Factors associated with outcomes for looked-after children and young people: a correlates review of the literature

Access to best-evidenced mental health support for care-experienced young people: Learnings from the implementation of cognitive therapy for PTSD

OBJECTIVES

Rates of PTSD are up to 12 times higher in care-experienced young people (CEYP) compared to their peers. Trauma-focused CBTs (tf-CBT) are the best-evidenced treatment for youth with PTSD, yet, in practice, CEYP often struggle to access this treatment. We worked alongside services to understand barriers and facilitators of the implementation of cognitive therapy for PTSD (a type of tf-CBT) to CEYP.

DESIGN

This was an active, open implementation trial.

METHODS

We recruited 28 mental health teams across England, including general CAMHS, targeted CAMHS for CEYP and social care-based teams. From these teams, participants were 243 mental health professionals, from a wide variety of professional backgrounds. Following recruitment/intervention training, teams participated in rolling three monthly focus groups and individual interviews, to understand what helped and hindered implementation. Data were analysed using a framework analysis conducted using CFIR 2.0.

RESULTS

Almost half of the teams were able to implement, but only approximately one quarter with CEYP, specifically. Universal barriers that were discussed by almost all teams particularly highlighted service structures and poor resourcing as major barriers to delivery to CEYP, as well as the complexities of the young person and their network. Unique factors that differentiated teams who did and did not implement included commissioning practices, the culture of the team, leadership engagement and style, and the development of supervision structures.

CONCLUSIONS

Findings offer key considerations for mental health teams, service leads, commissioners and policy-makers to enhance delivery of best-evidenced mental health treatments like CT-PTSD, for CEYP.

Understanding how young people transitioning from out-of-home care acquire and develop independent living skills and knowledge: A systematic review of longitudinal studies

Young people leaving state care often experience hardship in many areas of their life. At a population level, their outcomes in early adulthood are poorer compared to general populations. Effective preparation for leaving care and post-care support systems is vital to improving outcomes. Individual and systemic support for young people to acquire Independent Living Skills (ILS) in the following eight ILS domains have been identified: Financial Management, Knowledge of Accessing Available Supports, Managing Housing, Education Planning, Job Seeking, Health Risk Management, Domestic and Self-help Task, and Managing Relationships. This systematic review aims to identify, summarise, and appraise longitudinal studies that address ILS across these ILS domains to understand better how outcomes could be improved. Seven databases (CINAHL, Embase, ProQuest, PsychINFO, PubMed, Scopus, and Web of Science) were searched on 20th July 2023. In total, twenty-seven studies published between 1994 and 2022 from various countries met the eligibility criteria. The included studies reported on 2-4 waves and adopted different methodological approaches. Study quality was scored using Qualsyst. Study characteristics and details of the interventions are presented in tables. Studies cover overlapping ILS domains, which are mapped in a matrix. Results revealed that nearly three-quarters (74% or 20 out of 27) of studies explored four or fewer of the eight ILS domains. The most frequent ILS domain covered was 'Knowledge of Accessing Available Supports' (19/27 studies). The main conclusion considers the concept of independence as a misnomer, with ILS covering multiple, intersecting, and interdependent domains, which ultimately help and hinder one another. Further research is required to adopt a more comprehensive approach encompassing all the domains to better inform policy, programs, and practice. A limitation is that a meta-analysis was not conducted for this review. This study registered a 'Protocol' with OSF Registries (DOI: 10.17605/OSF.IO/MJ3ZX) on June 5th, 2022.

Longitudinal Associations Between Parenting and Child Behaviour Problems and the Moderating Effect of Child Callous Unemotional Traits in Foster and Biological Families

The goals of the current study were to examine (i) differences in parenting between foster and biological parents, (ii) the longitudinal associations with children's internalising and externalising problems and iii) the potential moderation of these by children's callous-unemotional traits (CU traits). Data from 86 foster children (M = 4.44 years, male = 48%) and 148 biological children (M = 3.69 years, male = 49%) with their families were analysed in a longitudinal study with three measurement times. Parenting behaviour did not significantly differ between the foster and biological family groups. Significant longitudinal cross-lagged effects were found for parental warmth and support and children's externalising problems. CU traits moderated the relationship between warmth and support and externalising problems of children. Findings suggest that parenting behaviours and child psychopathology do influence each other over time reciprocally and to a similar extent in both groups. However, there was also evidence for greater temporal stability of psychopathological symptoms and reduced responsivity to parental warmth in children with higher CU traits.

