in Swedish schools by Save the Children, Sweden (SCS). We compare, for the first time, an intervention group (N = 160) and a control group (N = 160) over time (pre-intervention, immediately after, 6 and 12 months post-intervention), assessing teacher stress, compassion fatigue, self-efficacy and trauma-informed knowledge. We monitor teacher attitudes and attributions of students' academic weaknesses and behavioural and mental difficulties. The trial is preregistered (DOI:10.17605/OSF.IO/V7SH8).Results: We hope that the mitigating effects of the SCS-TIC school intervention may be independent of social category, and that the trial will additionally generate knowledge of how providers and recipients of TIC may respond to it differently depending on their social and cultural identities. As school-based TIC practices and interventions are expansively relied on as means of preventing teacher burnout and career attrition, and buffering negative consequences of ACEs for children, establishing their effects with methodological robustness is important and timely.Conclusion: Such knowledge may be used to tailor and target interventions to specific populations, while ensuring maximum effectiveness.

Adapting prevention programs for virtual delivery: A case study in adapting a parent-focused child sexual abuse prevention module

Background

Evolving and emerging contexts require interventions to respond and adapt. The COVID-19 pandemic necessitated a quick adaptation from in-person to virtual delivery. Not only were there few programs able to transition to virtual delivery, there was a lack of parent-focused CSA-prevention programs. The current study describes the responsive adaptation of a parent-focused child sexual abuse (CSA) prevention module (Smart Parents-Safe and Healthy Kids; SPSHK) for virtual delivery.

Design and methods

This two-phase study used mixed-methods to inform and pilot test adaptations to the virtual module. In Phase 1, parenting providers with and without experience delivering SPSHK (N = 110) completed anonymous surveys and a subsample (n = 27) subsequently participated in brief interviews elaborate on challenges and needed adaptations for virtual platforms.

Results

Providers indicated the greatest technological difficulties with parents' access to technology noting the inability to use a screensharing function. Thus, providers recommended no adaptations for the virtual delivery of SPSHK. In Phase 2, the virtual SPSHK module was piloted with nine parents. Results demonstrated virtual SPSHK was acceptable and feasibly implemented. Pre-posttest assessments indicated increases in parents' CSA-related awareness and use of protective behaviors.

Conclusion

The current study suggests the promise of virtual SPSHK implementation and may act as a blueprint for other parent-focused CSA-prevention programs, but also more general parenting programs, considering virtual delivery.

Parenting interventions to support parent/child attachment and psychosocial adjustment in foster and adoptive parents and children: A systematic review

Background

Adopted children and children placed in foster care are at increased risk of developing a range of mental health, behavioural, and psychosocial adjustment problems. Previous studies suggest that due to early experiences of separation and loss some children may have difficulties forming a secure attachment relationship with the adoptive/foster parents.

Objectives

The objectives of the present review were: (1) to assess the efficacy of attachment-based interventions on measures of favourable parent/child outcomes (attachment security, dyadic interaction, parent/child psychosocial adjustment, behavioural and mental health problems, and placement breakdown) within foster and adoptive families with children aged between 0 and 17 years. (2) to identify factors that appear to be associated with more effective outcomes and factors that modify intervention effectiveness (e.g., age of the child at placement and at intervention start, programme duration, programme focus).

Search Methods

Relevant studies were identified through electronic searches of bibliographic databases, governmental and grey literature repositories, hand search in specific targeted journals, citation tracking, contact to international experts and Internet search engines. The database searches were carried out to October 2020.

Selection Criteria

The interventions of interest were parenting interventions aimed at helping the foster/adopted children and their parents to form or sustain a secure attachment relationship. The interventions had to be at least partly informed by attachment theory.

Data Collection and Analysis

The total number of potentially relevant studies constituted 17.822 hits after duplicates were removed. A total of 44 studies (27 different populations) met the inclusion criteria and were critically appraised by the review authors. Due to critical study quality, missing numeric data and re-use of the same data, only 24 studies analysing 16 different populations could be used in the data synthesis (children, N = 1302; parents, N = 1344). Meta-analysis using both child and parent outcomes were conducted on each metric separately. All analyses were inverse variance weighted using random effects statistical models. Random effects weighted mean effect sizes were calculated using 95% confidence intervals (CIs). When possible, we conducted moderator analysis using meta-regression and single factor sub group moderator analysis. Sensitivity analysis were conducted across study design and domains of the risk of bias assessment.

