Mental health and foster carer training

Effectiveness of Mental Health and Wellbeing Interventions for Children and Young People in Foster, Kinship, and Residential Care: Systematic Review and Meta-Analysis

The mental health and wellbeing of children and young people who have been in care, primarily foster care, kinship care or residential care, remains a public health priority. The Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) synthesized evidence for the effectiveness of interventions targeting: subjective wellbeing; mental, behavioral and neurodevelopmental disorders; and suicide-related outcomes. Searches were conducted in 16 bibliographic databases and 22 websites between 1990 and 2022. This was supplemented by citation tracking, screening of relevant systematic reviews, and expert recommendation. We identified 35 interventions, with 44 evaluations via randomized controlled trials. Through meta-analyses, we found that interventions have a small beneficial impact on a variety of mental health outcomes in the short term (0-6 months). Interventions improved total social, emotional, and behavioral problems (d = -0.15, 95% CI [-0.28, -0.02]), social-emotional functioning difficulties (d = -0.18, 95% CI [-0.31, -0.05]), externalizing problem behaviors (d = -0.30, 95% CI [-0.53, -0.08]), internalizing problem behaviors (d = -0.35, 95% CI [-0.61, -0.08]); and depression and anxiety (d = -0.26, 95% CI [-0.40, -0.13]). Interventions did not demonstrate any effectiveness for outcomes assessed in the longer term (>6 months). Certainty of effectiveness was limited by risk of bias and imprecision. There was limited available evidence for interventions targeting subjective wellbeing and suicide-related outcomes. Future intervention design and delivery must ensure that programs are sufficient to activate causal mechanisms and facilitate change. Evaluation research should use a robust methodology.PROSPERO Registration: CRD42020177478.

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.

Interventions targeting the mental health and wellbeing of care-experienced children and young people in higher-income countries: Evidence map and systematic review

BACKGROUND

The mental health and wellbeing of care-experienced children and young people (i.e. foster care, kinship care, residential care) is poorer than non-care-experienced populations. The Care-experienced cHildren and young people's Interventions to improve Mental health and wEll-being outcomes Systematic review (CHIMES) aimed to synthesise the international evidence base for interventions targeting subjective wellbeing, mental health and suicide amongst care-experienced young people aged ≤ 25 years.

METHODS

For the first phase of the review, we constructed an evidence map identifying key clusters and gaps in interventions and evaluations. Studies were identified through 16 electronic databases and 22 health and social care websites, in addition to expert recommendations, citation tracking and screening of relevant systematic reviews. We charted interventions and evaluations with a summary narrative, tables and infographics.

RESULTS

In total, 64 interventions with 124 associated study reports were eligible. The majority of study reports were from the USA (n = 77). Interventions primarily targeted children and young people's skills and competencies (n = 9 interventions), the parental functioning and practices of carers (n = 26), or a combination of the two (n = 15). While theoretically under-specified, interventions were largely informed by theories of Attachment, Positive Youth Development, and Social Learning Theory. Current evaluations prioritised outcomes (n = 86) and processes (n = 50), with a paucity of study reports including theoretical descriptions (n = 24) or economic evaluations (n = 1). Interventions most frequently targeted outcomes related to mental, behavioural or neurodevelopmental disorders, notably total social, emotional and behavioural problems (n = 48 interventions) and externalising problem behaviours (n = 26). There were a limited number of interventions targeting subjective wellbeing or suicide-related outcomes.

CONCLUSIONS

Future intervention development might focus on structural-level intervention theories and components, and target outcomes related to subjective wellbeing and suicide. In accordance with current methodological guidance for intervention development and evaluation, research needs to integrate theoretical, outcome, process and economic evaluation in order to strengthen the evidence base.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020177478.

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.

A pragmatic randomised controlled trial of the fostering changes programme

BACKGROUND

Many looked after young people in Wales are cared for by foster or kinship carers, usually as a consequence of maltreatment or developmentally traumatising experiences within a family context. Confidence in Care is a pragmatic unblinded individually randomised controlled parallel group trial evaluating a training programme to improve foster carer self-efficacy, when compared to usual care.

OBJECTIVE

To determine whether group-based training improves foster carer self-efficacy.

PARTICIPANTS AND SETTING

Participants are foster carers, currently looking after children aged 2+ years for at least 12 weeks. Carers from households where one or more carer had previously attended the training were not eligible. Sixteen local authorities and three independent fostering providers in Wales took part.