The mental health of all children in contact with social services: a population-wide record-linkage study in Northern Ireland

AIMS

Children in contact with social services are at high risk for mental ill health, but it is not known what proportion of the child population has contact with social services or how risk varies within this group compared to unexposed peers. We aim to quantify the extent and nature of contact with social services within the child population in Northern Ireland (NI) and the association with mental ill health. We also examine which social care experiences identify those most at risk.

METHODS

This is a population-based record-linkage study of 497,269 children (aged under 18 years) alive and resident in NI in 2015 using routinely collected health and social care data. Exposure was categorized as (1) no contact, (2) referred but assessed as not in need (NIN), (3) child in need (CIN) and (4) child in care (CIC). Multilevel logistic regression analyses estimated odds ratios (ORs) for mental ill health indicated by receipt of psychotropic medication (antidepressants, anxiolytics, antipsychotics and hypnotics), psychiatric hospital admission and hospital-presenting self-harm or ideation.

RESULTS

Over one in six children (17.2%, n = 85,792) were currently or previously in contact with social services, and almost one child in every 20 (4.8%, n = 23,975) had contact in 2015. Likelihood of any mental ill health outcome increased incrementally with the level of contact with social services relative to unexposed peers: NIN (OR 5.90 [95% confidence interval (CI) 5.10-6.83]), CIN (OR 5.99 [95% CI 5.50-6.53]) and CIC (OR 12.60 [95% CI 10.63-14.95]). All tiers of contact, number of referrals, number of care episodes and placement type were strongly associated with the likelihood of mental ill health.

CONCLUSION

Children who have contact with social services account for a large and disproportionate amount of mental ill health in the child population. Likelihood of poor mental health across indicators is highest in care experienced children but also extends to the much larger population of children in contact with social services but never in care. Findings suggest a need for targeted mental health screening and enhanced support for all children in contact with social services.

Reactive attachment disorder and disinhibited social engagement disorder in adolescence: co-occurring psychopathology and psychosocial problems

Insufficient care is associated with most psychiatric disorders and psychosocial problems, and is part of the etiology of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). To minimize the risk of misdiagnosis, and aid treatment and care, clinicians need to know to which degree RAD and DSED co-occur with other psychopathology and psychosocial problems, a topic little researched in adolescence. In a national study of all adolescents (N = 381; 67% consent; 12-20 years old; 58% girls) in Norwegian residential youth care, the Child and Adolescent Psychiatric Assessment interview yielded information about psychiatric diagnoses and psychosocial problems categorized as present/absent, and the Child Behavior Check List questionnaire was applied for dimensional measures of psychopathology. Most adolescents with a RAD or DSED diagnosis had several cooccurring psychiatric disorders and psychosocial problems. Prevalence rates of both emotional and behavioral disorders were high in adolescent RAD and DSED, as were rates of suicidality, self-harm, victimization from bullying, contact with police, risky sexual behavior and alcohol or drug misuse. Although categorical measures of co-occurring disorders and psychosocial problems revealed few and weak associations with RAD and DSED, dimensional measures uncovered associations between both emotional and behavioral problems and RAD/DSED symptom loads, as well as DSED diagnosis. Given the high degree of comorbidity, adolescents with RAD or DSED-or symptoms thereof-should be assessed for co-occurring psychopathology and related psychosocial problems. Treatment plans should be adjusted accordingly.

Mental disorders among adults formerly in out-of-home care: a systematic review and meta-analysis of longitudinal studies

While children and adolescents placed in child welfare or juvenile justice out-of-home care show higher prevalence rates of mental disorders compared to the general population, it remains unclear whether this pattern persists into adulthood. A quantitative synthesis of existing studies is lacking. The aim of this meta-analysis was to estimate the prevalence rates for mental disorders among adults with a foster or residential child welfare or juvenile justice care history, comparing them where possible to rates among the general population. PubMed, PsycInfo, EMBASE, and Web of Science were systematically searched for epidemiological studies published up to 28 October 2020. Nineteen studies, totaling 604,257 participants, met our inclusion criteria. Random-effects models were used for prevalence rates and odds ratios (OR) of mental disorders, and study quality was rated. A prevalence rate of 30% [95% CI (23.36, 37.36)] for any mental disorder in adults with a child welfare care history was found (3-17% for specific disorders). A prevalence rate of 45% [95% CI (42.38, 47.38)] for any mental disorder was found in adults with a juvenile justice care history (6-66% for specific disorders). For out-of-home placement history, adult mental disorders were significantly higher than in the general population (OR = 1.33-2.76). Studies differed in terms of methodology and the disorder groups considered, so heterogeneity between effect sizes ranged from low to high. Our findings suggest that the high risk that mental health issues will persist in adults with an out-of-home placement history needs to be taken seriously in the transition from adolescence to adulthood. The care systems involved need to collaborate and to be aware of these risks.

