A Randomized Evaluation of Multidimensional Treatment Foster Care: Effects on School Attendance and Homework Completion in Juvenile Justice Girls

Applying ecological systems theory to juvenile legal system interventions outcomes research: a measurement framework

Intervention research and development for youth in the juvenile legal system (JLS) has often focused on recidivism as the primary outcome of interest. Although recidivism is an important outcome, it is ultimately a downstream marker of success and is affected by changes in other domains of youths' lives (e.g., family and peer relations, neighborhood safety, local and state-level policies). Thus, the present manuscript proposes the application of ecological systems theory to selecting outcomes to assess intervention effects in JLS intervention research to better capture proximal and distal influences on youth behavior. To that end, we first provide an overview of the strengths and limitations of using recidivism as an outcome measure. Next, the current application of social ecology theory to existing research on both risk and protective factors of JLS involvement is discussed, as well as existing work on assessing social-ecological domains within intervention studies. Then, a measurement framework is introduced for selecting pertinent domains of youths' social ecologies to assess as intervention outcomes, moderators, and mediators. To facilitate this, we provide examples of concrete constructs and measures that researchers may select. We conclude with potential new avenues of research to which our proposed framework could lead, as well as potential limitations of implementing our framework.

Using economic evaluations in implementation science to increase transparency in costs and outcomes for organizational decision-makers

Background

Economic evaluations frequently are utilized to compare the value of different interventions in medicine and health in concrete terms. Implementation science also would benefit from the incorporation of economic evaluations, but such studies are rare in the literature. The National Cancer Institute has supported a special collection of articles focusing on economic evaluations in implementation science. Even when interventions are supported by substantial evidence, they are implemented infrequently in the field. Implementation costs are important determinants for whether organizational decision-makers choose to adopt an intervention and whether the implementation process is successful. Economic evaluations, such as cost-effectiveness analyses, can help organizational decision-makers choose between implementation approaches for evidence-based interventions by accounting for costs and succinctly presenting cost/benefit tradeoffs.

Main text

This manuscript presents a discussion of important considerations for incorporating economic evaluations into implementation science. First, the distinction between intervention and implementation costs is presented, along with an explanation of why the comprehensive representation of implementation costs is elusive. Then, the manuscript describes how economic evaluations in implementation science may differ from those in medicine and health intervention studies, especially in terms of determining the perspectives and outcomes of interest. Finally, referencing a scale-up trial of an evidence-based behavioral health intervention, concrete case examples of how cost data can be collected and used in economic evaluations targeting implementation, rather than clinical outcomes, are described.

Conclusions

By gaining a greater understanding of the costs and economic impact associated with different implementation approaches, organizational decision-makers will have better transparency for future replication and scale-up. The use of economic evaluations can help to advance this understanding and provide researchers, purveyors or third-party intermediaries, and organizational decision-makers with essential information to facilitate implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00295-1.

A Meta-Analysis of Program Characteristics for Youth with Disruptive Behavior Problems: The Moderating Role of Program Format and Youth Gender

There is high variability in efficacy for interventions for youth with disruptive behavior problems (DBP). Despite evidence of the unique correlates and critical consequences of girls' DBP, there is a dearth of research examining treatment efficacy for girls. This meta-analysis of 167 unique effect sizes from 29 studies (28,483 youth, 50% female; median age: 14) suggests that existing treatments have a medium positive effect on DBP (g = .33). For both boys and girls, the most effective interventions included (a) multimodal or group format, (b) cognitive skills or family systems interventions, and (c) length-intensive programs for (d) younger children. Boys demonstrated significantly greater treatment gains from group format interventions compared to girls, which is particularly important given that the group program format was the most prevalent format for boys and girls, with 14 studies involving 10,433 youth encompassing this category. This is the first meta-analysis to examine the effect of program characteristics in a sample of programs selected to be specifically inclusive of girls. Given that girls are underrepresented in intervention research on DBP, findings are discussed in terms of gender-responsive considerations and elucidating how key aspects of program structure can support more effective intervention outcomes for youth.

Overview of European forensic youth care: towards an integrative mission for prevention and intervention strategies for juvenile offenders

All over Europe youth delinquency is decreasing; our understanding of the factors related to juvenile delinquency and the characteristics of effective forensic youth care has increased substantially. However, effective prevention and intervention strategies are not always employed due to financial, demographical and socio-political challenges countries face, while the burden of mental health in juvenile justice populations is high. With this commentary, we highlight the importance of international collaboration to set out a direction to improve forensic youth care, to bundle our strengths and overcome our challenges. It is a continuation of the course that was set out by Doreleijers and Fegert (Child Adolesc Psychiatry Ment Health 5:20, 2011), in their editorial they highlighted the importance of collaboration and presented an overview of the state of the art on forensic youth care in eight European countries (and Russia). With this manuscript, we present an overview of statistics in juvenile justice of all European countries and present an integrated mission statement for forensic youth care, which was formulated in a keynote debate at the 6^th biennial congress of the European Association for Forensic Child and Adolescent Psychiatry, Psychology and other involved professions (EFCAP).

Long-Term Economic Benefit of Treatment Foster Care Oregon (TFCO) for Adolescent Females Referred to Congregate Care for Delinquency

Treatment Foster Care Oregon (TFCO) is an alternative to congregate care, for youth involved in the juvenile justice and/or child welfare systems. Though demonstrated as clinically-and cost-effective across multiple rigorous trials, the long-term cost benefit of TFCO has not been considered. This study follows n = 166 females from adolescence to young adulthood, who were involved in both systems and referred for out-of-home-care. Records of arrest, court, incarceration (juvenile, jail, and prison), monitoring (parole and probation) and child-welfare services were included in a long-term cost-benefit analysis. Outcomes highlight ongoing benefit of the TFCO intervention, nearly 10 years post-intervention.

