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

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.

Adaptation of a trauma-informed intervention for youth involved in the legal system

Background

Youth in the legal system (YILS) have high rates of trauma exposure, which are associated with increased risk of behavioral health needs (e.g., substance-use problems) and recidivism. Research suggests that a trauma-focused therapeutic approach can improve outcomes for YILS, but few evidence-based interventions (EBIs) are designed with justice-involved youth in mind. Consequently, implementing trauma-informed EBIs within juvenile justice (JJ) systems is challenging. The current paper describes the systematic adaptation of Trust-based Relational Intervention (TBRI) as a substance use prevention intervention for YILS and their caregivers.

Methods

The current study utilized a methodology based on the ADAPT-ITT framework to adapt TBRI Caregiver Training, an evidence-based, trauma-informed intervention program. 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., YILS and their caregivers). Adaptations were made to both content (e.g., terminology and activities) and structure (e.g., session duration and delivery setting) in an iterative process 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 an implementation science 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 EBIs in juvenile justice, facilitating uptake and ultimately improving outcomes for youth.

Trial registration

ClinicalTrials.gov Identifier: NCT04678960.

School-Based Speech-Language Pathologists' Attitudes and Knowledge About Trauma-Informed Care

PURPOSE

The purpose of this study was to evaluate the attitudes and knowledge of school-based speech-language pathologists toward trauma-informed care.

METHOD

School-based speech-language pathologists (N = 116) completed the Attitudes Related to Trauma-Informed Care Scale Version 45 Education (ARTIC-45) survey via an online survey platform and provided information about their work experience, history with trauma training, and demographic variables.

RESULTS

Although speech-language pathologists had responses that, on average, aligned with trauma-informed perspectives, those perspectives varied and were not at ceiling. Characteristics such as age, years of experience, and foster care experience did not significantly influence the results, but self-rating of trauma-informed care knowledge did correlate with the ARTIC-45 survey. Participants who had engaged in trauma-informed care trainings had more trauma-informed perspectives and knowledge than participants who had not.

CONCLUSIONS

The results of this study provide preliminary evidence that trauma-informed care trainings may benefit those speech-language pathologists working with children who have experienced trauma. This study also provides preliminary evidence supporting the validity of the ARTIC-45 for use with speech-language pathologists.

Trauma-Informed Intervention with Children: Integrating the CANS Assessment with the ARC Framework in a Clinical Setting

Ongoing trauma-focused assessment is critical to developing trauma-informed treatment plans. The current study examines the clinical benefits of utilizing the Child and Adolescent Needs and Strengths (CANS) assessment to guide intervention based on the Attachment, Self-Regulation, and Competency (ARC) model to address children's trauma related symptoms in a rural state. WV CANS was developed by adapting the language of original CANS to be culturally specific to the state's unique situation and culture in consultation with the original CANS developer. This study included the data from children who received mental health services under WV CANS-ARC mapping from 2017 to 2019. Children's trauma-related symptoms are assessed using the WV CANS at intake and every 90 days to identify any changes in their symptoms. In order to examine the changes of traumatic symptoms over time, the study was limited to children who have at least three time points, with a total of 362 children used for the current analyses using Multilevel modeling with SAS PROC MIXED. The study found that children's trauma related symptoms significantly decreased in all ARC outcome domains over time after adjusting for basic demographic variables. The current study contributes to the evidence on treatment for children's trauma-related symptoms, especially with the application of the CANS-ARC mapping in a real-world clinical setting. The findings have significant implications for clinicians in integrating the assessment and treatment process using CANS-ARC mapping and for cross-system collaboration with continuity of care serving children who have experienced trauma.

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.

Trauma-informed care for children involved with the child welfare system: A meta-analysis

BACKGROUND

There has been a burgeoning development of trauma-informed care (TIC) interventions for children involved with the child welfare system. A quantitative synthesis of these interventions' effects on child wellbeing is warranted for the advancement of evidence-based practices.