Youth in Residential Care: A Cross-Sectional Mediation Analysis of Youth’s Perceptions of Their Social Images, Self-Representations, and Adjustment Outcomes

Individuals’ perceptions of their social images [i.e., meta-representations (MR)] and perceived stereotyping threat create involuntary stress responses that may affect important outcomes, such as self-esteem, academic achievement, and mental health. This study aimed to (1) analyze the indirect associations between residential care youth’s MR and their psychological adjustment (i.e., externalizing and internalizing problems) through their self-representations (SR) and (2) test the moderating role of youth’s age and residential unit size in those associations. A sample of 926 youth aged between 12 and 25years old filled out self-report questionnaires regarding their representations about how people in general perceive them (i.e., MR) and their SR. Residential care professionals filled in the socio-demographic questionnaires and the Child Behavior Checklist. Data were analyzed through multiple mediation models and moderated mediation models. Results showed that (1) youth’s behavioral MR were indirectly associated with higher internalizing and externalizing behavior through higher levels of behavioral SR and (2) youth’s emotional MR were associated with higher internalizing problems through higher emotional SR, but also with lower internalizing problems through lower levels of behavioral SR. These results emphasize the importance of stimulating positive SR, by showing that they can be a protective factor for youth in residential care.

Educational and health outcomes of schoolchildren in local authority care in Scotland: A retrospective record linkage study

BACKGROUND

Looked after children are defined as children who are in the care of their local authority. Previous studies have reported that looked after children have poorer mental and physical health, increased behavioural problems, and increased self-harm and mortality compared to peers. They also experience poorer educational outcomes, yet population-wide research into the latter is lacking, particularly in the United Kingdom. Education and health share a bidirectional relationship; therefore, it is important to dually investigate both outcomes. Our study aimed to compare educational and health outcomes for looked after children with peers, adjusting for sociodemographic, maternity, and comorbidity confounders.

METHODS AND FINDINGS

Linkage of 9 Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, examinations, school absences/exclusions, unemployment, and looked after children provided retrospective data on 715,111 children attending Scottish schools between 2009 and 2012 (13,898 [1.9%] looked after). Compared to peers, 13,898 (1.9%) looked after children were more likely to be absent (adjusted incidence rate ratio [AIRR] 1.27, 95% confidence interval [CI] 1.24 to 1.30) and excluded (AIRR 4.09, 95% CI 3.86 to 4.33) from school, have special educational need (SEN; adjusted odds ratio [AOR] 3.48, 95% CI 3.35 to 3.62) and neurodevelopmental multimorbidity (AOR 2.45, 95% CI 2.34 to 2.57), achieve the lowest level of academic attainment (AOR 5.92, 95% CI 5.17 to 6.78), and be unemployed after leaving school (AOR 2.12, 95% CI 1.96 to 2.29). They were more likely to require treatment for epilepsy (AOR 1.50, 95% CI 1.27 to 1.78), attention deficit hyperactivity disorder (ADHD; AOR 3.01, 95% CI 2.76 to 3.27), and depression (AOR 1.90, 95% CI 1.62 to 2.22), be hospitalised overall (adjusted hazard ratio [AHR] 1.23, 95% CI 1.19 to 1.28) for injury (AHR 1.80, 95% CI 1.69 to 1.91) and self-harm (AHR 5.19, 95% CI 4.66 to 5.78), and die prematurely (AHR 3.21, 95% CI 2.16 to 4.77). Compared to children looked after at home, children looked after away from home had less absenteeism (AIRR 0.35, 95% CI 0.33 to 0.36), less exclusion (AIRR 0.63, 95% CI 0.56 to 0.71), less unemployment (AOR 0.53, 95% CI 0.46 to 0.62), and better attainment (AIRR 0.31, 95% CI 0.23 to 0.40). Therefore, among those in care, being cared for away from home appeared to be a protective factor resulting in better educational outcomes. The main limitations of this study were lack of data on local authority care preschool or before 2009, total time spent in care, and age of first contact with social care.