Economic Impact of the Statewide Implementation of an Evidence-Based Treatment: Multisystemic Therapy in New Mexico

Several states have made considerable investments into large-scale implementation of evidence-based treatments (EBTs), yet little is known about key success indicators for these implementation efforts such as cost and sustainability. To that end, the present study examined the economic impact of statewide implementation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cuningham, 2009), a family- and community-based behavioral EBT for serious juvenile offenders in New Mexico. Participants were 1,869 youth who received MST across 23 teams during the study period. We conducted a cost-benefit analysis using metrics from state data sources that compared the cost of MST to its benefits (i.e., avoided expenses from pre- to posttreatment) in two domains: (a) behavioral health services (i.e., Medicaid claims) and (b) juvenile crime (i.e., taxpayer expenses, tangible and intangible expenses to crime victims). MST costs were based on Medicaid claims, which were reimbursed at an enhanced billing rate that was intended to cover expenses for both clinical and implementation (e.g., training, quality assurance) activities. Results suggest that implementation of MST in New Mexico over the 7-year study period may have produced net benefits, through 2 years posttreatment, of more than $4,643 per youth in avoided behavioral health claims and $15,019 per youth through reductions in juvenile crime. Stated differently, every dollar that New Mexico spent on MST appeared to have returned $3.34 for a total benefit of $64.2 million over the course of the study. We discuss implications of these findings for policymakers, administrators, and researchers who are interested in increasing the sustainability of complex EBTs in community settings.

Systematic review of educational interventions for looked-after children and young people: Recommendations for intervention development and evaluation

Looked-after children and young people (LACYP) are educationally disadvantaged compared to the general population. A systematic review was conducted of randomised controlled trials evaluating interventions aimed at LACYP aged ≤18 years. Restrictions were not placed on delivery setting or delivery agent. Intervention outcomes were: academic skills; academic achievement and grade completion; special education status; homework completion; school attendance, suspension, and drop-out; number of school placements; teacher-student relationships; school behaviour; and academic attitudes. Fifteen studies reporting on 12 interventions met the inclusion criteria. Nine interventions demonstrated tentative impacts. However, evidence of effectiveness could not be ascertained due to variable methodological quality, as appraised by the Cochrane risk of bias tool. Theoretical and methodological recommendations are provided to enhance the development and evaluation of educational interventions.

Predicting the transition from juvenile delinquency to adult criminality: Gender-specific influences in two high-risk samples

BACKGROUND

Most juvenile offenders desist from offending as they become adults, but many continue and ultimately enter the adult corrections system. There has been little prospective examination of which variables may predict the latter transition, particularly for women.

AIMS

Our aim was to find out, for men and women separately, what variables identifiable in adolescent offenders predict their continuation of offending into adult life.

METHODS

Participants were 61 male and 81 female youths who had been referred from the juvenile justice system for chronic delinquency and recruited into randomised controlled trials comparing Multidimensional Treatment Foster Care with group care ('treatment as usual'). All participants had attained adulthood by the time of our study. We first examined gender differences in childhood risk factors and then used Cox proportional-hazards models to estimate the relationship of potential risk factors to first adult arrest.

RESULTS

Results indicated that, for men, juvenile justice referrals alone predicted risk of any first adult arrest as well as arrest for felony arrest specifically. Each additional juvenile referral increased the risk of any adult arrest by 9% and of adult felony arrest by 8%. For women, family violence, parental divorce and cumulative childhood risk factors, but not juvenile justice referrals, were significant predictors of adult arrest. Each additional childhood risk factor increased the risk of adult arrest by 21%. Women who experienced parental divorce were nearly three times more likely to be arrested as an adult, and those who experienced family violence 2.5 times more so than those without such experiences.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

We found preliminary evidence of gender differences in childhood risk factors for adult offending, and, thus potentially, for the development and use of interventions tailored differently for girls and boys and young men and young women to reduce their risk of becoming adult recidivists. Copyright © 2015 John Wiley & Sons, Ltd.

The Oregon Model of Behavior Family Therapy: From Intervention Design to Promoting Large-Scale System Change

This paper reviews the evolution of the Oregon model of family behavior therapy over the past four decades. Inspired by basic research on family interaction and innovation in behavior change theory, a set of intervention strategies were developed that were effective for reducing multiple forms of problem behavior in children (e.g., Patterson, Chamberlain, & Reid, 1982). Over the ensuing decades, the behavior family therapy principles were applied and adapted to promote children's adjustment to address family formation and adaptation (Family Check-Up model), family disruption and maladaptation (Parent Management Training-Oregon model), and family attenuation and dissolution (Treatment Foster Care-Oregon model). We provide a brief overview of each intervention model and summarize randomized trials of intervention effectiveness. We review evidence on the viability of effective implementation, as well as barriers and solutions to adopting these evidence-based practices. We conclude by proposing an integrated family support system for the three models applied to the goal of reducing the prevalence of severe problem behavior, addiction, and mental problems for children and families, as well as reducing the need for costly and largely ineffective residential placements.

An evaluation of Neuro-Physiological Psychotherapy: An integrative therapeutic approach to working with adopted children who have experienced early life trauma

Research into the effectiveness of therapeutic interventions for older children who have experienced multiple forms of trauma within the context of their early development is scant. This article explores the effectiveness of Neuro-Physiological Psychotherapy (NPP): a wrap-around multi-disciplinary, neuro-sequential, attachment-focussed intervention for children and families who present with multiple, clinically significant, emotional and behavioural difficulties. In total, 31 young people and their adoptive parents took part in the study. Baseline measures were repeated and parents and children interviewed. An assessment of the parent/child relationship and child attachment was undertaken but not analysed for this article. Analysis of the repeated measures received statistically significant changes in behavioural regulation, metacognitive executive functioning and externalising and internalising difficulties, alongside an improvement in thought and social problems. An analysis of the parent interviews provided positive results in terms of the children's engagement in education, an absence of further mental health diagnosis or involvement in the criminal justice system. Further hypotheses are posited regarding the impact of the treatment and further research into the effectiveness of the model outlined.

