Trauma-Informed Care for Youth in Foster Care

Cognitive Functioning of Children in Out-of-Home Care

PURPOSE

Most children who enter out-of-home care (OHC) have been subjected to prolonged maltreatment. Maltreatment potentially contributes to a cumulative deficit in neurocognitive maturation and development that is likely to proceed with the child's placement into OHC and persist throughout adulthood. From the theoretical perspective of how maltreatment may affect the developing brain, this study examines the IQ and executive function of children placed in OHC on standardized, norm-referenced measures. Furthermore, the study investigates the prevalence of serious cognitive delays, defined by scores in the clinical range on the administered instruments.

METHODS

The study included 153 children in foster care (66% female), aged 6-15 (M = 10.5, SD = 2.1). Independent two-sample t-tests were run to test for significant differences between the sample and the norm population on the applied neuropsychological measures.

RESULTS

The results showed that discrepancies in cognitive development were global in scope, with the children lagging significantly behind the norm population on all applied measures with discrepancies ranging from 0.61 to 2.10 SD (p < .001). Also, serious developmental delays in all cognitive domains were vastly overrepresented in the sample ranging from 11.3% (IQ) to 66.0% (executive function).

CONCLUSIONS

The results document a very high prevalence of cognitive deficits and delays among the children in the sample. The implications of identifying the neurocognitive effects of maltreatment in the practices of the child welfare system are discussed in terms of developing suitable assessment and intervention strategies.

"We are not our case files": A qualitative analysis of child welfare professionals' relationships with young adults with foster care experience

BACKGROUND

Young adults of color with foster care experience are disproportionately represented in foster care in the United States. Developing meaningful connections with child welfare professionals can help young adults develop healthy relationships in emerging adulthood.

OBJECTIVE

This exploratory qualitative study addressed how young adults with foster care experience described their relationships with child welfare professionals and the impact of these relationships on their overall mental health and well-being in young adulthood.

PARTICIPANTS AND SETTING

A sample of young adults of color, (ages 18-29) with lived experience in foster care from a performing arts program in New York City.

METHODS

Reflexive thematic analysis was conducted on 14 semi-structured interviews with young adults of color with prior or ongoing foster care experience.

RESULTS

The following themes were identified: safe space to be myself, listen to more than words, and understand my trauma. Child welfare professionals were dropped from support networks if they were disingenuous or did not attend to their own self-care needs.

CONCLUSIONS

The study underscores the importance of promoting positive mental health outcomes for young adults through building stronger connections with child welfare professionals. Future research should explore the incorporation of individualized approaches to better serve this population of young adults.

The Effectiveness of Psychological Interventions on the Impact of Trauma Exposure in Foster Care: A Meta-Analysis

Due to prevalent exposure to trauma in the biological family, children in foster care often experience post-traumatic stress symptoms, difficulties in forming secure attachments with the caregivers, and can present a complex range of symptoms and impairments across several areas of development. Therefore, there is an increased necessity for interventions on the effects of trauma exposure in foster care. This is the first meta-analysis to investigate the effectiveness of interventions on the effects of trauma exposure in foster care against control groups. Twelve randomized controlled trials on interventions for children with trauma-related diagnoses or with other mental health problems that are a result of complex trauma were included. A random-effects model was used for pooling the effect sizes, which were calculated for trauma-related outcomes at posttreatment and follow-up. Several potential moderator variables were analyzed. The results showed that participants receiving the intervention on trauma-related problems reported significantly better outcomes than those in the control conditions at posttreatment, after the exclusion of one outlier (g = 0.39; 95% CI [0.18 to 0.62]). The effect size was smaller at follow-up (g = 0.24; 95% CI [0.03 to 0.46]), but significant. Clinical diversity, methodological diversity, as well as other limitations were identified and discussed. Overall, the findings highlight the potential of interventions for trauma-related problems in foster care. These findings bring important contributions to the child welfare system in their efforts to develop and adapt suitable interventions for children with mental health problems due to trauma.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-023-00563-9.