METHODS

The primary outcome measure was the Carer Efficacy Questionnaire assessed at 12 months. Secondary outcomes included the Strengths and Difficulties Questionnaire, Quality of Attachment Questionnaire, Carer Defined Problems Scale, Carer Coping Strategies, placement moves.

RESULTS

312 consented foster carers were allocated to FC (n = 204) or usual care (n = 108) group. 65.3 % of FC group participants attended sufficient training sessions (8/12, including sessions three and four). There were no differences in carer-reported self-efficacy at 12 months (adjusted difference in means (95 % CI): -0.19 (-1.38 to 1.00)). Small differences in carer-reported child behaviour difficulties and carer coping strategies over time favoured the intervention but these effects diminished from three to 12 months. No other intervention effects were observed.

CONCLUSIONS

Although well-received by participants, training was associated with small and mostly short-term benefit for trial secondary outcomes.

Evaluating the long-term impact of the Fostering Changes training programme for foster carers in Wales, the Confidence in Care trial: study protocol for a randomised controlled trial

BACKGROUND

The Fostering Changes programme was developed by the Adoption and Fostering National Team at the Maudsley Hospital, South London, in conjunction with King's College London. It is a 12-week group-based training programme for foster and kin carers, which aims to build positive relationships between carers and children, encourage positive child behaviour and set appropriate limits, through a practical skills-based approach. The programme also aims to improve foster carers' understanding of the causes of children's social and emotional difficulties and their confidence in applying this knowledge in various situations.

METHODS

This is a pragmatic open-label individually randomised controlled trial, with embedded process evaluation. A total of 237 participants will be recruited from Welsh Local Authorities and Independent Fostering Providers; those allocated to the intervention group will be offered enrolment in the next Fostering Changes programme group at their site. Participants in the control group will be offered the Fostering Changes programme at the end of the follow-up period. Data will be collected at baseline, immediately following the 12 week Fostering Changes intervention, and 12 months from the start of the Fostering Changes programme. The primary outcome measure assesses the extent to which carers feel able to cope with and make positive changes to the lives of their foster children and is measured by the Carer Efficacy Questionnaire at 12 months.

DISCUSSION

The trial will determine whether the Fostering Changes programme, in the long term, can deliver important, significant differences to the way foster carers build positive relationships with their foster children, encourage positive child behaviour and set appropriate limits, compared with usual care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number, ISRCTN19090228 . Registered on 11 January 2017.

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.

Bindungsauffälligkeiten und psychische Belastung bei Kindern aus der Pflegekinderhilfe und Heimerziehung

Zusammenfassung. Symptome von Bindungsstörungen, auch in Verbindung zu anderen psychischen Symptomen, sind von hoher Relevanz für die Hilfeplanung in der Kinder- und Jugendhilfe. Dennoch wurde diesen im Bereich der epidemiologischen Forschung in der Kinder- und Jugendhilfe bisher kaum die notwendige Beachtung geschenkt. Vor diesem Hintergrund wurden 116 Heimkinder, 276 Pflegekinder und 339 Kinder aus der Allgemeinbevölkerung mit der Child Behavior Checklist (CBCL) und dem Relationship Problems Questionnaire (RPQ) untersucht. Heimkinder erreichten in der CBCL signifikant höhere Werte als Pflegekinder. Die Wahrscheinlichkeit für einen auffälligen Wert in der CBCL war bei Heimkindern 20.96-mal und bei Pflegekindern 8.02-mal so hoch wie in der Allgemeinbevölkerung. Im RPQ zeigten sich keine Unterscheide zwischen Heim- und Pflegekindern. Die Wahrscheinlichkeit für einen auffälligen Wert im RPQ war bei Heimkindern 25.29-mal und bei Pflegekindern 19.37-mal so hoch wie in der Allgemeinbevölkerung. Eine Abklärung der psychischen Belastung und Bindungsproblematik des Kindes sowie eine darauf abgestimmte Hilfeplanung sind wesentlich, um einer Überforderung des Kindes und der Fürsorgeperson vorzubeugen und dem Kind korrigierende Bindungserfahrungen zu ermöglichen.