Evidence-Based Psychosocial Treatments for Adolescents With Disruptive Behavior

This article updates the earlier reviews of evidence-based psychosocial treatments for disruptive behavior in adolescents (Brestan & Eyberg, 1998; Eyberg, Nelson, & Boggs, 2008), focusing primarily on the treatment literature published from 2007 to 2014. Studies were identified through an extensive literature search and evaluated using Journal of Clinical Child and Adolescent Psychology (JCCAP) level of support criteria, which classify studies as well-established, probably efficacious, possibly efficacious, experimental, or of questionable efficacy based on existing evidence. The JCCAP criteria have undergone modest changes in recent years. Thus, in addition to evaluating new studies from 2007 to 2014 for this update, all adolescent-focused articles that had been included in the 1998 and 2008 reviews were reexamined. In total, 86 empirical papers published over a 48-year period and covering 50 unique treatment protocols were identified and coded. Two multicomponent treatments that integrate strategies from family, behavioral, and cognitive-behavioral therapy met criteria as well-established. Summaries are provided for those treatments, as well as for two additional multicomponent treatments and two cognitive-behavioral treatments that met criteria as probably efficacious. Treatments designated as possibly efficacious, experimental, or of questionable efficacy are listed. In addition, moderator/mediator research is summarized. Results indicate that since the prior reviews, there has been a noteworthy expansion of research on treatments for adolescent disruptive behavior, particularly treatments that are multicomponent in nature. Despite these advances, more research is needed to address key gaps in the field. Implications of the findings for future science and clinical practice are discussed.

Characterizing implementation strategies using a systems engineering survey and interview tool: a comparison across 10 prevention programs for drug abuse and HIV sexual risk behavior

Background

Although many behavioral interventions have proven to be efficacious, new methodologies are required beyond efficacy trials to understand how to adopt, implement with fidelity, and sustain behavioral interventions in community settings. In this paper, we present a new approach, based on systems engineering concepts and methods, for characterizing implementation strategies that are used to deliver evidence-based behavioral interventions in health and social service settings. We demonstrate the use of this approach with implementation strategies, used or being used for broader dissemination of 10 evidence-based prevention program projects focused on the prevention of drug or HIV sex risk behaviors.

Results

The results indicate that there are wide variations in intervention approaches and that there are challenges in program implementation including maintaining program fidelity, serving community needs, and adequate resources. The results also indicate that implementation requires a committed partnership between the program developers, implementation researchers, and community partners. In addition, there is a need for adaptability within programs to meet community needs, resources, and priorities while maintaining program fidelity.

Conclusions

Our methodological approach enabled us to highlight challenges associated with the community implementation of health risk prevention interventions. We also demonstrate how comprehensive descriptions of interventions facilitate understanding of the requirements of program implementation and decisions about the feasibility of implementing a program in community settings.

Stakeholders' Voices: Defining Needs of Students with Emotional and Behavioral Disorders Transitioning between School Settings

Students with emotional and behavioral disorders (EBD) too often do not receive adequate services or care in their school settings, particularly during transitions in educational placements. In addition, school support teams often struggle with creating transition plans that honor the needs of students with input from key stakeholders responsible for supporting student success. This article presents findings from the information-gathering phase of an iterative project that aims to develop a support program for students with EBD transitioning from day-treatment schools to district schools. We conducted 5 semistructured, qualitative focus groups with parents and teachers to explore needs during students' transitions between school settings. Five themes emerged from the focus groups: (a) consistent, behavior-specific feedback and positive reinforcement are vital to sustaining learned prosocial skills; (b) students benefit from regular opportunities to learn and practice social skills; (c) transition programming should emphasize communication between school and home; (d) routines at home and school should be coordinated; and (e) parents need support at school meetings. We will use findings from this study to develop a multifaceted intervention that aims to support students, their caregivers, and their teachers during transitions between the aforementioned types of schools.

Mental Illness and Juvenile Offenders

Within the past decade, reliance on the juvenile justice system to meet the needs of juvenile offenders with mental health concerns has increased. Due to this tendency, research has been conducted on the effectiveness of various intervention and treatment programs/approaches with varied success. Recent literature suggests that because of interrelated problems involved for youth in the juvenile justice system with mental health issues, a dynamic system of care that extends beyond mere treatment within the juvenile justice system is the most promising. The authors provide a brief overview of the extent to which delinquency and mental illness co-occur; why treatment for these individuals requires a system of care; intervention models; and the juvenile justice systems role in providing mental health services to delinquent youth. Current and future advancements and implications for practitioners are provided.

Risks, Outcomes, and Evidence-Based Interventions for Girls in the US Juvenile Justice System

The proportion of the juvenile justice population that comprises females is increasing, yet few evidence-based models have been evaluated and implemented with girls in the juvenile justice system. Although much is known about the risk and protective factors for girls who participate in serious delinquency, significant gaps in the research base hamper the development and implementation of theoretically based intervention approaches. In this review, we first summarize the extant empirical work about the predictors and sequelae of juvenile justice involvement for girls. Identified risk and protective factors that correspond to girls' involvement in the juvenile justice system have been shown to largely parallel those of boys, although exposure rates and magnitudes of association sometimes differ by sex. Second, we summarize findings from empirically validated, evidence-based interventions for juvenile justice-involved youths that have been tested with girls. The interventions include Functional Family Therapy, Multisystemic Therapy, Multidimensional Family Therapy, and Treatment Foster Care Oregon (formerly known as Multidimensional Treatment Foster Care). We conclude that existing evidence-based practices appear to be effective for girls. However, few studies have been sufficiently designed to permit conclusions about whether sex-specific interventions would yield any better outcomes for girls than would interventions that already exist for both sexes and that have a strong base of evidence to support them. Third, we propose recommendations for feasible, cost-efficient next steps to advance the research and intervention agendas for this under-researched and underserved population of highly vulnerable youths.

