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

Developmental trajectories of socio-emotional outcomes of children and young people in out-of-home care - Insights from data of Pathways of Care Longitudinal Study (POCLS)

BACKGROUND

There has been a limited understanding of the longitudinal trajectory and determinants of socio-emotional outcomes among children in out-of-home care (OOHC).

OBJECTIVES

This study aimed to examine child socio-demographics, pre-care maltreatment, placement, and caregiver factors associated with trajectories of socio-emotional difficulties of children in OOHC.

PARTICIPANTS AND SETTING

The study sample (n = 345) included data from the Pathways of Care Longitudinal Study (POCLS), a prospective longitudinal cohort of children aged 3-17 years who entered the OOHC system in New South Wales (NSW) Australia, between 2010 and 2011.

METHODS

Group-based trajectory models were used to identify distinct socio-emotional trajectory groups based on the Child Behaviour Check List (CBCL) Total Problem T-scores completed at all four Waves 1-4. Modified Poisson regression analysis was conducted to assess the association (risk ratios) of socio-emotional trajectory group membership with pre-care maltreatment, placement, and caregiver-related factors.

RESULTS

Three trajectories of socio-emotional development were identified: 'persistently low difficulties' (average CBCL T-score changed from 40 to 38 over time), normal (average CBCL T-score changed from 52 to 55 over time), and clinical (average CBCL T-score remained at 68 over time) trajectories. Each trajectory presented a stable trend over time. Relative/kinship care, as compared with foster care, was associated with the "persistently low" socio-emotional trajectory. Being male, exposure to ≥8 pre-care substantiated risk of significant harm (ROSH) reports, placement changes, and caregiver's psychological distress (more than two-fold increased risk) were associated with the clinical socio-emotional trajectory.

CONCLUSIONS

Early intervention to ensure children have a nurturing care environment and psychological support to caregivers are vital for positive socio-emotional development over time among children in long-term OOHC.

Academic Functioning of Youth in Foster Care: The Influence of Unique Sources of Social Support

Youth in foster care often experience more difficulty in school compared to their non-foster care peers. Difficulties exist across domains of academic functioning, including both performance (e.g., low grades) and behavioral health (e.g., high externalizing concerns) in school. One factor that has shown to be associated with positive academic functioning in the general population but remains to be comprehensively examined among youth in foster care is social support. This includes examining specific sources of support for youth in foster care and taking into consideration the context of the frequent placement disruptions many children in foster care experience. This study sought to determine which sources of social support are associated with academic functioning for youth in foster care by examining child-report of social support from parents, teachers, friends, and classmates in relation to school grades and teacher-reported behavioral health outcomes. Information on each source of social support was obtained from the self-report of 257 youth in foster care, and information on placement characteristics were obtained from child welfare casefiles. Teachers provided information on youth's behavioral health in school, and academic grades were obtained from school records. Results suggested that youth reported teacher social support, as compared to parent, friend, or classmate social support, was most influential for both performance and behavioral health in school. Findings highlight the need for additional research on the important role of teachers for promoting academic success amongst youth in foster care, as well as the importance of placement changes in relation to academic functioning.

Hearing the voices of looked-after children: Considering the challenges of obtaining feedback on healthcare services

The voices of looked-after children (LAC) are rarely heard in health services or research. Obtaining feedback on services from children and adolescents and involving them in decision-making is important; yet communicating with vulnerable groups, like LAC, is not straightforward. Improving communication practices and ways of gaining feedback can facilitate quality improvement across healthcare. Using focus groups with 49 LAC aged 5-17 years, we identified three core themes. First, feedback tools need to be child-centred and LAC-friendly; second, tools should be gender-neutral and developmentally appropriate; and third, the current UK feedback tool was not fit for purpose. If feedback tools for children and adolescents are unfit for purpose, then any quality improvement and changes to services made are not sufficiently paying attention to this important population.