Evidence-Based Parenting Interventions to Promote Secure Attachment: Findings From a Systematic Review and Meta-Analysis

Various interventions are used in clinical practice to address insecure or disorganized attachment patterns and attachment disorders. The most common of these are parenting interventions, but not all have a robust empirical evidence base. We undertook a systematic review of randomized trials comparing a parenting intervention with a control, where these used a validated attachment instrument, in order to evaluate the clinical and cost-effectiveness of interventions aiming to improve attachment in children with severe attachment problems (mean age <13 years). This article aims to inform clinicians about the parenting interventions included in our systematic review that were clinically effective in promoting secure attachment. For completeness, we also briefly discuss other interventions without randomized controlled trial evidence, identified in Patient Public Involvement workshops and expert groups at the point our review was completed as being used or recommended. We outline the key implications of our findings for clinical practice and future research.

Clinical effectiveness and cost-effectiveness of parenting interventions for children with severe attachment problems: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Services have variable practices for identifying and providing interventions for 'severe attachment problems' (disorganised attachment patterns and attachment disorders). Several government reports have highlighted the need for better parenting interventions in at-risk groups. This report was commissioned to evaluate the clinical effectiveness and cost-effectiveness of parenting interventions for children with severe attachment problems (the main review). One supplementary review explored the evaluation of assessment tools and a second reviewed 10-year outcome data to better inform health economic aspects of the main review.

DATA SOURCES

A total of 29 electronic databases were searched with additional mechanisms for identifying a wide pool of references using the Cochrane methodology. Examples of databases searched include PsycINFO (1806 to January week 1, 2012), MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to December week 4, 2011) and EMBASE (1974 to week 1, 2012). Searches were carried out between 6 and 12 January 2012.

REVIEW METHODS

Papers identified were screened and data were extracted by two independent reviewers, with disagreements arbitrated by a third independent reviewer. Quality assessment tools were used, including quality assessment of diagnostic accuracy studies - version 2 and the Cochrane risk of bias tool. Meta-analysis of randomised controlled trials (RCTs) of parenting interventions was undertaken. A health economics analysis was conducted.

RESULTS

The initial search returned 10,167 citations. This yielded 29 RCTs in the main review of parenting interventions to improve attachment patterns, and one involving children with reactive attachment disorder. A meta-analysis of eight studies seeking to improve outcome in at-risk populations showed statistically significant improvement in disorganised attachment. The interventions saw less disorganised attachment at outcome than the control (odds ratio 0.47, 95% confidence interval 0.34 to 0.65; p < 0.00001). Much of this focused around interventions improving maternal sensitivity, with or without video feedback. In our first supplementary review, 35 papers evaluated an attachment assessment tool demonstrating validity or psychometric data. Only five reported test-retest data. Twenty-six studies reported inter-rater reliability, with 24 reporting a level of 0.7 or above. Cronbach's alphas were reported in 12 studies for the comparative tests (11 with α > 0.7) and four studies for the reference tests (four with α > 0.7). Three carried out concurrent validity comparing the Strange Situation Procedure (SSP) with another assessment tool. These had good sensitivity but poor specificity. The Disturbances of Attachment Interview had good sensitivity and specificity with the research diagnostic criteria (RDC) for attachment disorders. In our supplementary review of 10-year outcomes in cohorts using a baseline reference standard, two studies were found with disorganised attachment at baseline, with one finding raised psychopathology in adolescence. Budget impact analysis of costs was estimated because a decision model could not be justifiably populated. This, alongside other findings, informed research priorities.

LIMITATIONS

There are relatively few UK-based clinical trials. A 10-year follow-up, while necessary for our health economists for long-term sequelae, yielded a limited number of papers.

CONCLUSIONS

Maternal sensitivity interventions show good outcomes in at-risk populations, but require further research with complex children. The SSP and RDC for attachment disorders remain the reference standards for identification until more concurrent and predictive validity research is conducted. A birth cohort with sequential attachment measures and outcomes across different domains is recommended with further, methodologically sound randomised controlled intervention trials. The main area identified for future work was a need for good-quality RCTs in at-risk groups such as those entering foster care or adoption.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001395.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Cortisol secretion in children with symptoms of reactive attachment disorder

Maltreated children with reactive attachment disorder (RAD) have severe problems with social relationships and affect regulation. An association between early maltreatment and changes in the daily rhythm of cortisol secretion has already been reported for maltreated toddlers. We sought to find out whether such changes were apparent in school-age children with symptoms of RAD, who had experienced early maltreatment but were currently adopted in well-functioning families. We recruited 66 children: 34 adopted children, aged 5-12 years, with an early history of maltreatment and with social difficulties such as indiscriminate friendliness; and 32 age- and sex-matched comparison children with no history of maltreatment or social difficulties. Daily rhythms of cortisol production were determined from saliva samples collected over 2 days. The adopted group had significantly lower absolute levels of cortisol compared to the control group, but a typical profile of cortisol secretion. There was no association between cortisol secretion and symptom scores for psychopathology.