Suicidal Behavior Outcomes of Childhood Sexual Abuse: Longitudinal Study of Adjudicated Girls

Childhood sexual abuse (CSA) histories are prevalent among adolescent girls in the juvenile justice system (JJS) and may contribute to their high rates of suicidal behavior. Among 166 JJS girls who participated in an intervention trial, baseline CSA and covariates were examined as predictors of suicide attempt and nonsuicidal self-injury (NSSI) reported at long-term follow-up (7-12 years later). Early forced CSA was related to lifetime suicide attempt and NSSI history and (marginally) to postbaseline attempt; effects were not mediated by anxiety or depressive symptoms. Findings suggest that earlier victimization and younger entry into JJS are linked with suicide attempt and NSSI.

An Integrated Intervention to Address the Comorbid Needs of Families Referred to Child Welfare for Substance Use Disorders and Child Neglect: FAIR Pilot Outcomes

Despite repeated calls for evidence-based practice to address the co-occurring needs of families referred to the child welfare system for parental substance use disorders and child neglect, limited attention has been given to the rigorous evaluation of such interventions. This paper describes the initial testing of an intervention developed to meet the complex needs of such families. The Families Actively Improving Relationships (FAIR) program and preliminary outcomes are described. The need for integrated interventions is highlighted.

Maternal caregiving and girls' depressive symptom and antisocial behavior trajectories: an examination among high-risk youth

Past research has identified maternal depression and family of origin maltreatment as precursors to adolescent depression and antisocial behavior. Caregiving experiences have been identified as a factor that may ameliorate or accentuate adolescent psychopathology trajectories. Using a multilevel approach that pools the unique attributes of two geographically diverse, yet complementary, longitudinal research designs, the present study examined the role of maternal caregiver involvement as a factor that promotes resilience-based trajectories related to depressive symptoms and antisocial behaviors among adolescent girls. The first sample comprises a group of US-based adolescent girls in foster care (n = 100; mean age = 11.50 years), each of whom had a history of childhood maltreatment and removal from their biological parent(s). The second sample comprises a group of UK-based adolescent girls at high familial risk for depression (n = 145; mean age = 11.70 years), with all girls having biological mothers who experienced recurrent depression. Analyses examined the role of maternal caregiving on girls' trajectories of depression and antisocial behavior, while controlling for levels of co-occurring psychopathology at each time point. Results suggest increasing levels of depressive symptoms for girls at familial risk for depression but decreasing levels of depression for girls in foster care. Foster girls' antisocial behavior also decreased over time. Maternal caregiver involvement was differentially related to intercept and slope parameters in both samples. Results are discussed with respect to the benefits of applying multilevel (multisample, multiple outcome) approaches to identifying family-level factors that can reduce negative developmental outcomes in high-risk youth.

Juvenile justice girls' depressive symptoms and suicidal ideation 9 years after Multidimensional Treatment Foster Care

OBJECTIVE

Multidimensional Treatment Foster Care (MTFC) has been found to reduce delinquency among girls in juvenile justice through 2-year follow-up. Given that such girls are at elevated risk for suicide and depression into adulthood, we tested MTFC effects on long-term trajectories of suicidal ideation and depressive symptoms.

METHOD

Girls (N = 166; mean [SD] age = 15.3 [1.2] years; 68% White) with a recent criminal referral who were mandated to out-of-home care were enrolled in 2 sequential cohorts. Girls were randomized to receive MTFC (n = 81) or group care (GC) treatment as usual (TAU; n = 85); the second MTFC cohort also received modules targeting substance use and risky sexual behavior. Depressive symptoms and suicidal ideation were assessed repeatedly through early adulthood (mean [SD] follow-up = 8.8 [2.9] years). Suicide attempt history was assessed in early adulthood.

RESULTS

Girls assigned to MTFC showed significantly greater decreases in depressive symptoms across the long-term follow-up than GC girls (π = -.86, p < .05). Decreases in suicidal ideation rates were slightly stronger in MTFC than in GC as indicated by a marginal main effect (odds ratio [OR] = .92, p < .10) and a significant interaction that favored MTFC in the second cohort relative to the first (OR = .88, p < .01). There were no significant MTFC effects on suicide attempt.

CONCLUSIONS

MTFC decreased depressive symptoms and suicidal thinking beyond the decreases attributable to time and TAU. Thus, MTFC has further impact on girls' lives than originally anticipated.

Drug Use Trajectories After a Randomized Controlled Trial of MTFC: Associations with Partner Drug Use

Trajectories of drug use were examined in a sample of women with prior juvenile-justice system involvement. One hundred fifty-three young women who participated in a randomized controlled trial of Multidimensional Treatment Foster Care (MTFC) in adolescence were assessed on five occasions over a 24-month period in young adulthood (mean age = 22.29 years at T1). Participants assigned to the MTFC condition during adolescence reported greater decreases in drug use than girls assigned to the treatment as usual (TAU) condition. Partner drug use was significantly associated with women's concurrent drug use, although participants in the MTFC condition were more resilient to partner drug use than in the TAU condition. Implications for drug use prevention and intervention programs during adolescence are discussed.

Intervention Effects on Health-Risking Sexual Behavior Among Girls in Foster Care: The Role of Placement Disruption and Tobacco and Marijuana Use

The present study examined the effects of the Middle School Success intervention (MSS), a program to promote healthy adjustment in foster girls, on their health-risking sexual behavior, using a randomized controlled trial (RCT) design. As hypothesized, girls in the intervention condition (n = 48) showed significantly lower levels of health-risking sexual behavior than did girls in the control condition (n = 52) at 36 months postbaseline. Further path analysis indicated that this intervention effect was fully mediated through its effects on girls' tobacco and marijuana use. Findings highlight the importance of providing preventive intervention services to foster girls during early adolescence.