Childhood Adversity and Affective Touch Perception: A Comparison of United Kingdom Care Leavers and Non-care Leavers

In the United Kingdom, the most common reasons for a child to come under the care of social services are neglect and abuse. Such early childhood adversity is a risk factor for social-isolation and poor mental health in adulthood. Touch is a key channel for nurturing interactions, and previous studies have shown links between early somatosensory input, experience dependent neural plasticity, and later life emotional functioning. The aim of the present study was to test the relationship between childhood neglect/abuse and later life experiences, attitudes, and hedonic ratings of affective touch. Here, affective touch is defined as low force, dynamic touch which C-Tactile afferents (CTs) respond optimally to. We hypothesized that a childhood lacking in early nurturing tactile stimulation would be associated with reduced sensitivity to socially relevant affective touch in adulthood. To test this, 19 care leavers (average 9.32 ± 3.70 years in foster care) and 32 non-care leavers were recruited through opportunity sampling (mean age = 21.25 ± 1.74 years). Participants completed a range of psychophysical somatosensory tests. First, they rated the pleasantness of CT-optimal (3 cm/s) and non-CT-optimal (0.3 and 30 cm/s) stroking touch applied to their forearm, both robotically and by an experimenter. They also made vicarious ratings of the anticipated pleasantness of social tactile interactions depicted in a series of videos. Finally, they filled in the Childhood Trauma Questionnaire (CTQ) and the Touch Experiences and Attitudes Questionnaire (TEAQ). As expected, care leavers reported significantly higher levels of childhood trauma than the control group. They also reported significantly lower levels of positive childhood touch compared to non-care leavers, but their attitudes and experiences of current intimate and affiliative touch did not differ. Across all psychophysical tests, care leavers showed specific reduction in sensitivity to the affective value of CT targeted 3 cm/s touch. The results of this study support the hypothesis that a lack of nurturing touch in early developmental periods leads to blunted sensitivity to the specific social value of affective touch. Future research should investigate the neural and physiological mechanisms underlying the observed effect.

Behaviour change interventions to reduce risky substance use and improve mental health in children in care: the SOLID three-arm feasibility RCT

Background

Looked-after children and care leavers (henceforth children in care) are young people placed under the care of local authorities, often because of a history of family abuse and/or neglect. These young people have significantly increased risk of substance use and mental health problems compared with peers.

Aim

The Supporting Looked After Children and Care Leavers In Decreasing Drugs, and alcohol (SOLID) trial aimed to investigate the feasibility of a definitive randomised controlled trial comparing two behaviour change interventions to reduce risky substance use (illicit drugs and alcohol) in and improve the mental health of children in care aged 12–20 years.

Methods

The study consisted of two phases: (1) a formative phase that adapted the motivational enhancement therapy and social behaviour and network therapy interventions for use with children in care and (2) a three-arm pilot randomised controlled trial (comparing motivational enhancement therapy, social behaviour and network therapy and usual care), and a linked process and economic (return on investment) evaluation. Trial feasibility was compared with prespecified STOP/GO criteria.

Setting

Six local authority areas in the north-east of England.

Participants

Children in care (aged 12–20 years) who screened positive for drug and/or alcohol use within the last 12 months were eligible for the trial. The formative and process evaluations included children in care, carers, social workers, and drug and alcohol workers.

Outcome measures

The primary outcomes were recruitment and retention rates at 12 months’ follow-up. Baseline and 12-month follow-up questionnaires measured self-reported drug and alcohol use, mental health and health-related quality of life. The process evaluation considered acceptability and engagement with the interventions and trial procedures.

Results

Formative findings (n = 65) highlighted the need for interventions to increase the emphasis on therapeutic relationships, use creative methods of engagement and support the identification of treatment goals wider than substance misuse. Within the randomised controlled trial, of 860 participants screened, 211 (24.5%) met the inclusion criteria. One hundred and twelve (53%) of the 211 eligible children were recruited and randomised. Just 15 of the 76 (20%) participants allocated to intervention attended any of the motivational enhancement therapy of social behaviour and network therapy sessions, and 60 (54%) participants completed the 12-month follow-up. The screening and recruitment of children in care required significantly more time and resource investment by researchers and children’s services than planned. The process evaluation (n = 116) demonstrated that, despite participants engaging in risky substance use, they did not often acknowledge this nor felt that they needed help. Children in care had complex, chaotic lives and children’s services departments were less research mature and extremely stretched; this, coupled with the multiple steps in the intervention pathway and study protocol, resulted in low adherence to the intervention and the trial.

Conclusions

The SOLID trial demonstrated successful engagement with children in care to adapt the motivational enhancement therapy and social behaviour and network therapy interventions. However, the pilot randomised controlled trial found that a definitive trial is not feasible. The current screen, refer and treat pathway for children in care did not work. There is an urgent need to radically rethink how we deliver therapeutic services for children in care. A pragmatic evaluation design, coupled with additional research resource for children’s services, is needed to evaluate these novel models of care at scale.

Trial registration

This study is registered as PROSPERO CRD42018098974 and Current Controlled Trials ISRCTN80786829.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 13. See the NIHR Journals Library website for further project information.

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.

Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews

BACKGROUND

Adverse Childhood Experiences (ACEs) such as abuse, neglect or household adversity may have a range of serious negative impacts. There is a need to understand what interventions are effective to improve outcomes for people who have experienced ACEs.

METHODS

Systematic review of systematic reviews. We searched 18 database sources from 2007 to 2018 for systematic reviews of effectiveness data on people who experienced ACEs aged 3-18, on any intervention and any outcome except incidence of ACEs. We included reviews with a summary quality score (AMSTAR) of 5.5 or above.

RESULTS

Twenty-five reviews were included. Most reviews focus on psychological interventions and mental health outcomes. The strongest evidence is for cognitive-behavioural therapy for people exposed to abuse. For other interventions - including psychological therapies, parent training, and broader support interventions - the findings overall are inconclusive, although there are some positive results.

CONCLUSIONS

There are significant gaps in the evidence on interventions for ACEs. Most approaches focus on mitigating individual psychological harms, and do not address the social pathways which may mediate the negative impacts of ACEs. Many negative impacts of ACEs (e.g. on health behaviours, social relationships and life circumstances) have also not been widely addressed by intervention studies.

Inequalities in educational outcomes in individuals with childhood experience of out-of-home care: What are driving the differences?

Background

Prior research has shown that individuals with experience of out-of-home care (foster family care or residential care) in childhood are educationally disadvantaged compared to their peers. In order to be better equipped to design interventions aimed at improving the educational outcomes of children for whom society has assumed responsibility, this study seeks to further our understanding about which factors that contribute to the educational disparities throughout the life course.

Methods

Using longitudinal data from a cohort of more than 13,000 Swedes, of which around 7% have childhood experience of out-of-home care, Peters-Belson decomposition is utilized to quantify the extent to which the gap in educational achievement in school (age 16) and midlife educational attainment (age 50) captures differences in the prevalence of factors influencing educational outcomes, and differences in the impacts between these factors.

Results

We find that the achievement and the attainment gap was around 13% and 9% respectively. These gaps were to a large extent explained by differences in the distribution of predictors. The major explanatory factor for placed children’s lower achievement was a lower average cognitive ability. Yet there were some evidence that the rewards of cognitive ability in these children differed across the life course. While the lower returns of cognitive ability suggest that they were underperforming in compulsory school, the higher returns of cognitive ability on midlife attainment indicate that–given previous underperformance–their attainment at age 50 reflects their cognitive capacity more accurately than their achievement at age 16 do.

Conclusion

The large influence of the unequal distribution of predictors suggests that policy efforts are needed to promote equity in the distribution of factors contributing to educational achievement and attainment. Since cognitive ability was found to be an important contributory factor, such efforts may include promoting cognitive and intellectual development among children in out-of-home care, preferably starting at a young age.

Reading and numeracy attainment of children reported to child protection services: A population record linkage study controlling for other adversities

BACKGROUND

Maltreated children are at risk of poor educational outcomes, but also experience greater individual, family, and neighbourhood adversities that may obscure an understanding of relationships between child protection involvement and educational attainment.

OBJECTIVE

To examine associations between child protection involvement and 3rd- and 5th-grade reading and numeracy attainment, while controlling multiple other adversities.

PARTICIPANTS AND SETTING

Participants were 56,860 Australian children and their parents from the New South Wales Child Development Study with linked multi-agency records.

METHODS

Multinomial logistic regressions examined associations between level of child protection involvement (Out-Of-Home Care [OOHC] placement; substantiated Risk Of Significant Harm [ROSH]; unsubstantiated ROSH; non-ROSH; and no child protection report) and standardised tests of 3rd- and 5th-grade reading and numeracy. Fully adjusted models controlled demographic, pregnancy, birth, and parental factors, and early (kindergarten) developmental vulnerabilities on literacy and numeracy, and other developmental domains (social, emotional, physical, communication).

RESULTS

All children with child protection reports were more likely to attain below average, and less likely to attain above average, 3rd- and 5th-grade reading and numeracy, including children with reports below the ROSH threshold. Children with substantiated ROSH reports who were not removed into care demonstrated the worst educational attainment, with some evidence of protective effects for children in OOHC.

CONCLUSIONS

A cross-agency response to supporting educational attainment for all children reported to child protection services is required, including targeted services for children in OOHC or with substantiated ROSH reports, and referral of vulnerable families (unsubstantiated and non-ROSH cases) to secondary service organisations (intermediate intervention).