Interventions in foster and kinship care: a systematic review

Foster care is a complex setting in which to provide therapeutic interventions due to the high rates of difficulty, poor outcomes and high numbers of professionals and carers involved. This systematic review aims to examine interventions that have been empirically assessed in foster care. Thirty papers describing 20 interventions were included. It was found that there was good support for wraparound services and relational interventions, but little support for widely used carer training programmes. A need was identified to further research and implement wraparound services within the UK, and to empirically test interventions which may be efficacious with a foster care population.

Practitioner review: Children in foster care--vulnerabilities and evidence-based interventions that promote resilience processes

BACKGROUND

An increasing number of children are placed in foster care (i.e., a kin or nonkin family home other than the biological parent) due to experiences of physical, sexual, emotional, or psychological abuse, and/or neglect. Children in foster care are at increased risk for a host of negative outcomes encompassing emotional, behavioral, neurobiological, and social realms.

METHODS

Areas of risk and vulnerability among foster children are described, including emotional and behavioral deficits, impaired neurobiological development, and social relationship deficits. Evidence suggesting the significance of family placement changes and prenatal exposure to substances as contributing mechanisms is presented. Based on a systematic search of the PsycINFO database (to March 2012), eight efficacious evidence-based interventions for foster families are summarized.

FINDINGS

Although the development of evidence-based interventions that improve outcomes for foster children has lagged behind the delivery of interventions in other service sectors (e.g., mental health and educational sectors), several interventions across childhood and adolescence offer promise. Service system constraints offer both challenges and opportunities for more routine implementation of evidence-based interventions.

CONCLUSIONS

Given the increased likelihood of poor outcomes for foster children, increased efforts to understand the pathways to vulnerability and to implement interventions shown to be effective in remediating risks and improving outcomes for this population are indicated. Evaluation of efficacious interventions in countries outside of the United States is also needed.

The effectiveness of training and support for carers and other professionals on the physical and emotional health and well-being of looked-after children and young people: a systematic review

Looked-after children and young people (LACYP) are recognized as a high-risk group for behavioural and emotional problems, and additional specialist training for foster carers may reduce such problems. This systematic review aimed to identify and synthesize evidence on the effectiveness of additional training and support provided to approved carers, professionals and volunteers on the physical and emotional health and well-being of LACYP (including problem behaviours and placement stability). Searches of health and social science databases were conducted and records were screened for inclusion criteria. Citation and reference list searches were conducted on included studies. Included studies were synthesized and critically appraised. Six studies were included (five randomized controlled trials and one prospective cohort study), all of which focused on foster carers. Three studies reported a benefit of training and three reported no benefit but no detriment. Those reporting a benefit of training were conducted in the USA, and had longer-duration training, shorter follow-up assessment and recruited carers of younger children than studies that reported no benefit of training, which were conducted in the UK. Whether the difference in results is due to the type of training or to cultural or population differences is unclear. The findings suggest a mixed effect of training for foster carers on problem behaviours of LACYP. The evidence identified appears to suggest that longer-duration training programmes have a beneficial effect on the behaviour problems of LACYP, although future research should examine the impact of training durations and intensity on short-medium and longer-term outcomes of LACYP of different ages. Only training and support for foster carers was identified.

Identifying speech, language and communication needs among children and young people in residential care

BACKGROUND

There are claims that elevated levels of speech, language and communication needs (SLCN) exist among looked-after children and young people, and that their needs remain largely undetected and unmet. Scarce empirical evidence exists to support these assertions.

AIMS

To investigate whether elevated levels of communication impairment exist among children and young people in residential care; to begin to explore the nature of any communication impairment indicated, including social and pragmatic difficulties; to consider the extent to which communication impairment may be undetected and unmet; and to consider the suitability of the Children's Communication Checklist 2 (CCC-2) as a screening tool in this context.

METHODS & PROCEDURES

In four local authority areas in Scotland residential care workers completed the CCC-2 on children and young people well known to them, and provided information about previous concerns and/or referrals regarding communication.

OUTCOMES & RESULTS

Results are presented for 30 children and young people ranging in age from 11;01 to 17;01 years (133-205 months, mean = 172.57, SD = 19.97 months). CCC-2 scores indicated impairment in 19 out of 30 cases. In eight of those 19 cases profiles were suggestive of autistic spectrum disorder (ASD), while for the remaining eleven cases impairment was indicated in other aspects of speech, language or communication. The general trend was towards greater severity of impairment in both ASD and non-ASD profiles. Information regarding previous concerns and/or referrals was available for ten of the 19 cases whose profiles indicated impairment: in nine out of these ten cases there had been no concerns, and in the final case no referrals had been made despite concerns.