Depressive symptom trajectories among girls in the juvenile justice system: 24-month outcomes of an RCT of Multidimensional Treatment Foster Care

Youth depression is a significant and growing international public health problem. Youth who engage in high levels of delinquency are at particularly high risk for developing problems with depression. The present study examined the impact of a behavioral intervention designed to reduce delinquency (Multidimensional Treatment Foster Care; MTFC) compared to a group care intervention (GC; i.e., services as usual) on trajectories of depressive symptoms among adolescent girls in the juvenile justice system. MTFC has documented effects on preventing girls' recidivism, but its effects on preventing the normative rise in girls' depressive symptoms across adolescence have not been examined. This indicated prevention sample included 166 girls (13-17 years at T1) who had at least one criminal referral in the past 12 months and who were mandated to out-of-home care; girls were randomized to MTFC or GC. Intent-to-treat analyses examined the main effects of MTFC on depression symptoms and clinical cut-offs, and whether benefits were greatest for girls most at risk. Depressive symptom trajectories were specified in hierarchical linear growth models over a 2 year period using five waves of data at 6 month intervals. Depression clinical cut-off scores were specified as nonlinear probability growth models. Results showed significantly greater rates of deceleration for girls in MTFC versus GC for depressive symptoms and for clinical cut-off scores. The MTFC intervention also showed greater benefits for girls with higher levels of initial depressive symptoms. Possible mechanisms of effect are discussed, given MTFC's effectiveness on targeted and nontargeted outcomes.

Performance of evidence-based youth psychotherapies compared with usual clinical care: a multilevel meta-analysis

IMPORTANCE

Research across more than 4 decades has produced numerous empirically tested evidence-based psychotherapies (EBPs) for psychopathology in children and adolescents. The EBPs were developed to improve on usual clinical interventions. Advocates argue that the EBPs should replace usual care, but this assumes that EBPs produce better outcomes than usual care.

OBJECTIVE

To determine whether EBPs do in fact produce better outcomes than usual care in youth psychotherapy. We performed a meta-analysis of 52 randomized trials directly comparing EBPs with usual care. Analyses assessed the overall effect of EBPs vs usual care and candidate moderators; we used multilevel analysis to address the dependency among effect sizes (ES) that is common but typically unaddressed in psychotherapy syntheses.

DATA SOURCES

We searched the PubMed, PsychINFO, and Dissertation Abstracts International databases for studies from January 1, 1960, through December 31, 2010.

STUDY SELECTION

We identified 507 randomized youth psychotherapy trials. Of these, the 52 studies that compared EBPs with usual care were included in the meta-analysis.

DATA EXTRACTION AND SYNTHESIS

Sixteen variables (participant, treatment, outcome, and study characteristics) were extracted from studies, and ESs were calculated for all comparisons of EBP vs usual care. We used an extension of the commonly used random-effects meta-analytic model to obtain an overall estimate of the difference between EBP and usual care while accounting for the dependency among ESs. We then fitted a 3-level mixed-effects model to identify moderators that might explain variation in ESs within and between studies by adding study or ES characteristics as fixed predictors.

MAIN OUTCOMES AND MEASURES

Primary outcomes of our meta-analysis were mean ES estimates across all studies and for levels of candidate moderators. These ES values were based on measures of symptoms, functioning, and other outcomes assessed within the 52 randomized trials.

RESULTS

Evidence-based psychotherapies outperformed usual care. Mean ES was 0.29; the probability was 58% that a randomly selected youth would have a better outcome after EBP than a randomly selected youth after receiving usual care. The following 3 variables moderated treatment benefit: ESs decreased for studies conducted outside North America, for studies in which all participants were impaired enough to qualify for diagnoses, and for outcomes reported by informants other than the youths and parents in therapy. For certain key groups (eg, studies of clinically referred samples and youths with diagnoses), significant EBP effects were not demonstrated.

CONCLUSIONS AND RELEVANCE

Evidence-based psychotherapies outperform usual care, but the EBP advantage is modest and moderated by youth, location, and assessment characteristics. The EBPs have room for improvement in the magnitude and range of their benefit relative to usual clinical care.

Predicting program start-up using the stages of implementation measure

Recent efforts to better understand the process of implementation have been hampered by a lack of tools available to define and measure implementation progress. The Stages of Implementation Completion (SIC) was developed as part of an implementation trial of MTFC in 53 sites, and identifies the duration of time spent on implementation activities and the proportion of activities completed. This article examines the ability of the first three stages of the SIC (Engagement, Consideration of Feasibility, Readiness Planning) to predict successful program start-up. Results suggest that completing SIC stages completely, yet relatively quickly, predicts the likelihood of successful implementation.

Examining the equivalence of fidelity over two generations of KEEP implementation: A preliminary analysis

PROBLEM

In order to obtain and maintain positive outcomes garnered from evidence-based practice (EBP) models, it is necessary to implement them effectively in "real world" settings, to continually monitor intervention fidelity to prevent drift, and to train new staff due to turnover. The fidelity monitoring processes that are commonly employed in research settings are labor intensive and probably unrealistic to employ in community agencies given the additional burden and cost that they represent over and above the cost of implementing the EBP. Efficient strategies for implementing fidelity monitoring and staff training procedures within the inner context of agency settings are needed to promote agency self-sufficiency and program sustainability.

METHOD

A cascading implementation model was used whereby agencies who achieved proficiency in KEEP, an EBP designed to prevent placement disruptions in foster and kinship child welfare homes, were trained to take on fidelity management roles to improve the likelihood of program sustainability. Agency staff were trained to self-monitor fidelity and to train internal staff to achieve model fidelity. A web-based system for conducting fidelity assessments and for onsite/internal and remote program quality monitoring was utilized.

RESULTS

Scores on fidelity ratings from streamed observations of intervention sessions showed no differences for foster parents treated by first generation interventionists trained by model developers compared to a second generation of interventionists trained by the first generation.