Introducing Routine Assessment of Adverse Childhood Experiences For Looked-After Children: The Use and Properties of the Trauma and Adverse Life Events (TALE) Screening Tool

The present study aims to illustrate the process of developing, implementing, and clinically validating a new assessment measure, the Trauma and Adverse Life Events (TALE) screening tool, to assess Adverse Childhood Experiences (ACEs) among looked-after children. The TALE was developed by adapting existing ACEs measures to reflect the experiences of looked-after children. The TALE was completed by the local authority social worker for 218 children placed with Five Rivers Child Care (a UK fostering agency, residential, and educational care provider). Reliability was examined and exploratory factor analysis was conducted. Correlations between TALE scores, background variables, and psychosocial wellbeing using the carer-report Strengths and Difficulties Questionnaire (SDQ) and Child Dissociative Checklist (CDC) were also explored. The TALE was found to have acceptable reliability (α = .71). A three-factor solution was found which explained 46.24% of the variance, with factors labelled 'Direct Experience of Abuse', 'Witnessing Harm', and 'Household Dysfunction'. Exposure score was significantly associated with total difficulties score on the SDQ (rs = .24, p < .001) and Impact score was associated with the SDQ's impact score (rs = .33, p < .001). Exposure and Impact scores were both positively correlated with CDC scores (rs = .16, p = .021 and rs = .22, p = .002). This paper presents evidence of the importance of screening looked-after children for ACEs and demonstrates that the TALE is a valid and reliable tool for this purpose. Adverse and traumatic experiences were highly prevalent in this population and appeared to be closely related with children's psychosocial wellbeing. Results emphasise the importance of routine assessment of past experiences within trauma-informed psychological care and intervention planning for looked-after children.

Trauma and female reproductive health across the lifecourse: motivating a research agenda for the future of women's health

The aetiology behind many female reproductive disorders is poorly studied and incompletely understood despite the prevalence of such conditions and substantial burden they impose on women's lives. In light of evidence demonstrating a higher incidence of trauma exposure in women with many such disorders, we present a set of interlinked working hypotheses proposing relationships between traumatic events and reproductive and mental health that can define a research agenda to better understand reproductive outcomes from a trauma-informed perspective across the lifecourse. Additionally, we note the potential for racism to act as a traumatic experience, highlight the importance of considering the interaction between mental and reproductive health concerns, and propose several neuroendocrinological mechanisms by which traumatic experiences might increase the risk of adverse health outcomes in these domains. Finally, we emphasize the need for future primary research investigating the proposed pathways between traumatic experiences and adverse female reproductive outcomes.

What Mediates the Link Between Foster Parents' Sensitivity Towards Child Posttraumatic Stress Symptoms and Job Satisfaction? The Role of Compassion Fatigue and Foster Parent-Child Relationship

Purpose: It is very likely that many children who enter the foster care system have experienced at least one traumatic event, and can develop symptoms of PTSS. Consequently, foster parents' level of sensitivity towards child symptoms of PTSS plays a significant role in child development, but the link between sensitivity and several professional characteristics is not well understood. The current study aims to explain the effect foster parents' sensitivity towards child trauma exert on their job satisfaction, via foster parents' compassion fatigue and the quality of their relationship with the children in care. This study is one of the few to investigate foster parents' sensitivity towards child trauma, and the direct and indirect effects on other variables. Methods: Structural equation modeling was used to test a mediating model on this sample (N = 165) after using an online survey to collect the cross-sectional data. Results: The model produced good fit (RMSEA = 0.087; CFI = 0.899). The direct effects between variables are significant. The relationship between foster parents' sensitivity towards trauma and their job satisfaction can be better understood with the contribution of compassion fatigue. Conclusion: Findings confirm the mediation effect of compassion fatigue and reveal more aspects of the sensitivity towards trauma concept. These results could be implemented by considering more accurate measurements for the caregiver's sensitivity towards child trauma. The importance of considering interventions for increasing foster parents' trauma knowledge and skills is highlighted.

The Complexity of Psychotropic Medication Prescription and Treating Trauma Among Youth in Foster Care: Perspectives from the Lived Experience