CONCLUSIONS & IMPLICATIONS

This study indicates the presence of high levels of SLCN among individuals in residential care, much of it severe and pervasive in nature, and in large part unsuspected. The CCC-2 has the potential for use as a screening tool for this population. There is a compelling case for speech and language therapy services to address issues of awareness and access with regard to this population. This preliminary research supports the need for further investigation on a larger and wider scale.

Enhancing Adoptive Parenting: A Cost-Effectiveness Analysis

BACKGROUND

  Children adopted from care often exhibit behavioural difficulties. There is however limited cost-effectiveness evidence regarding different interventions to address this. This paper reports a cost-effectiveness analysis of parenting programmes for these children.

METHOD

  Adoptive parents of children aged between 3 and 8 years participated in home-based, manualised, parenting programmes delivered by trained family social workers. The adopters were randomly allocated to one of two interventions (n = 19) or to a 'services as usual' control group (n = 18). Baseline, immediate post-intervention and 6-month follow-ups were assessed by questionnaires and adopter interviews. Economic costs were calculated.

RESULTS

  At 6-month follow-up, a significant difference (p < .007) was found for 'satisfaction with parenting' in favour of the intervention group. No significant differences were found on child measures between the combined intervention groups and control group, adjusting for baseline scores. The mean costs for the combined intervention group were £1528 higher than for the control group at the post-intervention point, which was statistically significant (95% CI, £67 to £2782). However, over the entire follow-up period the difference (£1652) was not statistically significant (-£1709 to £4268). The cost-effectiveness analysis showed that costs of £731 would be incurred to achieve a point improvement in satisfaction with parenting compared to routine care by the end of treatment, whilst the figure was £337 for a point improvement by the 6-month follow-up.

CONCLUSIONS

  Findings suggest that a home-based parenting programme for adopters caring for difficult children in the first 18 months of placement may be cost-effective in enhancing satisfaction with parenting, but not in reducing child behavioural problems, compared with 'services-as-usual'.

Residential Childcare Workers' Knowledge of Reactive Attachment Disorder

BACKGROUND

  Reactive Attachment Disorder (RAD) is associated with a history of 'pathogenic care' therefore residential childcare workers are likely to come into contact with children with this disorder. An 'appropriately supportive environment' may be a mitigating factor in terms of the disorder's severity and duration (Corbin, 2007); therefore it is important that behaviours suggestive of RAD are recognised early and that these children are given the attention they require in the care setting. We aimed to gain an understanding of residential childcare workers' knowledge of RAD to determine if their understanding of RAD was sufficient to recognise RAD-like behaviour.

METHOD

  A mixed methods study (qualitative focus groups and whole population survey) was undertaken with residential childcare workers.

RESULTS

  Liaison with Child and Adolescent Mental Health Services was seen by residential workers as being useful and workers thought their knowledge of mental health problems had improved in recent years. However, less than half of respondents (49.1%) identified RAD from a case history given in the questionnaire.

CONCLUSIONS

  Child and Adolescent Mental Health Services staff and residential workers may need more specialised training on RAD to be able to recognise behaviours suggestive of the disorder and refer appropriately, ensuring the child's needs are met as early as possible.

Rebuilding relationships: a pilot study of the effectiveness of the Mellow Parenting Programme for children with Reactive Attachment Disorder

Mellow Parenting is an intensive parenting programme which has been shown to be effective in improving the psychosocial functioning of very vulnerable babies and preschool children. We used a complex interventions model to evaluate its use with school-age children with Reactive Attachment Disorder (RAD), a serious disorder of social functioning associated with maltreatment. The programme had a positive effect on mothers' mental health, but had no measurable effects on symptoms of RAD or on parent-child interaction, although the variation between families after the group suggested that some had responded more than others. Mellow Parenting is an effective programme for vulnerable families with younger children and may be a useful adjunct in the treatment of school-age children with RAD, but it cannot be considered a definite treatment for RAD in this age group. The search continues for safe and effective treatments for RAD in school-age children.

