Patterns of movement for youth within an integrated continuum of residential services

Families in transition (FIT) study protocol: feasibility, acceptability and preliminary effects of a group-based parent training in parents of youth in psychiatric residential treatment

INTRODUCTION

Although adolescents make treatment gains in psychiatric residential treatment (RT), they experience significant difficulty adapting to the community and often do not sustain treatment gains long term. Their parents are often not provided with the necessary support or behaviour management skillset to bridge the gap between RT and home. Parent training, a gold standard behaviour management strategy, may be beneficial for parents of these youth and web-based parent training programmes may engage this difficult-to-reach population. This study focuses on a hybrid parent training programme that combines Parenting Wisely (PW), a web-based parent training with facilitated discussion groups (Parenting Wisely for Residential Treatment (PWRT)). This study aims to: (1) establish the feasibility and acceptability of PWRT, (2) evaluate whether PWRT engages target mechanisms (parental self-efficacy, parenting behaviours, social support, family function) and (3) determine the effects of PWRT on adolescent outcomes (internalising and externalising behaviours, placement restrictiveness).

METHODS AND ANALYSIS

In this randomised control trial, parents (n=60) will be randomly assigned to PWRT or treatment as usual. Each week for 6 weeks, parents in the PWRT condition will complete two PW modules (20 min each) and attend one discussion group via Zoom (90 min). Adolescents (n=60) will not receive intervention; however, we will evaluate the feasibility of adolescent data collection for future studies. Data from parents and adolescents will be collected at baseline, post intervention (6 weeks post baseline) and 6 months post baseline to allow for a robust understanding of the longer-term effects of PWRT on treatment gain maintenance.

ETHICS AND DISSEMINATION

The study has been approved by The Ohio State University Institutional Review Board (protocol number 2022B0315). The outcomes of the study will be shared through presentations at both local and national conferences, publications in peer-reviewed journals and disseminated to the families and organisations that helped to facilitate the project.

TRIAL REGISTRATION NUMBER

NCT05764369 (V.1, December 2022).

Mental health treatment programs for children and young people in secure settings: A systematic review

BACKGROUND

While there are mental health treatment programs for children and young people in secure settings (i.e., secure treatment programs) in many countries, there is a lack of transparency and consistency across these that causes confusion for stakeholders and challenges for the design and delivery of high-quality, evidence-based programs. This systematic review addresses two questions: What do mental health treatment programs for children and young people in secure community settings look like across jurisdictions? What is the evidence underlying the various components of these programs?

METHODS

Twelve databases were searched in November 2021: CINAHL, EMBASE, MEDLINE, PsycINFO, PubMed, Scopus, Science Direct, Academic Search Complete, Psychology and Behavioral Sciences Collection, Google Scholar, OpenDOAR, and GreyLit.org. To be included, publications had to be empirical literature or a report on mental health treatment within a secure setting for people under the age of 25; contain pre-identified keywords; be based on a research or evaluation study conducted since 2000; and be assessed as low risk of bias using an adaptation of the Critical Appraisal Skills Programme qualitative research checklist. The systematic review included 63 publications. Data were collected and analyzed in NVivo qualitative software using a coding framework.

RESULTS

There are secure treatment programs in Australia, Belgium, Canada, New Zealand, the Netherlands, England and Wales, Scotland, and the United States. Although there are inconsistencies across programs in terms of the systems in which they are embedded, client profiles, treatments provided, and lengths of stays, most share commonalities in their governance, definitions, designs, and intended outcomes.

CONCLUSIONS

The commonalities across secure treatment programs appear to stem from them being designed around a need for treatment that includes a mental disorder, symptom severity and salience involving significant risk of harm to self and/or others, and a proportionality of the risks and benefits of treatment. Most share a common logic; however, the evidence suggested that this logic may not to lead to sustained outcomes. Policymakers, service providers, and researchers could use the offered recommendations to ensure the provision of high-quality secure treatment programming to children and young people with serious and complex mental health needs.

Are we practicing what we preach? Family partnership in therapeutic residential care for children and youth

This study presents a tiered conceptualization of family partnership developed by the Family-Run Executive Director Leadership Association (FREDLA) with examples of strategies from the literature. This sub-study was part of an overarching systematic review project that aimed to review the literature on family partnership in relation to youth outcomes. The tiers of family partnership include family involvement (i.e., family's inclusion in their child's care); family engagement (i.e., collaboration between TRC and families); family-driven (i.e., families as full partners). This review included thirty studies (n=23 family involvement, n=7 family engagement, n=0 family-driven). The most common family involvement methods were family therapy and family visits to the program, primarily delivered face-to-face. The most common family engagement method was activities, therapies, and skill building occurring at the home with family present. Methods of measuring family partnership primarily included the use of administrative data. Implications for research and practice include the provision of research that evaluates the effects of family partnership on outcomes important in the TRC setting and the development of research-practice and family-research collaborations to increase the uptake of effective family partnering methods.