CONCLUSION AND RELEVANCE TO CHILD WELFARE

Development of the local intra-agency capacity to manage quality intervention delivery is an important feature of successful EBP implementation. Use of the cascading implementation model appears to support the development of methods for effective monitoring of fidelity of the KEEP intervention, for training new staff, and ultimately for the development of internal methods for maintaining program sustainability and effectiveness.

Ten ways to improve the use of statistical mediation analysis in the practice of child and adolescent treatment research

Despite guidelines and repeated calls from the literature, statistical mediation analysis in youth treatment outcome research is rare. Even more concerning is that many studies that have reported mediation analyses do not fulfill basic requirements for mediation analysis, providing inconclusive data and clinical implications. As a result, after more than five decades of research, it is still largely unknown through which processes youth treatment works and what the effective treatment components are. In this article, we present ten ways in which the use of statistical mediation analysis in youth treatment outcome research may be improved. These ten ways are related both to conceptual and methodological issues. In discussing how youth clinical researchers may optimally implement these directions, we argue that studies should employ the strongest research designs possible. In so doing, we describe different levels of a mediation evidence ladder. Studies on each step of the ladder contribute to an understanding of mediation processes, but the strongest evidence for mediation is provided by studies that can be classified at the highest level. With the help of the ladder of mediation evidence, results from youth mediation treatment outcome research can be evaluated on their scientific as well as clinical impact.

Multidimensional Treatment Foster Care: An Alternative to Residential Treatment for High Risk Children and Adolescents

This paper describes the Multidimensional Treatment Foster Care program (MTFC), an evidence based approach for providing psychotherapeutic treatment for very troubled children and adolescents that is an alternative to residential care. Versions of the MTFC program have been developed and validated for young children with a history of maltreatment as well as for older children and adolescents who are involved with the youth justice system. In the paper we describe the development of the MTFC program and its foundations in the social learning model that originated at the Oregon Social Learning Center in the 1960's and 70's. We present information about program elements. We then review the research that has been conducted on MTFC.

Affiliation with delinquent peers as a mediator of the effects of multidimensional treatment foster care for delinquent girls

OBJECTIVE

This study evaluated the ability of delinquent peer affiliation to mediate the effects of multidimensional treatment foster care (MTFC; Chamberlain, 2003) on girls' delinquent behavior.

METHOD

This study used a sample of girls from 2 cohorts (N = 166; M = 15.31 years old at baseline, range 13-17 years; 74% European American, 2% African American, 7% Hispanic, 4% Native American, 1% Asian, and 13% mixed ethnicity) and measures of delinquent behavior, including general delinquency, number of criminal referrals, and number of days in locked settings. As the mediator, we used self-reports of affiliation with delinquent peers. Our analytic plan specified an intent-to-treat analysis within the framework of a randomized controlled trial comparing MTFC with traditional community-based group care.

RESULTS

Random assignment to the MTFC program reduced girls' number of criminal referrals and number of days in locked settings at 24 months. The MTFC condition also reduced girls' exposure to delinquent peers at 12 months, which in turn reduced levels of all forms of delinquent behavior at 24 months; indirect effects were statistically significant.

CONCLUSIONS

Reduction in exposure to delinquent peers mediated MTFC effects on the number of criminal referrals and number of days in locked settings; delinquent peers also served as an intervening variable between MTFC and self-report delinquency, suggesting that, by reducing contact with delinquent peers, MTFC helped to encourage lower levels of self-report delinquency. Existing prevention and intervention programs targeting similar populations may benefit from increased attention to reductions in delinquent peer affiliation in female samples.

Research into Theory into Practice: An Overview of Family Based Interventions for Child Antisocial Behavior Developed at the Oregon Social Learning Center

Although many psychotherapeutic approaches exist for treating troubled children and their families, not all have been evaluated to be effective through research. Moreover, among those that have been determined to be "evidence-based," few have followed as coherent and rigorous a path of rigorous scientific investigation as the interventions that have been developed at the Oregon Social Learning Center. As such, these interventions serve as a model of "research to theory to practice" that may not only be employed to support families with children in need of treatment, but may also guide other programs of treatment development. This is the story of how this work has unfolded over the past four decades.

Empirically supported family-based treatments for conduct disorder and delinquency in adolescents

Several family-based treatments of conduct disorder and delinquency in adolescents have emerged as evidence-based and, in recent years, have been transported to more than 800 community practice settings. These models include multisystemic therapy, functional family therapy, multidimensional treatment foster care, and, to a lesser extent, brief strategic family therapy. In addition to summarizing the theoretical and clinical bases of these treatments, their results in efficacy and effectiveness trials are examined with particular emphasis on any demonstrated capacity to achieve favorable outcomes when implemented by real-world practitioners in community practice settings. Special attention is also devoted to research on purported mechanisms of change as well as the long-term sustainability of outcomes achieved by these treatment models. Importantly, we note that the developers of each of the models have developed quality assurance systems to support treatment fidelity and youth and family outcomes; and the developers have formed purveyor organizations to facilitate the large-scale transport of their respective treatments to community settings nationally and internationally.

Substance use and delinquency among middle school girls in foster care: a three-year follow-up of a randomized controlled trial

OBJECTIVE

The present study evaluated the efficacy of the Middle School Success intervention (MSS) for reducing substance use and delinquency among girls in foster care, using a randomized controlled trial design. The program was designed to fill a service gap during the summer prior to the middle school transition and to prevent delinquency, substance use, and related problems.

METHOD

One hundred girls in foster care and their caregivers were randomly assigned either to the intervention (n = 48) or to a regular foster care control (n = 52) condition. The girls completed a baseline (T1) assessment and follow-up assessments at 6 months (T2), 12 months (T3), 24 months (T4), and 36 months (T5) postbaseline. Caregivers participated in assessments from T1 through T4. This study is a follow-up to Smith, Leve, and Chamberlain's (2011) study, which examined immediate outcomes at T2.