OBJECTIVES

We conducted a systematic review and meta-analysis to estimate TIC interventions' pooled effect on the wellbeing of children involved with the child welfare system, while examining factors that may moderate the effect.

METHODS

The search and review yielded 15 eligible studies. We first estimated the interventions' pooled effect based on a compound child wellbeing indicator, and then on three specific child wellbeing indicators: posttraumatic stress disorder (PTSD) symptom reduction, behavioral problem reduction, and other psychological wellbeing improvement. We further conducted subgroup meta-analyses to evaluate factors that may moderate the effect.

RESULTS

TIC interventions had a moderate effect as shown through the compound child wellbeing indicator (SMD = 0.47, 95% CI = [0.27, 0.67]) as well as the three specific indicators (SMD = 0.37 to 0.52, 95% CI = [0.02, 0.88]). Subgroup meta-analyses indicated that the intervention effects varied but generally remained at a moderate level across study and intervention characteristics.

CONCLUSIONS

The findings suggest that TIC interventions for children involved with the child welfare system are promising, but the effect may vary by intervention strategies and other factors. Implications for practices and research are discussed.

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 .

Perioperative care for internationally adopted children: Medical, surgical, and psychosocial considerations for a population of concern

The overall number of international adoptions has dropped in the last 20 years, but a relative increase in the proportion of these children with special and surgical needs has occurred. Cleft lip/palate and anorectal malformations are two common surgical pathologies for internationally adopted children. Internationally adopted children with cleft lip/palate have high rates of speech impairment and frequent need for reoperation, and children with anorectal malformation commonly need multiple reoperations. For both groups, surgery prior to adoption may have actually contributed to morbidity. Both speech impairment and anorectal malformation negatively affect quality of life, independent of adoption. Additionally, internationally adopted children frequently have experienced trauma, single or complex, and institutionalization. Each of these can independently contribute to impaired psychosocial and behavioral development. These children face surgery, sometimes multiple surgeries, while adapting to a new culture, learning a new language, and bonding with a new family. The impact of prior medical experiences without the presence of a caregiver and/or while institutionalized is understudied. The surgical experience and perioperative outcomes within this population warrant research, and clinical coordination between teams may help improve care for this uniquely vulnerable population.

Effectiveness of a trauma-informed care psychoeducational program for foster carers - Evaluation of the Fostering Connections Program

BACKGROUND

The need to improve the quality of foster care training has been highlighted and evidenced-based programs that aim to support foster carers in the care of children who have experienced trauma are warranted.

OBJECTIVE

This study aimed to evaluate the effectiveness of the Fostering Connections program, a newly developed trauma-informed care program within the national child welfare agency in Ireland.

PARTICIPANTS AND SETTING

The study included 79 foster carers. The Fostering Connections group-based experiential intervention was delivered over a period of 6-weeks in a community-based setting to intervention group participants.

METHODS

A quasi-experimental design was used to compare the results of the intervention group (n = 49), to a control group (n = 30,) who received usual care. Standardized assessment measures were used at baseline, 6-weeks on completion, 16 weeks and 15 months post-intervention. Foster carers' knowledge of trauma-informed fostering, tolerance of misbehavior and fostering efficacy, and children's emotional and behavioral difficulties were assessed.

RESULTS

Significant improvements were found in foster carers' knowledge of trauma-informed fostering (p < 0.001), tolerance of child misbehavior (p = 0.007) and fostering efficacy (p < 0.001), with effect sizes ranging from medium to large and sustained over fifteen months (ES = 0.07-0.14). Significant improvement was also found in children's emotional and behavioral difficulties at fifteen months (p = 0.019), with a small effect size (ES = 0.05).

CONCLUSION

Preliminary evidence suggests that Fostering Connections is potentially an effective intervention in increasing foster carer's capacity to provide children with trauma-informed care.

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.