CONCLUSIONS

Looked after children had poorer health and educational outcomes than peers independent of increased neurodevelopmental conditions and SEN. Further work is required to understand whether poorer outcomes relate to reasons for entering care, including maltreatment and adverse childhood events, neurodevelopmental vulnerabilities, or characteristics of the care system.

A Systematic Review of Controlled-Trials for PTSD in Maltreated Children and Adolescents

Child maltreatment is associated with elevated risk of post-traumatic stress disorder (PTSD), which can often present alongside comorbidities. While evidence-based treatments for PTSD in young people already exist, there remains ongoing clinical and academic debate about the suitability of these approaches, particularly cognitive-behavioral approaches, for young people who have been exposed to more complex traumatic experiences, such as maltreatment. We conducted an updated systematic review of the evidence-base for psychological treatments for PTSD, specifically for maltreated young people. Fifteen randomized controlled trials and five non-randomized controlled clinical trials satisfied the inclusion criteria. Trials included treatments ranging from trauma-focused CBT to creative-based therapies. Trauma-focused CBT remained the best supported treatment for children and adolescents following child maltreatment, with new evidence that symptom improvements are maintained at longer-term follow up. The evidence for other therapies remained limited, and there were concerns regarding methodological quality. Implications for treatment decision-making are discussed.

Foster Parents' Parenting and the Social-Emotional Development and Adaptive Functioning of Children in Foster Care: A PRISMA-Guided Literature Review and Meta-Analysis

Children in foster care (CFC) are at increased risk for negative developmental outcomes. Given the potential influence of foster parents' parenting on the development of CFC, this literature review and meta-analysis provide an initial overview of how parenting factors in foster families relate to CFC's developmental outcomes. We aimed to explore (1) whether foster parents' parenting conceptualizations are related differently to various CFC developmental outcome variables and (2) how characteristics of foster parents and CFC moderate these associations. Following the recommendations of the PRISMA statement, we searched four databases in 2017 (with an update in May 2020). Forty-three primary studies were coded manually. The interrater agreement was 92.1%. Parenting variables were specified as parenting behavior, style, and goals and were distinguished further into functional and dysfunctional parenting. CFC development was divided into adaptive (including cognitive) development and maladaptive development. Meta-analyses could be performed for foster parenting behavior and developmental outcomes, as well as for functional parenting goals and maladaptive socioemotional outcomes in CFC. Associations between functional parenting behavior and adaptive child development were positive and negative for maladaptive child development, respectively. For dysfunctional, parenting effects were in the opposite direction. All effects were small to moderate. Similar results were found descriptively in the associations of parenting style and child developmental outcomes. We found similar effect sizes and directions of the associations between parenting behavior in foster families and the child's developmental outcomes as those previously reported for biological families. These findings provide strong support for the significant role of parenting in foster families regarding children's development in foster care.

Coping and support-seeking in out-of-home care: a qualitative study of the views of young people in care in England

OBJECTIVES

Young people who have been removed from their family home and placed in out-of-home care have commonly experienced abuse, neglect and/or other forms of early adversity. High rates of mental health difficulties have been well documented in this group. The aim of this research was to explore the experiences of these young people within the care system, particularly in relation to support-seeking and coping with emotional needs, to better understand feasible and acceptable ways to improve outcomes for these young people.

DESIGN AND STUDY SETTING

This study used 1:1 semistructured qualitative interviews with young people in out-of-home care in England, to provide an in-depth understanding of their views of coping and support for their emotional needs, both in terms of support networks and experiences with mental health services. Participants were 25 young people aged 10-16 years old (56% female), and included young people living with non-biological foster carers, kinship carers and in residential group homes.

RESULTS

Participants described positive (eg, feeling safe) and negative (eg, feeling judged) aspects to being in care. Carers were identified as the primary source of support, with a supportive adult central to coping. Views on support and coping differed for young people who were experiencing more significant mental health difficulties, with this group largely reporting feeling unsupported and many engaging in self-harm. The minority of participants had accessed formal mental health support, and opinions on usefulness were mixed.

CONCLUSIONS

Results provide insight, from the perspective of care-experienced young people, about both barriers and facilitators to help-seeking, as well as avenues for improving support.

Exploring placement stability for children in out-of-home care in England: a sequence analysis of longitudinal administrative data

BACKGROUND

To monitor stability of care, the proportion of children in England who have experienced three or more placements in the preceding 12-month period is published in government statistics. However, these annual snapshots cannot capture the complexity and heterogeneity of children's longitudinal care histories.