Enhancing adoptive parenting: a randomized controlled trial

The aim was to conduct a pragmatic randomized controlled trial (RCT) to evaluate two parenting programmes designed for adopters of children late placed from care. Adoptive parents, with children between 3 and 8 years who were screened to have serious behavioural problems early in the placement, participated in home-based, manualized, parenting programmes delivered by trained and supervised family social workers. The adopters who agreed to join the study were randomly allocated to one of two parenting interventions or to a "services as usual" group. Baseline, immediate post-intervention and six-month follow-ups were assessed using questionnaires and adopter interviews. No cases were lost to follow-up at any point and satisfaction was high with both parenting interventions. At the six-month follow-up, a significant difference (p < 0.007) was found for "satisfaction with parenting" in favour of the intervention group (Effect Size d = 0.7). Negative parenting approaches were reduced in the intervention group. However, no significant differences in child problems were found between the intervention groups and control group, adjusting for baseline scores. Costs analysis showed that a relatively modest investment in post-adoption support would be well spent in improving adopters' satisfaction with parenting in the intervention group compared to the routine service group.

Mental health services for children in public care and other vulnerable groups: implications for international collaboration

Children in public care and other vulnerable young groups (homeless, adopted, refugees) are increasingly becoming the focus of policy and service planning. There is strong evidence that all these client populations have high rates of mental health problems which are closely associated with other needs. We also have good knowledge on the factors that predispose individuals to and maintain mental health problems, as well as on the reasons for their not easily accessing and engaging with services. There is less evidence on the effectiveness of interventions or service models, although some interesting patterns are beginning to emerge. These include the need for inter-agency commissioning, clear care pathways, designated provision, applied therapeutic interventions, training for carers and frontline practitioners, and multi modal programmes. This paper discusses these issues, as well as ways forward, both for systems with relatively well developed child mental health services and for low-income countries. Service quality can be greatly strengthened by international collaboration on policy, practice and research networks, training and research.

Early identification of mental health needs for children in care: a therapeutic assessment programme for statutory clients of child protection

Infants, children and young people enter out of home care in distressing circumstances. They have often suffered traumatic experiences and have had their primary relationships disrupted. They and their families and carers have specific mental health needs at this time but few have attended a mental health service. A systematic comprehensive therapeutic assessment approach is described for all child protection clients who entered out-of-home care for the first time in one calendar year. The work of the programme is described using both case study and assessment findings. More than 60 per cent of participants met criteria for a major psychiatric diagnosis, with Post Traumatic Stress and Adjustment Disorders being the most common diagnostic categories. Nearly three-quarters of participants over the age of 5 years scored in the borderline or abnormal range on the Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997). There was an over-representation of infants less than 1 year of age and adolescents in the cohort, representing particular developmental challenges. The findings are discussed within the context of specific mental health service delivery to this vulnerable population of maltreated infants, children and young people.

Cognitive-behavioural training interventions for assisting foster carers in the management of difficult behaviour

BACKGROUND

The provision of training for foster carers is now seen as an important factor contributing to the successful outcome of foster care placements. Since the late 1960s, foster carer training programs have proliferated, and few of the many published and unpublished training curricula have been systematically assessed and evaluated. The advent of cognitive-behavioural therapy (CBT) and the research evidence demonstrating its effectiveness as a psychotherapeutic treatment of choice, has prompted many working in the social care field to devise CBT-based training programmes. CBT approaches to foster care training derive from a 'skill-based' training format that also seeks to identify and correct problematic thinking patterns that are associated with dysfunctional behaviour by changing and/or challenging maladaptive thoughts and beliefs.

OBJECTIVES

To assess the effectiveness of cognitive-behavioural training interventions in improving a) looked-after children's behavioural/relationship problems, b) foster carers' psychological well-being and functioning, c) foster family functioning, d) foster agency outcomes.

SEARCH STRATEGY

We searched databases including: CENTRAL (Cochrane Library Issue 3, 2006), MEDLINE (January 1966 to September 2006), EMBASE (January 1980 to April 2004), CINAHL (January 1982 to April 2004), PsycINFO (January 1872 to April 2004), ASSIA (January 1987 to April 2004), LILACS (up to April 2004), ERIC (January 1965 to April 2004), Sociological Abstracts (January 1963 to April 2004), and the National Research Register 2004 (Issue 3). We contacted experts in the field concerning current research.

SELECTION CRITERIA

All studies in which participants were foster parents/carers, and who were allocated by random or quasi-random methods to a CBT-based training intervention (in a group and/or one-to-one settings) versus a no-treatment or wait-list control, were selected.