Youth in the US foster care system are disproportionately prescribed antipsychotic and psychotropic medication compared to youth not involved with foster care. Research on the relationship between experiences of trauma, mental health symptoms, evidence-based treatment, and safe psychotropic prescribing practices for youth in foster care is limited. We explored stakeholders' perspectives of the relationship between psychotropic medications and trauma informed care (TIC) for youth in foster care. We conducted semi-structured individual and group interviews with foster caregivers, caseworkers, prescribing clinicians, and alumni of the foster care system. Data were recorded and transcribed verbatim, and analyzed using a directed content analysis approach. Five themes emerged across and within stakeholder groups: (1) acknowledging trauma; (2) role of psychotropic medication; (3) psychosocial resources; (4) additional supports; and, (5) training and education. Stakeholders identified TIC as an important component of mental health services for youth in foster care. There was not consensus around the role of psychotropic medication in treating trauma; however, most stakeholders felt that it was overused. Respondents suggested including additional supportive team members to help guide youth through the mental health treatment system, and emphasized the importance of support from individuals with common lived experiences. Results demonstrate the need for a system that emphasizes trauma-sensitive clinical interactions and psychosocial supports. Improving training and education for stakeholders, and providing additional sources of support for youth in foster care, could help better identify and treat the effects of trauma and the safe pharmacotherapy for youth in foster care.

Preventing E-cigarette use among high-risk adolescents: A trauma-informed prevention approach

Exposure to childhood trauma increases the risk of tobacco use during adolescence. Recent studies have also reported potentially increased vulnerabilities to electronic cigarette (e-cigarette) use among youth with a history of childhood trauma. While empirical evidence supporting the relationship between childhood trauma and adolescent e-cigarette use is emerging, few effective preventive interventions are available to curb e-cigarette use among adolescent victims of childhood trauma. This article reviews current evidence with respect to how childhood trauma could increase risk for nicotine dependence and e-cigarette use in adolescent populations. Furthermore, this paper describes the development, design, and implementation of Rise Above (RA), a randomized, controlled trial of a trauma-informed, e-cigarette preventive intervention. Lessons learned are also discussed, including the challenges of implementing evidence-informed prevention work within communities vulnerable to traumatic events.

Child Labor Trafficking Essentials for Forensic Nurses

Human trafficking is a form of modern-day slavery and is a significant pediatric healthcare problem in the United States. The term "human trafficking" encompasses both sex and labor trafficking. Sex trafficking, especially child sex trafficking, has received significant lay and professional attention. However, few efforts have focused on learning more about youth experiencing labor trafficking in the United States. Pediatric healthcare providers, including forensic nurses, are likely to encounter victims of child labor trafficking in their practice. A basic understanding of child labor trafficking will assist forensic nurses in timely identification of and appropriate intervention for victims. In this article child labor trafficking is discussed in terms of definition, epidemiology, history, risk factors, consequences, identification, and implications for practice.

Confronting the Social Determinants of Health: Has the Language of Trauma Informed Care Become a Defense Mechanism?

Many writers have been calling for the incorporation of trauma-informed care (TIC) in nursing education and practice, with some recently advocating the adoption of formal TIC competencies in psychiatric nursing. In light of this heightened interest, it is worth engaging seriously with criticisms of TIC. This paper reviews some of the published criticisms of TIC, starting with those emerging from within the TIC scholarly community. These focus mostly on matters of methodological rigor and conceptual clarity. It then presents critiques that emerge through the lenses of feminism, cultural sociology, and psychoanalysis. These focus on the shift away from political and historical consciousness in some TIC language and call attention to discursive mechanisms that split off our concern for patients from concern about ongoing social determinants of trauma in the world. The paper then addresses the implications for TIC in nursing, advocating a social justice orientation to the teaching of trauma.

Social determinants of health and maxillofacial injuries in children and adolescents victims of violence: A novel GIS-based modelling application

BACKGROUND

Physical violence against children and adolescents comprises a serious public health problem and often results in oral and maxillofacial traumas. Social determinants may favour the occurrence of these events, but few studies have critically evaluated the interaction between social and geographical risk factors.

AIMS

To investigate the spatiotemporal distribution of oral and maxillofacial traumas resulting from violence against children and adolescents through geostatistical techniques.

METHODS

This study was an ecological analysis of cases of trauma caused by violence against Brazilian children and adolescents using aggregated data from victims attended at a Center of Forensic Medicine and Forensic Dentistry between January 2012 and December 2015. Data were analysed through modelling based on geographic information system (GIS).

RESULTS

Two distinct patterns of longitudinal trajectory of oral and maxillofacial trauma related to violence against children and adolescents were identified (TP1 and TP2, P < 0.05). The spatial regression analysis revealed a statistically significant association between higher incidence of cases and areas with worse socioeconomic conditions (β = 0.047, SE = 0.020, P < 0.05).

CONCLUSION

Neighbourhoods with considerable socio-spatial vulnerability for violence against children and adolescents and maxillofacial traumas were identified.