OBJECTIVE

To describe the stability of care histories from birth to age 18 for children in England using a national administrative social care dataset, the Children Looked After return (CLA).

PARTICIPANTS AND SETTING

We analyzed CLA data for a large, representative sample of children born between 1992 and 1994 (N = 16,000).

METHODS

Using sequence analysis methods, we identified distinct patterns of stability, based on the number, duration, and timing of care placements throughout childhood.

RESULTS

Although care histories were varied, six distinct patterns of stability were evident including; adolescent 1^st entries (17.6%), long-term complex care (13.1%) and early intervention (6.9%). Overall, most children (58.4%) had a care history that we classified as shorter term care with an average of 276 days and 2.48 placements in care throughout childhood. Few children (4.0%) had a care history that could be described as long-term stable care.

CONCLUSIONS

Longitudinal analyses of administrative data can refine our understanding of how out-of-home care is used as a social care intervention. Sequence analysis is a particularly useful tool for exploring heterogeneous and complex care histories. Considering out-of-home care histories from a life course perspective over the entire childhood period could enable service providers to better understand and address the needs of looked after children.

Qualitative process evaluation of the Fostering Changes program for foster carers as part of the Confidence in Care randomized controlled trial

BACKGROUND

Fostering Changes is an in-service training program for foster carers designed to enhance carer skills, coping strategies and carer-child relationships. The training program has been evaluated in a randomised controlled trial comparing Fostering Changes to usual care.

OBJECTIVE

To conduct a qualitative process evaluation drawing on stakeholder perspectives to describe the logic model of Fostering Changes, identify potential mechanisms of impact of the program and enhance understanding of the trial results.

PARTICIPANTS AND SETTING

Participants were stakeholders in the Fostering Changes program delivered in Wales, UK including foster carers invited to attend the program (18 attendees, eight non-attendees), two program developers, five trainers, 12 social workers who attended or recruited to the program.

METHODS

Total population sampling with qualitative data collection methods. Qualitative data were subject to thematic analysis.

RESULTS

A logic model summarising the program resources, activities and anticipated outcomes was generated. Implementation themes were quality of training, setting and group composition. Mechanisms of impact were identified with themes falling into two categories, group process and skills development. Potential barriers to effectiveness included a poor fit between the carer needs and the program in relation to levels of challenge being faced, age-appropriate content and responsiveness. Contextual factors were also relevant, including the existing relationship between foster carers and the agency and the perceived value of training.

CONCLUSIONS

Although the group aspects of the program were well received, the program itself did not help foster carers deal with more complex challenges and needed to be more targeted in terms of carers needs and circumstances.

Validity of reactive attachment disorder and disinhibited social engagement disorder in adolescence

Although reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) are acknowledged as valid disorders in young children, controversy remains regarding their validity in adolescence. An unresolved question is whether symptoms of RAD and DSED are better conceptualized as other psychiatric disorders at this age. All adolescents (N = 381; 67% consent; 12-20 years old) living in residential youth care in Norway were interviewed to determine the symptoms and diagnosis of RAD/DSED and other common psychiatric disorders using the Child and Adolescent Psychiatric Assessment (CAPA). The construct validity of RAD and DSED, including structural and discriminant validity, was investigated using confirmatory factor analysis and latent profile analysis. Two-factor models distinguishing between symptoms of RAD and DSED and differentiating these symptoms from the symptoms of other psychiatric disorders revealed better fit than one-factor models. Symptoms of RAD and DSED defined two distinct latent groups in a profile analysis. The prevalence of RAD was 9% (95% CI 6-11%), and the prevalence of DSED was 8% (95% CI 5-11%). RAD and DSED are two distinct latent factors not accounted for by other common psychiatric disorders in adolescence. RAD and DSED are not uncommon among adolescents in residential youth care and therefore warrant easy access to qualified health care and prevention in high-risk groups.

Children and Young People "In Care" Participating in a Peer-Mentoring Relationship: An Exploration of Resilience

The aim of this study was to explore how a 1-year peer-mentoring relationship contributed to change in young women "in care." Twenty semistructured, one-to-one interviews were conducted with mentors (n = 11) and mentees (n = 9) recruited from two different London local authorities. Participants' accounts were interpreted through a developmental lens to uncover developmental aspects and locus mechanisms through which transformative change took place. Resilience as a healthy outcome was the result of the dual function the mentoring relationship performed. The mentoring relationship was protective against the risks associated with transitioning to independent living and/or adulthood, and promoted internal assets and competencies whereby the mentees' ability to resist them was enhanced. Establishing a trustworthy connection with a role model promoted developmental domains within mentees.