DATA COLLECTION AND ANALYSIS

Data from the six eligible trials (total n = 463 ) were extracted and entered into RevMan. Results were synthesised and presented in both graphical (forest plots) and narrative form (where insufficient data were provided for effect size computations).

MAIN RESULTS

Training interventions evaluated to date appear to have very little effect on outcomes relating to looked-after children, assessed in relation to psychological functioning, extent of behavioural problems and interpersonal functioning. Results relating to foster carer(s) outcomes also show no evidence of effectiveness in measures of behavioural management skills, attitudes and psychological functioning. Analysis pertaining to fostering agency outcomes did not show any significant results.

AUTHORS' CONCLUSIONS

There is currently little evidence about the efficacy of CBT-based training intervention for foster carers. The need for further research in this area is highlighted.

Reactive attachment disorder--a theoretical model beyond attachment

Despite its importance in public health, reactive attachment disorder (RAD) is an under-researched and little used clinical category. Abnormalities of social relatedness have long been documented in children who have been abused, neglected or institutionalised, but there have been more recent efforts to define these behaviours within the psychiatric nosology. There has been an implicit assumption that the central deficit in RAD is in the attachment system, but this has caused controversy and may have blocked research. We propose that RAD is better construed within the framework of intersubjectivity, which has a central role in the development of core brain and social functions and may also have had an important role in the evolution of a key human characteristic-complex social functioning. This broader framework may potentially explain apparently diverse symptoms such as indiscriminate friendliness and negative or unpredictable reunion responses. Finally, we suggest that a change of name may be useful in progressing the field, but accept that this may be difficult until there is better agreement in the clinical and scientific communities about the core features and aetiology of this disorder.

Children in foster care: mental health, service use and costs

OBJECTIVE

To assess the prevalence of mental health problems in children in foster care, their families' use of services and the associated costs.

METHODS

Information on mental health problems, service use and costs was collected, by postal questionnaires and home interviews, on 182 children, their foster carers and teachers from 17 local authorities in Central Scotland.

RESULTS

Over 90% of the children had previously been abused or neglected and 60 % had evidence of mental health problems including conduct problems, emotional problems, hyperactivity and problems with peer relations. When compared with 251 children from local schools, the children in foster care had significantly higher symptom scores for Reactive Attachment Disorder. Those children with highest scores for mental health problems were attracting a high level of service support from a wide range of agencies, except Child and Adolescent Mental Health Services (CAMHS). Costs were associated with learning disability, mental health problems, and a history of residential care.

CONCLUSIONS

Children in "mainstream" foster care are at greater risk of mental health problems, and are attracting greatest costs, but CAMHS are not successfully targeting these problems. CAMHS may need to develop new models of service delivery.

A promising parenting intervention in foster care

The purpose of this study was to evaluate the effectiveness of a 2-component intervention for biological and foster parent (pairs) to improve parenting practices, co-parenting, and child externalizing problems. Participants were biological and foster parents (N=128) of primarily neglected children (ages 3 to 10 years) placed in regular foster homes. Biological and foster parents were randomly assigned in pairs to the intervention (n=80) or a usual care (n=48) condition. Intervention families received a 12-week parenting course (Incredible Years) and a newly developed co-parenting component. Key findings included significant gains in positive parenting and collaborative co-parenting for both biological and foster parents at the end of the intervention. At follow-up, intervention parents sustained greater improvement in positive parenting, showed gains in clear expectations, and reported a trend for fewer child externalizing problems. Findings supported the feasibility of offering joint parenting training to meet the needs of participating families and demonstrated that the co-parenting construct applied to families in the foster care system was amenable to intervention.

The Computerized MacArthur Story Stem Battery--a pilot study of a novel medium for assessing children's representations of relationships

Story stem measures allow the assessment of children's representations of relationship functioning, but are expensive and time-consuming to administer. We developed a computerized story stem measure which does not require specific training for administrators and which allows the child to produce their own animated, narrated story completion. This paper describes, firstly, the reliability of the Computerized MacArthur Story Stem Battery (CMSSB) and, secondly, a preliminary comparison of children in foster care and school controls on narrative coherence, intentionality and avoidance. The CMSSB showed good inter-rater reliability. A group of children in foster care showed significantly poorer coherence of narrative, less intentionality and greater avoidance on the CMSSB compared to a school comparison group.