End-of-life trends and patterns among children in the US foster care system: 2005-2015

Drawing on national, longitudinal Adoption and Foster Care Analysis, and Reporting System data (2005-2015), demographic, health, foster care, and geographic characteristics of decedents (N = 3653) aged 1-17 years were examined. On average, decedents were 6 years old, the highest proportion died as infants, and experienced significant trauma in their short lives either through maltreatment or exposure to parental substance use. A noted increase in Medicaid coverage among decedents over time suggests critical access to concurrent treatment and hospice care, but this is unavailable to children with private insurance. This study has policy implications related to the 2010 Affordable Care Act.

Prior Trauma Exposure and Serious Illness at End of Life: A National Study of Children in the U.S. Foster Care System From 2005 to 2015

CONTEXT

Children in foster care suffer with serious illness at end of life. However, the relationship between prior trauma exposure and serious illness has received little empirical attention.

OBJECTIVES

The objectives were to examine the prevalence and type of trauma exposure and investigate the relationship between prior trauma and serious illness among foster children at end of life.

METHODS

We used national longitudinal foster care data. We included children who were younger than 18 years with residence in the U.S. Serious illness (i.e., physical health, mental/behavioral health, developmental disabilities) was measured via the foster care files. Three measures of prior trauma exposure (i.e., maltreatment, drug/alcohol exposure, psychosocial stressors) were created. Using multivariate logistic regressions, we evaluated the influence of prior trauma on serious illness at end of life, while controlling for demographic, geographic, and foster care support characteristics.

RESULTS

Sixty-eight percent of children experienced maltreatment, 28% exposure to parental drug/alcohol misuse, and 39% psychosocial stressors before entering foster care. Maltreatment was positively associated with physical health and developmental disabilities, whereas parental drug/alcohol exposure was inversely related to developmental disabilities. Psychosocial stressors contributed to the prediction of poor physical, mental, and developmental health.

CONCLUSION

These findings suggest that trauma-informed end-of-life care may be a critical need among children in foster care with serious illness. Future directions are discussed, including collaboration between end-of-life clinicians and social service workers and the importance of future research to understand and improve the quality of health at end of life for this underserved population.

Psychosocial Needs of Children in Foster Care and the Impact of Sexual Abuse

Children in family foster care, especially those who have experienced sexual abuse, require a safe and nurturing environment in which their psychosocial needs are met. However, there is limited knowledge on how youth prioritize various needs and what impact previous experiences have on these needs. In this study, we asked youth (formerly) in family foster care to indicate their psychosocial needs, and analyzed if youth with a history of sexual abuse have different needs. A Q methodological study was conducted with 44 youth (age 16-28). Fifteen of them reported sexual abuse during their childhood. Using by-person factor analyses, respondents who share similar subjective views were grouped together. Qualitative interpretations of the factors show differences and similarities between and within the two groups, related to help from others, being independent, processing the past, and working toward the future. Although the needs of youth with and without experiences of sexual abuse seem mostly similar, one group of sexually abused youth specifically indicated not wanting an emotional connection to foster parents, but instead a strictly instrumental, professional relationship. This study captured the diverse perspectives of youth themselves, revealing that children in foster care differ with regard to what they consider as (most) important safety, belonging, self-esteem and self-actualization needs.

The Effect of a Youth-Centered Sexual Risk Event History Calendar (SREHC) Assessment on Sexual Risk Attitudes, Intentions, and Behavior

INTRODUCTION

The purpose of this study was to examine the effect of a youth-centered assessment, the Sexual Risk Event History Calendar (SREHC), compared with the Guidelines for Adolescent Preventive Services (GAPS) assessment, on sexual risk attitudes, intentions, and behaviors.

METHODS

The Interaction Model of Client Health Behavior guided this participatory research-based randomized control trial. Youth participants recruited from university and community clinics in the Midwestern United States were randomized to a health care provider visit using either the SREHC or GAPS and completed surveys at baseline, postintervention, and 3, 6, and 12 months.

RESULTS

Participants included 181 youth (15-25 years old) and nine providers. Findings showed that youth in the SREHC group reported stronger intentions to use condoms compared with those in the GAPS group. Age and race were also significant predictors of sexual experience.

DISCUSSION

This study highlights the importance of using a youth-centered, systematic approach in the assessment of sexual risk behaviors.