Interventions and practice models for improving health and psychosocial outcomes of children and young people in out-of-home care: protocol for a systematic review

INTRODUCTION

Children and young people placed in out-of-home care (OoHC) are often affected by a history of trauma and adverse childhood experiences. Trauma in early childhood can impact on children's health and psychosocial development, whereas early interventions can improve children's development and placement stability. Although several interventions and practice models have been developed to improve health and psychosocial outcomes for children and young people in OoHC, there remains a lack of rigorous research examining the impact of these interventions in OoHC settings, as there are no systematic reviews examining the impact these interventions and practice models have on the children and young people they serve. We aim to conduct a comprehensive systematic review to examine the effectiveness of interventions and practice models for improving health and psychosocial outcomes in children and young people living in OoHC and to identify relevant knowledge gaps.

METHODS AND ANALYSIS

Major electronic databases including Medline, Medline in-process and other non-indexed citations, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Sociological Abstracts and all Evidence-Based Medicine Reviews incorporating: Cochrane Database of Systematic Reviews, American College of PhysiciansJournal Club, Database of Abstracts of Reviews of Effects,Cochrane Central Register of Controlled Trials, CochraneMethodology Register, Health Technology Assessment and National Health Service Economic Evaluation Database, will be systematically searched for any studies published between 2008 and 2018 of interventions and practice models developed to improve health and psychosocial outcomes for children and young people in OoHC. Two independent reviewers will assess titles and abstracts for eligibility according to prespecified selection criteria and will perform data extraction and quality appraisal. Meta-analyses and/or metaregression will be conducted where appropriate.

ETHICS AND DISSEMINATION

This study will not collect primary data and formal ethical approval is therefore not required. Findings from this systematic review will be disseminated in a peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019115082.

The prognosis of out-patient alcohol treatment among parents with childcare responsibility

BACKGROUND

Despite expansive knowledge on the detrimental effects of growing up with parents with alcohol use disorders (AUDs), little is known about the prognosis of alcohol treatment among parents with childcare responsibility.

AIMS

This observational cohort study aimed to examine the prognosis of patients with and without childcare responsibility, in a conventional out-patient alcohol treatment clinic.

METHOD

A consecutive AUD sample (N = 2201), based on ICD-10 Diagnostic Criteria for Research, was assessed with the European Addiction Severity Index during the clinical routine, at treatment entry and conclusion. Data on addiction severity, treatment course and drinking outcomes were derived, and adjusted odds ratios (AORs) were calculated with logistic-regression models. Drinking outcomes were compared in an intention-to-treat analysis, including all patients in a logistic regression with inverse probability weighting.

RESULTS

Patients with childcare responsibility (aged <18 years) had a less severe addiction profile and lower drop-out rate compared with patients without children or with children living out-of-home. They were also more likely to improve on all drinking-related outcomes, including abstinence (AOR 2.68, 95% CI 1.82-3.95), number of drinking days (AOR 2.45, 95% CI 1.50-4.03) and excessive drinking days (AOR 4.66, 95% CI 2.36-9.17); and those with children living out-of-home had better outcomes on abstinence (AOR 1.59, 95% CI 1.08-2.34) than patients without children.

CONCLUSIONS

Childcare responsibility among out-patients was associated with better treatment course and outcomes than those without or not living with their children. This knowledge can help guide clinical practice, effectuate interventions and inform social authorities.

Adult psychosocial outcomes of men and women who were looked-after or adopted as children: prospective observational study

OBJECTIVE

To investigate whether men and women who were looked-after (in public care) or adopted as children are at increased risk of adverse psychological and social outcomes in adulthood.

DESIGN, SETTING

Prospective observational study using the Avon Longitudinal Study of Parents and Children, which recruited pregnant women and their male partners in and around Bristol, UK in the early 1990s.

PARTICIPANTS

8775 women and 3654 men who completed questionnaires at recruitment (mean age: women 29; men 32) and 5 years later.

EXPOSURE

Childhood public care status: looked-after; adopted; not looked-after or adopted (reference group).

OUTCOMES

Substance use (alcohol, cannabis, tobacco) prepregnancy and 5 years later; if ever had addiction; anxiety and depression during pregnancy and 5 years later; if ever had mental health problem; social support during pregnancy; criminal conviction.