Main Results

Ten studies analysed the effect of attachment-based interventions on the overall psychosocial adjustment of foster or adopted children as reported by their caregivers post intervention. Measures used include the Child Behaviour Checklist, The Strengths and Difficulties Questionnaire, Brief Infant-Toddler Social and Emotional Assessment (BITSEA) and Eyberg Child Behaviour Inventory. The random effects weighted standardised mean difference (SMD) favouring the intervention group was 0.37 (95% CI, 0.10-0.65) and statistically significant. Three studies analysed the effects of attachment-based interventions on the observed attachment security of foster and adopted children as measured by independent observation. Measures include the Strange Situation Procedure, Attachment Q-Set, and The Emotional Availability Clinical Screener. The random effects weighted SMD was 0.59 (95% CI, -0.40-1.57) and not statistically significant. Four studies analysed the effect of attachment-based interventions on positive child behaviour post intervention as measured by independent observation of video-taped interaction between the child and caregivers. Measures include Disruptive Behaviour Diagnostic Observation Schedule (DB-DOS) and Emotional Availability Scales). The random effects weighted SMD was 0.39 (95% CI, 0.14-0.64) and statistically significant. Ten studies analysed the effect of attachment-based interventions on positive parenting behaviour post intervention as measured by independent observation of video-taped interaction between the child and caregivers or coding of audio-taped recordings of parental speech. Measures include Adapted Ainsworth Scales for sensitivity and noninterference, Measurement of Empathy in Adult-Child Interaction, The Dyadic Parent-Child Interaction Coding System, Reflective functioning scale, and Emotional Availability Scales. The random effects weighted SMD was 1.56 (95% CI, 0.81-2.31) and statistically significant. Nine studies analysed the effect of attachment-based interventions on self-reported post intervention parenting stress (Parenting Stress Index). The random effects weighted SMD was 0.24 (95% CI, 0.03-0.46.) and statistically significant. Three studies analysed the effect of attachment-based interventions on parental post intervention self-reported depressive symptoms (Beck Depression Inventory). The random effects weighted SMD was 0.59 (95% CI, -0.08-1.25.) and not statistically significant. Follow-up analyses were carried out for the outcomes externalising behaviour, positive parenting, and parenting stress, but due to the low number of studies, results should be viewed with caution. Results of the single factor sub group moderator analysis suggest that it cannot be ruled out the effects differ depending on whether the interventions take place in the family home or in a clinical setting. However, it is unclear which location is associated with more positive effects as our findings differ between child and parent outcomes. Results of the sensitivity analysis showed no appreciable changes in the results following the removal of any of the studies in any of the analyses.

Authors' Conclusions

Parenting interventions based on attachment theory increase positive parent/child interactional behaviours, decrease parenting stress, and increase the overall psychosocial adjustment of children in foster and adoptive families postintervention. Due to the low number of studies evidence regarding the effects of attachment-based parenting interventions on attachment security and disorganised attachment in foster and adopted children was inconclusive. Theoretically, it is possible that child attachment security and/or attachment disorganisation cannot change within the relatively short period of time that parenting interventions typically last. It is possible that if postintervention improvements in parenting behaviours are sustained over time, it may lead to possible improvement in child attachment security and a decrease in child disorganised attachment. Thus, more longitudinal research is needed. Furthermore, evidence regarding the long-term effects of attachment-based parenting interventions on any outcomes was inconclusive due to too few studies, but findings suggest that attachment-based interventions increase positive parenting behaviour at follow-up points 3-6 months after the intervention. No study included in the present review provided a measure of placement stability or breakdown as an outcome, which could be used in the meta-analysis. This further emphasises the need for future longitudinal research in prevention of placement breakdown.

Preventing opioid use among justice-involved youth as they transition to adulthood: leveraging safe adults (LeSA)

BACKGROUND

Juvenile justice (JJ) youth are at high risk of opioid and other substance use (SU), dysfunctional family/social relationships, and complex trauma. The purpose of the Leveraging Safe Adults (LeSA) Project is to examine the effectiveness of Trust-Based Relational Intervention® (TBRI®; leveraging family systems by providing emotional and instrumental guidance, support, and role modeling) in preventing opioid and other SU among youth after release from secure residential facilities.