Mind-mindedness in out-of-home Care for Children: Implications for caregivers and child

Most out-of-home placed children have experienced early adversities, including maltreatment and neglect. A challenge for caregivers is to adequately interpret their foster child’s internal mental states and behavior. We examined caregivers’ mind-mindedness in out-of-home care, and the association among caregivers’ mind-mindedness (and its positive, neutral, and negative valence), recognition of the child’s trauma symptoms, and behavior problems. Participants (N = 138) were foster parents, family-home parents, and residential care workers. Caregivers’ mind-mindedness was assessed with the describe-your-child measure. Caregivers’ recognition of the child’s trauma symptoms, their child’s emotional symptoms, conduct problems, prosocial behavior, and quality of the caregiver-child relationship were assessed using caregivers’ reports. Foster parents produced more mental-state descriptors than did residential care workers. General mind-mindedness, as well as neutral and positive mind-mindedness, related negatively to conduct problems. Besides, positive mind-mindedness was associated with prosocial behavior and neutral mind-mindedness with a better quality of the caregiver-child relationship and fewer child conduct problems. Negative mind-mindedness related positively to the caregiver’s recognition of the child’s trauma symptoms, and indirectly, to emotional symptoms. In conclusion, mind-mindedness seems to be an essential characteristic of out-of-home caregivers, connected to the understanding of their child’s behavior problems and trauma symptoms, as well as to the relationship with the child. The findings suggest a possible use of mind-mindedness in out-of-home care evaluation and intervention.

Children and youth in out-of-home care: What can predict an initial change in placement?

BACKGROUND

A significant proportion of children placed in out of-home care experience placement disruptions in the United States. Placement instability has deleterious effects on children's well-being.

OBJECTIVES

(a) To measure the time-to-initial placement change in different types of settings, including non-relative foster homes, kinship care, residential treatment centers (RTC), group homes and other types of settings; and (b) To identify predictors of the initial placement change.

PARTICIPANTS AND SETTING

Data were obtained from the State Automated Child Welfare Information System operated by the child welfare agency in a Mid-Atlantic state. The sample included 4177 children who entered into the foster care and were followed over three years.

METHOD

Descriptive, bivariate, and survival Cox regression models were conducted.

RESULTS

More than half (53%) of the children had experienced placement change within 3 years. The mean length for an initial change in placement was longer for children in RTC and kinship care compared to children in foster and group homes, and other placements (χ2 = 322.31, p < 0.001). Several factors significantly increased the likelihood of an initial change, including: older children (p < 0.001, HR = 1.01), children with behavioral problems (p < 0.001, HR = 1.26), parental substance abuse (p < 0.05, HR = 1.12), and cases in which the parents voluntarily gave up their parental rights (p < 0.05, HR = 1.12). The type of placement also increased the risk for placement change.

CONCLUSIONS

Providing early interventions and services to these children and their families is essential to increase placement stability.

Similarities and Differences in the Psychosocial Development of Children Placed in Different 24-h Settings

Similarities and differences in the (short-term) psychosocial development of children in foster care, family-style group care, and residential care were investigated in a sample of 121 Dutch children (M age = 8.78 years; SD = 2.34 years; 47% female; 59% Caucasian) one year after their initial placement. Pretest and posttest measurements were carried out at the substitute caregivers using the CBCL. The results were examined at group level and case level. At group level, the findings showed no evidence for higher effectiveness in favor to the family-oriented settings (foster care, and family-style group care), as hypothesized. By contrast, some small differences were found between foster care and family-style group care, in favor of the latter. At individual level, a more or less equal number of children (18%) with a clinical pretest score on psychosocial functioning clinically significant improved (behavioral normalization). An important concern is that a number of children without clinical psychosocial problems at the time of admission clinically significant deteriorated (behavioral aberration) in psychosocial functioning (20%). This might indicate a poor match between the risks, needs and responsivity of the child on the one hand and the chosen intervention on the other. Future research on factors that (prior and during placement) positively as well as negatively affect the child's psychosocial development is needed to further clarify this finding.

Characteristics of Children in Foster Care, Family-Style Group Care, and Residential Care: A Scoping Review

When risky child and family circumstances cannot be resolved at home, (temporary) 24-h out-of-home placement of the child may be an alternative strategy. To identify specific placement risks and needs, care professionals must have information about the child and his or her family, care history, and social-cultural characteristics at admission to out-of-home care. However, to date information on case characteristics and particular their similarities and differences across the three main types of out-of-home settings (namely foster care, family-style group care, and residential care) is largely lacking. This review compiles and compares characteristics of school-aged children of average intelligence and their families at the time of each child's admission to one of the three care modalities. A scoping review technique that provides a broad search strategy and ensures sufficient coverage of the available literature is used. Based on the 36 studies included, there is consensus that the majority of normally intelligent children in care demonstrate severe developmental and behavioral problems. However, the severeness as well as the kinds of defining characteristics present differ among the children in foster care, family-style group care, and residential care. The review also identifies several existing knowledge gaps regarding relevant risk factors. Future research is recommended to fill these gaps and determine the developmental pathway in relation to children's risks and needs at admission. This will contribute to the development of an evidence-based risks and needs assessment tool that will enable care professionals to make informed referrals to a specific type of out-of-home care when such a placement is required.