RESULTS

For women, 2.7% were adopted and 1.8% had been looked-after; for men, 2.4% and 1.4%, respectively. The looked-after group reported the poorest outcomes overall, but this was not a universal pattern, and there were gender differences. Smoking rates were high for both the looked-after (men 47%, women 58%) and adopted (men 44%, women 40%) groups relative to the reference group (both 28%). The looked-after group were at increased risk of a high depression score (men: 26% vs 11%, OR 2.9 (95% CI 1.5 to 5.6); women: 24% vs 9%, 3.4 (2.2 to 5.0)). A high anxiety score was reported by 10% of the reference women, compared with 26% of those looked-after (3.0 (2.0 to 4.5)) and 17% of those adopted (1.8 (1.2 to 2.6)). Looked-after men and women reported the lowest social support, while criminal convictions and addiction were highest for looked-after men. Adjustment for adult socioeconomic position generally attenuated associations for the looked-after group.

CONCLUSIONS

The needs of those who experience public care as children persist into adulthood. Health and social care providers should recognise this.

Patterns of referral and waiting times for specialist Child and Adolescent Mental Health Services

BACKGROUND

During 12-month period (2012/13) around 21,480 children and young people (CYP) were referred to Child and Adolescent Mental Health Service (CAMHS) in Scotland (NHS Scotland, 2013, Child and Adolescent Mental Health Services waiting times in Scotland). At the end of September 2012, there were 3,602 CYP still waiting for 'start of treatment' or 'removal from the waiting list', 375 (10%) CYP had waited over 26 weeks and 1,204 (33%) CYP had waited over 18 weeks (NHS Scotland, 2013, Child and Adolescent Mental Health Services waiting times in Scotland). Referral source, referral reason and the sociodemographic characteristics of CYP are not routinely collected, and therefore, associations between these factors and wait times for 'start of treatment' or 'removal from the waiting list' (i.e. the referral outcome) are unknown.

METHOD

In this exploratory study, a retrospective analysis of referral data was conducted in one CAMHS. Data for 476 referrals between 1st May 2013 and 31st May 2014 were initially analysed to define categories for each of the following key variables: referral source, referral reason and referral outcome. Data on CYP sociodemographic characteristics were extracted from referral records, including age, gender and postcode, from which Scottish Index of Multiple Deprivation quintile of residence was derived. Descriptive statistics were calculated for referral source, referral reason and CYP sociodemographic characteristics. Regression models were then built to determine predictors of a referral being rejected by CAMHS and waiting time for referrals accepted by CAMHS. Data were analysed in SPSS (Version 20).

RESULTS

Of the 476 referrals, 72% (n = 342) were accepted and 12% (n = 59) were rejected. Most referrals were made by general practitioners. Just under a third of referrals to CAMHS (31%) were for CYP with emotional and behavioural difficulties. The odds of being rejected by CAMHS were significantly higher if referred by teachers and for CYP with emotional and behavioural difficulties. Age and referral reason were significant independent predictors of waiting time after referral to CAMHS, with CYP referred for hyperactivity/inattention waiting significantly longer.

CONCLUSIONS

Policymakers should consider ways to foster dialogue and collaboration between different groups of professionals making and accepting referrals to CAMHS in order to improve timely access to appropriate mental health support services for CYP. Research is urgently needed to investigate the experiences of CYP who are either rejected by CAMHS or wait lengthy periods of time before starting their treatment with CAMHS.

Psychosocial screening and monitoring for children in foster care: Psychometric properties of the Brief Assessment Checklist in a Dutch population study

Children in foster care experience higher levels and rates of psychosocial difficulties than children from the general population. Governments and child welfare services have a responsibility to identify those children in care who have need for therapeutic services. This can be achieved through systematic screening and monitoring of psychosocial difficulties among all children in foster care. However, general screening and assessment measures such as the Strengths and Difficulties Questionnaire (SDQ) and Child Behavior Checklist (CBCL) might not adequately screen for the range of difficulties experienced by foster children. The Brief Assessment Checklists for Children (BAC-C) and Brief Assessment Checklists for Adolescents (BAC-A) are measures designed to screen for and monitor attachment- and trauma-related difficulties among child welfare populations. This article reports psychometric properties of the BAC-C and BAC-A, estimated in a population study of 219 Dutch foster children. The results suggest the BAC-C and BAC-A perform both screening and monitoring functions well. Their screening accuracy, internal reliability and concurrent validity are comparable to those estimated for the SDQ within the same child and adolescent sample. Future research is needed to assess the value of the Brief Assessment Checklists (BAC) compared to other measures and to validate cut-points for the BAC. This study further establishes the BAC-A and BAC-C as valid and useful mental health screening and monitoring measures for use with children and adolescents in foster care.