RESULTS

Girls in the intervention condition showed significantly lower levels of substance use than did girls in the control condition at 36 months postbaseline. The group difference was only marginally significant for delinquency. Further analyses indicated significant indirect effects of the intervention through increased prosocial behaviors that led to decreased internalizing and externalizing symptoms and then to lower levels of substance use. The direct effect of the intervention on substance use remained significant in the presence of the indirect effects. For delinquency, the intervention had positive effects mainly through increased prosocial skills.

CONCLUSIONS

Findings highlight the importance of providing preventive intervention services for early adolescent girls in foster care.

Observational measure of implementation progress in community based settings: the Stages of Implementation Completion (SIC)

BACKGROUND

An increasingly large body of research is focused on designing and testing strategies to improve knowledge about how to embed evidence-based programs (EBP) into community settings. Development of strategies for overcoming barriers and increasing the effectiveness and pace of implementation is a high priority. Yet, there are few research tools that measure the implementation process itself. The Stages of Implementation Completion (SIC) is an observation-based measure that is used to track the time to achievement of key implementation milestones in an EBP being implemented in 51 counties in 53 sites (two counties have two sites) in two states in the United States.

METHODS

The SIC was developed in the context of a randomized trial comparing the effectiveness of two implementation strategies: community development teams (experimental condition) and individualized implementation (control condition). Fifty-one counties were randomized to experimental or control conditions for implementation of multidimensional treatment foster care (MTFC), an alternative to group/residential care placement for children and adolescents. Progress through eight implementation stages was tracked by noting dates of completion of specific activities in each stage. Activities were tailored to the strategies for implementing the specific EBP.

RESULTS

Preliminary data showed that several counties ceased progress during pre-implementation and that there was a high degree of variability among sites in the duration scores per stage and on the proportion of activities that were completed in each stage. Progress through activities and stages for three example counties is shown.

CONCLUSIONS

By assessing the attainment time of each stage and the proportion of activities completed, the SIC measure can be used to track and compare the effectiveness of various implementation strategies. Data from the SIC will provide sites with relevant information on the time and resources needed to implement MTFC during various phases of implementation. With some modifications, the SIC could be appropriate for use in evaluating implementation strategies in head-to-head randomized implementation trials and as a monitoring tool for rolling out other EBPs.

Mitigating HPA axis dysregulation associated with placement changes in foster care

Maltreated foster children often exhibit alterations in diurnal hypothalamic-pituitary-adrenal (HPA) axis activity that are characterized by lower cortisol levels upon waking and smaller declines in morning-to-evening cortisol levels. Previous research has shown that this dysregulated pattern is associated with high caregiver stress levels over the course of foster care placements. In contrast, therapeutic interventions that emphasize consistent and responsive caregiving have been associated with more regulated cortisol rhythms. In this paper, two related issues were explored: whether placement changes (i.e., moving between foster homes or from a foster home to a permanent placement) were associated with more blunted daily cortisol rhythms and whether a caregiver-based intervention exerted a protective effect in this context. Because the intervention program has components specifically designed to prepare foster children for placement changes and to maintain consistent parenting techniques despite them, a prevention effect on HPA axis dysregulation during placement changes was hypothesized. The results of linear mixed modeling analyses showed that placement changes predicted dysregulation in cortisol rhythms in the regular foster care group but not in the intervention foster care group. These findings are discussed in terms of implications for child welfare policy and practice.

Factors that influenced county system leaders to implement an evidence-based program: a baseline survey within a randomized controlled trial

BACKGROUND

Despite the burgeoning number of well-validated interventions that have been shown in randomized trials to produce superior outcomes compared to usual services, it is estimated that only 10% of public systems deliver evidence-based mental health services. In California, for example, more than 15,000 children are placed in group homes or residential centers with some evidence of iatrogenic effects. The present study evaluates the willingness among county leaders of child public service systems to adopt a new evidence-based model, Multidimensional Treatment Foster Care, (MTFC), as a way to decrease the prevalence of out-of-home placements. Specifically, the study examines how county-level socio-demographic factors and child public service system leaders' perceptions of their county's organizational climate influence their decision of whether or not to consider adopting MTFC.

METHODS

Two levels were examined in this study: Stable and historical factors from 40 California counties gathered from public records including population size, number of entries into out-of-home care, financing of mental health services, and percent minority population; and system leaders' perceptions of their county's organizational climate and readiness for change measured via a web-based survey. The number of days-to-consent was the primary outcome variable defined as the duration of time between being notified of the opportunity to implement MTFC and the actual signing of a consent form indicating interest in considering implementation. Survival analysis methods were used to assess the predictors of this time-to-event measure. The present study is part of a larger randomized trial comparing two methods of implementation where counties are randomized to one of three time cohorts and two implementation conditions.

RESULTS

The number of entries into care was the primary predictor of days-to-consent. This variable was significantly correlated to county size. System leader's perceptions of positive climate and organizational readiness for change also contributed to but did not mediate or moderate the days-to-consent.

CONCLUSIONS

System leaders' decision to consider implementing a new evidence-based model was influenced most by their objective need for the program and next by their perception of the county's organizational climate and motivation to change. These findings highlight the importance of understanding the fit between the needs of the systems or agencies and the potential for addressing those needs with the proposed new program.

Preliminary Support for Multidimensional Treatment Foster Care in Reducing Substance Use in Delinquent Boys

Although effective outpatient treatments have been identified for the well-documented negative outcomes associated with delinquency and substance use, effective treatments for youths in out-of-home care are rare. In this study, 12- and 18-month substance use outcomes were examined for a sample of 79 boys who were randomly assigned to Multidimensional Treatment Foster Care (experimental condition) or to group care (comparison condition). The boys in the experimental condition had lower levels of self-reported drug use at 12 months and lower levels of tobacco, marijuana, and other drug use at 18 months. Limitations and future directions are discussed.