Development and piloting of a treatment foster care program for older youth with psychiatric problems

BACKGROUND

Older youth in out-of-home care often live in restrictive settings and face psychiatric issues without sufficient family support. This paper reports on the development and piloting of a manualized treatment foster care program designed to step down older youth with high psychiatric needs from residential programs to treatment foster care homes.

METHODS

A team of researchers and agency partners set out to develop a treatment foster care model for older youth based on Multi-dimensional Treatment Foster Care (MTFC). After matching youth by mental health condition and determining for whom randomization would be allowed, 14 youth were randomized to treatment as usual or a treatment foster home intervention. Stakeholders were interviewed qualitatively at multiple time points. Quantitative measures assessed mental health symptoms, days in locked facilities, employment and educational outcomes.

RESULTS

Development efforts led to substantial variations from the MTFC model and a new model, Treatment Foster Care for Older Youth was piloted. Feasibility monitoring suggested that it was difficult, but possible to recruit and randomize youth from and out of residential homes and that foster parents could be recruited to serve them. Qualitative data pointed to some qualified clinical successes. Stakeholders viewed two team roles - that of psychiatric nurse and skills coaches - very highly. However, results also suggested that foster parents and some staff did not tolerate the intervention well and struggled to address the emotion dysregulation issues of the young people they served. Quantitative data demonstrated that the intervention was not keeping youth out of locked facilities.

CONCLUSIONS

The intervention needed further refinement prior to a broader trial. Intervention development work continued until components were developed to help address emotion regulation problems among fostered youth. Psychiatric nurses and skills coaches who work with youth in community settings hold promise as important supports for older youth with psychiatric needs.

Patterns of maltreatment and diagnosis across levels of care in group homes

Patterns of Axis I psychiatric diagnosis and maltreatment history were explored among youth in group homes, including match of clinical need to level or restrictiveness of care. Data on demographics, diagnoses, maltreatment, and group home level of care (Level I, II, or III homes, representing lower to higher intensity of supervision and treatment) were obtained from 523 youth who participated in a quasi-experimental study of group homes. Three quarters of youth had a diagnosis and two-thirds of youth had a maltreatment history. Youth in higher level homes had more diagnoses and higher rates of all disorders except adjustment disorders. Youth in Level I homes had a history of more maltreatment types, particularly high rates of neglect. Sexual abuse, physical abuse, and emotional abuse were most common among youth in higher level homes. Regardless of diagnosis history, comparable proportions of youth had a maltreatment history, and similar patterns were found across levels of care. Together, findings indicate that group homes with varying degrees of restrictiveness serve youth with different psychiatric diagnosis and maltreatment histories. Youth triaged to higher level homes had more diagnoses, while youth placed in the least restrictive homes had a history of more maltreatment subtypes. Further, distinct patterns of diagnosis types and maltreatment subtypes were seen across homes. Implications include the importance of assessing unique clinical needs of youth to promote an appropriate match to level of care and treatment plan.

Characteristics and Behavioral Outcomes for Youth in Group Care and Family-Based Care: A Propensity Score Matching Approach Using National Data

This study aimed to answer two questions: (a) Given expected differences in children who are placed in group care compared to those in family-based settings, is it possible to match children on baseline characteristics? (b) Are there differences in behavioral outcomes for youth with episodes in group care versus those in family-based care? Using data from the National Survey of Child and Adolescent Well-Being, the study sample included 1,191 children with episodes in out-of-home care (n = 254 youth with group care episodes; n = 937 youth with episodes in family-based care and no group care). Conditioning variables were identified, which distinguished between the two groups of youth. Using propensity score matching, all youth placed into group care were matched on the propensity score with family-based care youth. Behavioral outcomes at 36 months, as measured by the Child Behavior Checklist, were compared for the matched sample. Of the total 254 youth with group care episodes, 157 could be matched to youth with episodes in family-based care. No significant differences remained between the two groups in the matched sample, and findings revealed no significant differences in longitudinal behavioral outcomes.

12-month follow-up outcomes for youth departing and integrated residential continuum of care

This study examined the 12-month post-departure outcomes for youth who exited a residential treatment program at differing levels of restrictiveness. Study participants were 120 youth who entered an integrated residential continuum of care at its most restrictive level and then either departed the program at the same level or stepped down and departed at a lower level of restrictiveness. Results indicate that youth who stepped down and exited at the lowest level of restrictiveness were the most likely to be living at home or in a homelike setting and experienced fewer formal post-departure out-of-home placements. However, there were no differences in post-departure rates of substance use, arrests, or being in school or having graduated. These results suggest that youth who were served in the integrated continuum and departed at the lowest level of restrictiveness had more positive outcomes at 12-month post-discharge.