Cognitive-behavioural training interventions for assisting foster carers in the management of difficult behaviour

BACKGROUND

The provision of training for foster carers is now seen as an important factor contributing to the successful outcome of foster care placements. It is believed to be associated with enhancing caring attitudes and skills, reducing behaviour problems in foster children, improving relationships between foster carers and child welfare agencies, and decreasing foster carer attrition. Since the late 1960s, foster carer training programs have proliferated, and few of the many published and unpublished training curricula have been systematically assessed and evaluated. The advent of cognitive-behavioural therapy (CBT) and the research evidence demonstrating its effectiveness as a psychotherapeutic treatment of choice, has prompted many working in the social care field to devise CBT-based training programmes. CBT approaches to foster care training derive from a 'skill-based' training format that also seeks to identify and correct problematic thinking patterns that are associated with dysfunctional behaviour by changing and/or challenging maladaptive thoughts and beliefs.

OBJECTIVES

To assess the effectiveness of cognitive-behavioural training interventions in improving a) looked-after children's behavioural/relationship problems, b) foster carers' psychological well-being and functioning, c) foster family functioning, d) foster agency outcomes.

SEARCH STRATEGY

We searched databases including: CENTRAL (Cochrane Library Issue 2, 2004), MEDLINE (January 1966 to April 2004), EMBASE (January 1980 to April 2004), CINAHL (January 1982 to April 2004), PsycINFO (January 1872 to April 2004), ASSIA (January 1987 to April 2004), LILACS (up to April 2004), ERIC (January 1965 to April 2004), Sociological Abstracts (January 1963 to April 2004), and the National Research Register 2004 (Issue 1). We contacted experts in the field concerning current research.

SELECTION CRITERIA

All studies in which participants were foster parents/carers, and who were allocated by random or quasi-random methods to a CBT-based training intervention (in a group and/or one-to-one settings) versus a no-treatment or wait-list control, were selected.

DATA COLLECTION AND ANALYSIS

Results from the five eligible trials (total n = 443 ) are reported narratively. Due to the diversity of measures employed, no meta-analysis was performed.

MAIN RESULTS

Training interventions evaluated to date appear to have very little effect on outcomes relating to looked-after children, assessed in relation to psychological functioning, extent of behavioural problems and interpersonal functioning. Results relating to foster carer(s) outcomes indicate some improvements in measures of behavioural management skills, attitudes and psychological functioning. Analysis pertaining to fostering agency outcomes did not show any significant results.

AUTHORS' CONCLUSIONS

Inconclusive evidence exists about the efficacy of CBT-based training intervention for foster carers. The need for further research in this area is highlighted.

[Children and adolescents in foster care: health problems and guidelines for their health care]

In Spain, between 8,000 and 10,000 children and adolescents enter foster or residential care every year. This article aims to provide a review to increase knowledge of the health problems of minors in foster care.Sixty-five percent of the studies consulted were performed in the USA, 25 % in Spain and 10 % in other developed and industrialized countries. These studies report that a high percentage of these minors present complicated and serious physical, mental, and/or developmental problems. However, no appreciable qualitative differences in the most frequent health problems presented by these minors have been observed and there is general consensus that the high-priority health needs are the provision of preventive and/or therapeutic psychopedagogic, psychiatric, dermatologic, dental, nutritional, ophthalmologic, respiratory and immunization services. Failure to identify and provide early treatment of the health needs of these minors not only adversely affects their quality of life and future physical, emotional and intellectual development, but can also increase their difficulties in adaptation while in foster care and their future social adaptation. Their permanent relationship with the biological or adoptive family when foster care stops could also be jeopardized. Therefore, all children and adolescents in foster care should receive initial health screenings, comprehensive assessments and monitoring of their physical, mental health, and developmental status. We provide guidelines for the healthcare of these minors, which should be of use to healthcare professionals taking care of these children and adolescents while they remain in foster care.

Development of a brief, clinically relevant, scale for measuring attachment disorders

A 17-item questionnaire for reactive attachment disorders (RAD) was developed and administered to 182 Scottish children living in foster care. The RAD questionnaire had a good test-retest reliability with an intra-class correlation (ICC) of 0.78 and inter-rater reliability with an ICC of 0.81. Cluster analysis showed that the children fell into three groups, two of which corresponded to the two reactive attachment disorder subtypes. High questionnaire scores for attachment disorders were significantly associated with conduct problems, emotional problems, hyperactivity and problems with peer relations and negatively associated with pro-social behaviour. High overall questionnaire scores for reactive attachment disorder were associated with previous sexual abuse, whereas there was no association with previous physical abuse. High scores for the disinhibited subtype were associated with previous neglect.