Smoking and Looked-After Children: A Mixed-Methods Study of Policy, Practice, and Perceptions Relating to Tobacco Use in Residential Units

Despite the implementation of smoke-free policies by local authorities and a statutory requirement to promote the health and well-being of looked-after children and young people in England, rates of tobacco use by this population are substantially higher than in the general youth population. A mixed-methods study, comprising a survey of residential care officers in 15 local authority-operated residential units and semi-structured, face-to-face interviews with residential carers in three local authority-operated residential units, was conducted in the East Midlands. Survey data were descriptively analysed; and interview data were transcribed and analysed using thematic framework analysis. Forty-two care officers (18% response rate) completed the survey, and 14 participated in the interviews. Despite reporting substantial awareness of smoke-free policies, a lack of adherence and enforcement became apparent, and levels of reported training in relation to smoking and smoking cessation were low (21%). Potential problems relating to wider tobacco-related harms, such as exploitative relationships; a reliance on tacit knowledge; and pessimistic attitudes towards LAC quitting smoking, were indicated. The findings highlight the need for the development of comprehensive strategies to promote adherence to and enforcement of local smoke-free policy within residential units for looked-after children and young people, and to ensure appropriate support pathways are in place for this population.

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.

Mental disorders in foster children: a study of prevalence, comorbidity and risk factors

BACKGROUND

The aim of this study is to examine the prevalence of mental disorders in 6- to 12-year-old foster children and assess comorbidity and risk factors.

METHODS

Information on mental health was collected from foster parents and from teachers using Developmental and Well-Being Assessment (DAWBA) Web-based diagnostic interview. Child welfare services provided information about care conditions prior to placement and about the child's placement history.

RESULTS

Diagnostic information was obtained about 279 (70.5%) of 396 eligible foster children. In total, 50.9% of the children met the criteria for one or more DSM-IV disorders. The most common disorders were grouped into 3 main diagnostic groups: Emotional disorders (24.0%), ADHD (19.0%), and Behavioural disorders (21.5%). The comorbidity rates among these 3 main groups were high: 30.4% had disorders in 2 of these 3 diagnostic groups, and 13.0% had disorders in all 3 groups. In addition, Reactive attachment disorder (RAD) was diagnosed in 19.4% of the children, of whom 58.5% had comorbid disorders in the main diagnostic groups. Exposure to violence, serious neglect, and the number of prior placements increased the risk for mental disorders.

CONCLUSIONS

Foster children in Norway have a high prevalence of mental disorders, compared to the general child population in Norway and to other societies. The finding that 1 in 2 foster children presented with a mental disorder with high rates of comorbidity highlight the need for skilled assessment and qualified service provision for foster children and families.

Multilevel correlates of behavioral resilience among children in child welfare

Resilience, defined as positive adaptation and functioning following exposure to significant adversity, is an important topic of investigation in child welfare. The current study used data from the Ontario Looking After Children (OnLAC) project to estimate the prevalence of behavioral resilience (i.e., lower frequency of conduct and emotional problems, higher frequency of prosocial behavior) in 531 5-9 year olds living in out-of-home care, and to determine how behaviorally-resilient children are functioning in other domains (i.e., peer relationships and academic performance). Furthermore, hierarchical linear modeling was used to examine the contribution of four levels of analysis (i.e., child, family, child welfare worker, and child welfare agency) on behaviors and to identify the contribution of predictor variables within each of these levels. Findings indicated that 50-70% of children exhibited resilience on one behavioral outcome while approximately 30% showed resilience on at least two of the outcomes. Also, 8.4-9.6% exhibited resilience on one of the behavioral outcomes in addition to peer relationships and academic performance. The child level accounted for the highest proportion of total explained variance in behavioral outcomes, followed by the family-, child welfare worker-, and child welfare agency-levels. A number of child and foster family variables predicted behavioral functioning. Findings indicate that it is important to inquire about children's functioning across multiple domains to obtain a comprehensive developmental assessment. Also, child and foster family characteristics appear to play considerable roles in the promotion of behavioral resilience.