Follow-up study of female delinquent adolescents in a detention centre: effectiveness of psychiatric intervention as a mental health service

RESULTS

of previous studies suggest that many female offenders have co-morbid psychiatric disorders, which require mental health services. However, few longitudinal studies examined subjects during incarceration or detention. This study compares depressive symptoms, abnormal eating behaviour and impulsivity before release from a detention centre and after incarceration, thereby indicating the effectiveness of psychiatric intervention in a Japanese detention centre.

METHOD

Of 64 young women, 36 were followed up. Self-report measures were used to assess depression, eating behaviour and impulsivity after incarceration and one month before release.

RESULT

s: Of the 36 participants, nine were diagnosed using the MINI-kids as needing mental health services. Those who received psychiatric intervention were diagnosed as having major depression and/or post-traumatic stress disorder. Significant main effects of intervention and effects of time were shown in the DSD. The EAT-26 score demonstrated the significance of the effects of time and interaction. In the BIS-11 scores, neither intervention nor time showed significant effects.

CONCLUSIONS

Results of this study showed that the time course and psychiatric intervention contributed to recovery of depression and therapeutic intervention. The time course might reduce eating problems. Psychiatric intervention might be necessary for female juvenile detainees, which presents an important issue for future studies.

Multidimensional treatment foster care as a preventive intervention to promote resiliency among youth in the child welfare system

Demographic trends indicate that a growing segment of families is exposed to adversity such as poverty, drug use problems, caregiver transitions, and domestic violence. Although these risk processes and the accompanying poor outcomes for children have been well studied, little is known about why some children develop resilience in the face of such adversity, particularly when it is severe enough to invoke child welfare involvement. This paper describes a program of research involving families in the child welfare system. Using a resiliency framework, evidence from 4 randomized clinical trials that included components of the Multidimensional Treatment Foster Care program is presented. Future directions and next steps are proposed.

Pregnancy rates among juvenile justice girls in two randomized controlled trials of multidimensional treatment foster care

Preventing adolescent pregnancy is a national research priority that has had limited success. In the present study, the authors examined whether Multidimensional Treatment Foster Care (MTFC) relative to intervention services as usual (group care [GC]) decreased pregnancy rates among juvenile justice girls mandated to out-of-home care. Girls (13-17 years of age) with histories of criminal referrals (Mdn = 10) were randomly assigned to MTFC (n = 81) or GC (n = 85) as part of 2 randomized controlled trials. Pregnancy histories were assessed from baseline through 24 months. Fewer postbaseline pregnancies were reported for MTFC girls (26.9%) than for GC girls (46.9%)--an effect that remained significant after controlling for baseline criminal referrals, pregnancy history, and sexual activity. MTFC has previously been shown to decrease arrest and lock-up rates. The present findings support the long-term preventive effects of MTFC on adolescent girls' pregnancy rates. Findings are consistent with the notion that programs that target delinquency by impacting general risk behavior pathways and contexts may more successfully prevent teen pregnancy than those that directly target sexual behaviors.

Treatment foster care for improving outcomes in children and young people

BACKGROUND

Treatment foster care (TFC) is a foster family-based intervention that aims to provide young people (and, where appropriate, their families) with a tailored programme designed to effect positive changes in their lives. TFC was designed specifically to cater for the needs of children whose difficulties or circumstances place them at risk of multiple placements and/or more restrictive placements such as hospital or secure residential or youth justice settings.

OBJECTIVES

To assess the impact of TFC on psychosocial and behavioural outcomes, delinquency, placement stability, and discharge status for children and adolescents who require out-of-home placement.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to January 2007), CINAHL (1982 to December 2006), PsycINFO (1872 to January 2007), ASSIA (1987 to January 2007), LILACS (1982 to January 2007), ERIC (1966 to January 2007), Sociological Abstracts (1963 to January 2007), and the National Research Register 2006 (Issue 4).

SELECTION CRITERIA

Included studies were randomised controlled trials investigating the effectiveness of TFC with children and young people up to the age of 18 who, for reasons of severe medical, social, psychological and behavioural problems, were placed in out of home care in restrictive settings (e.g. secure residential care, psychiatric hospital) or at risk of placement in such settings.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified in the search were independently assessed for eligibility by the two authors (GM and WT) who also extracted and entered into REVMAN. Date were synthesised on the few occasions where this was possible. Results are presented in tabular, graphical (forest plots) and textual form.

MAIN RESULTS

Five studies including 390 participants were included in this review. Data suggest that treatment foster care may be a useful intervention for children and young people with complex emotional, psychological and behavioural need, who are at risk of placements in non-family settings that restrict their liberty and opportunities for social inclusion.

AUTHORS' CONCLUSIONS

Although the inclusion criteria for this systematic review set a study design threshold higher than that of previous reviews, the results mirror those of earlier reviews but also highlights the tendency of the perceived effectiveness of popular interventions to outstrip their evidence base. Whilst the results of individual studies generally indicate that TFC is a promising intervention for children and youth experiencing mental health problems, behavioural problems or problems of delinquency, the evidence base is less robust than that usually reported.

Multidimensional treatment foster care for girls in the juvenile justice system: 2-year follow-up of a randomized clinical trial

This study is a 2-year follow-up of girls with serious and chronic delinquency who were enrolled in a randomized clinical trial conducted from 1997 to 2002 comparing multidimensional treatment foster care (MTFC) and group care (N = 81). Girls were referred by juvenile court judges and had an average of over 11 criminal referrals when they entered the study. A latent variable analysis of covariance model controlling for initial status demonstrated maintenance of effects for MTFC in preventing delinquency at the 2-year assessment, as measured by days in locked settings, number of criminal referrals, and self-reported delinquency. A latent variable growth model focusing on variance in individual trajectories across the course of the study also demonstrated the efficacy of MTFC. Older girls exhibited less delinquency over time relative to younger girls in both conditions. Implications for gender-sensitive programming for youths referred from juvenile justice are discussed.