METHODS

An effectiveness-implementation Hybrid Type 1 design is used to test the effectiveness of TBRI for preventing non-medical use of opioids among JJ-youth (delayed-start at the site level; a randomized controlled trial at participant level) and to gain insight into facility-level barriers to TBRI implementation as part of JJ re-entry protocols. Recruitment includes two samples (effectiveness: 360 youth/caregiver dyads; implementation: 203 JJ staff) from nine sites in two states over 3 years. Participant eligibility includes 15 to 18-year-olds disposed to community supervision and receiving care in a secure JJ facility, without active suicide risk, and with one caregiver willing to participate. Effectiveness data come from (1) youth and caregiver self-report on background, SU, psychosocial functioning, and youth-caregiver relationships (Months 0, 3, 6, 12, and 18), youth monthly post-release check-ins, and caregiver report on youth psychological/behavioral symptoms, and (2) JJ facility records (e.g., recidivism, treatment utilization). Fidelity assessment includes post-session checklists and measures of TBRI strategy use. Collected four times over four years, implementation data include (1) JJ staff self-report on facility and staff characteristics, use of trauma-informed care and TBRI strategies, and (2) focus groups (line staff, leadership separately) on use of trauma-informed strategies, uptake of new interventions, and penetration, sustainment, and expansion of TBRI practices.

DISCUSSION

The LeSA study is testing TBRI as a means to empower caregivers to help prevent opioid use and other SU among JJ-youth. TBRI's multiple components offer an opportunity for caregivers to supplement and extend gains during residential care. If effective and implemented successfully, the LeSA protocol will help expand the application of TBRI with a wider audience and provide guidance for implementing multi-component interventions in complex systems spanning multiple contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04678960 ; registered November 11, 2020; https://clinicaltrials.gov/ct2/show/NCT04678960 .

Improving Access to Trauma-Informed Adoption Services: Applying a Developmental Trauma Framework

Foster and adopted children often experience multiple traumatic and adverse experiences. A growing body of literature indicates the negative impact of trauma on developmental milestones and brain development, which supports the need to address complex trauma among this vulnerable population of foster and adopted youth. This paper presents an overview of the unique needs of children adopted from the foster care system from the perspective of adverse childhood experiences (ACEs), complex trauma, and developmental trauma disorder (DTD). There is an increasing number of evidence-based trauma-focused services and interventions for children and youth. However, many adoptive parents have limited trauma-informed training and limited access to trauma-informed and adoption-competent professionals, particularly long-term supports across developmental stages, making them ill-prepared to meet the needs of children in their care. This paper contributes to the understanding of how access to these trauma-focused services can be increased through new technologies, to better prepare and empower adoptive parents to deal effectively with difficult adoption issues when they arise and to improve outcomes for children and youth adopted from the public child welfare system. Several innovative approaches toward this end include harnessing technology to: (1) improve access to suitable adoption resources, (2) improve mechanisms to track critical events, behaviors, emotions, functional abilities, strengths, etc., in order to determine timely, on-demand contextual services, and (3) extend professional, supportive environments beyond the adoptive family context by proposing the use of technology to build interdisciplinary, virtual community partners.

The effectiveness of psychological interventions with adoptive parents on adopted children and adolescents' outcomes: A systematic review

Adopted children and adolescents are at an increased risk of experiencing emotional, behavioural and relational difficulties compared to their non-adopted peers. This systematic review aimed to establish the effectiveness of interventions with adoptive parents on adopted children and adolescents' psychological well-being, behavioural functioning and parent-child relationship. A systematic search was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), including studies that assessed the effects of interventions with adoptive parents on adopted child and adolescent outcomes. Electronic databases, key journals, grey literature sources, reference and citation lists were searched and published authors in the field were contacted; 19 papers describing 15 interventions were included. The findings from this review provide preliminary support for the use of interventions with adoptive parents for improving adopted children's emotional and behavioural outcomes. However, overall, the studies were found to have a high risk of bias, and the significant heterogeneity across the studies limits the conclusions that can be drawn. Further research is required to provide conclusive recommendations regarding the effectiveness of interventions with adoptive parents on the outcomes of adopted children.