'You've come to children that are in care and given us the opportunity to get our voices heard': The journey of looked after children and researchers in developing a Patient and Public Involvement group

BACKGROUND

Looked after children and care leavers (denoted as LAC) are often described as a 'hard to reach' group of young people, and their voices are rarely sought to inform academic research.

METHODS

This paper reports on experiences and reflections of a group of children and young people and academic researchers who developed a Patient and Public Involvement (PPI) group that was set up in the context of an ongoing health service intervention trial with LAC.

SETTING AND PARTICIPANTS

Eighteen qualitative semi-structured interviews were conducted with seven LAC, the participation officer within a North East Children in Care Council and the four researchers involved in developing and facilitating the PPI group. PPI sessions (n = 9) each approximately 1 hour in length were conducted over an 18-month period.

ANALYSIS

The qualitative interviews were transcribed verbatim. Thematic analysis was used to analyse the data, and direct quotes are used within the paper.

MAIN OUTCOMES

The LAC used the PPI group to produce a 5-minute video to highlight why they think young people should be involved in research. Overall findings suggested that it was feasible to develop a research-related PPI group with LAC. Findings from the research were used to co-develop 'top tips' of working with vulnerable young people such as looked after children.

CONCLUSION

This paper has shown that PPI with LAC can be done if a co-production approach to research is taken. It also suggests that assumptions regarding the capabilities of young people as researchers need to be re-evaluated.

Are the early benefits of the Adoption Support Fund (therapeutic support for adoptive families) sustainable?

Purpose

The purpose of this paper is to explore the wider context in which the national evaluation of the Adoption Support Fund (ASF) was delivered and raise concerns about the sustainability of the early outcomes.

Design/methodology/approach

The paper briefly summarises the outcomes of a two-year mixed-methods evaluation. This included a two-wave postal survey (n=792) and follow-up (n=481), an online survey of adopters (n=586) and professionals (providers n=50, local authority staff n=124) and in-depth family interviews. The focus of the discussion on sustainability is drawn from the qualitative research of 10 local authority case studies based on 86 interviews with adoption teams and 33 providers and the perspectives of parents.

Findings

Whilst the ASF showed modest early outcomes for families in terms of improved mental health and wellbeing without the scaffolding of wider support of services able to understand the complex lifelong needs of adoptive children and their families, the sustainability of the benefits of therapeutic support is questioned. Adoption teams struggled with the increased burden of administration of the fund, their knowledge of therapeutic interventions, an evidence base and quality of provision from a market that is difficult to regulate. In a society that is failing to meet the mental health and wellbeing needs of children generally, how can a single intervention meet the needs of a very vulnerable group?

Research limitations/implications

Research and evaluation on interventions in children’s social care could be more systems aware and instead of narrowly focusing on outcomes pay attention to the complex network of services that interlink to support vulnerable children and their families and the restraints on resources that they are working with.

Social implications

To prevent adoption breakdown and increase recruitment of adopters, support for adoptive families needs to be improved beyond the current scope of the ASF. A wide range of services are required to support adopted children particularly as they grow into adolescence. While families have the right to live independently of social services, the awareness of their needs throughout public organisations should be raised particularly in schools.

Originality/value

This paper represents the views of the evaluators at TIHR of the ASF beyond the scope of the original evaluation. It reflects on the wider context of the role out of the Fund and raises important questions about the failure to support the mental health and wellbeing needs of the most vulnerable children in society. It is an organisation reflection drawing on early research in children’s social care from its archive.

A decade lost: does educational success mitigate the increased risks of premature death among children with experience of out-of-home care?

Background

Past research has consistently identified children with out-of-home care (OHC) experience as a high-risk group for premature mortality. While many have argued that educational success is a key factor in reducing these individuals’ excessive death risks, empirical evidence has hitherto been limited. The aim of the current study was therefore to examine the potentially mitigating role of educational success in the association between OHC experience and premature mortality.

Methods

Drawing on a Stockholm cohort born in 1953 (n=15 117), we analysed the associations among placement in OHC (ages 0–12), school performance (ages 13, 16 and 19) and premature all-cause mortality (ages 20–56) by means of Cox and Laplace regression analyses.

Results

The Cox regression models confirmed the increased risk of premature mortality among individuals with OHC experience. Unadjusted Laplace regression models showed that, based on median survival time, these children died more than a decade before their majority population peers. However, among individuals who performed well at school, that is, those who scored above-average marks at the age of 16 (grade 9) and at the age of 19 (grade 12), the risks of premature mortality did not significantly differ between the two groups.

Conclusion

Educational success seems to mitigate the increased risks of premature death among children with OHC experience.