The effectiveness of creative bibliotherapy for internalizing,externalizing, and prosocial behaviors in children: A systematic review

IntroductionCreative bibliotherapy is the guided reading of fiction and poetry relevant to therapeutic needs. Experiencing stories is hypothesized to act on the same mechanisms as cognitive behavioral therapy (CBT). This systematic review assesses the efficacy and effectiveness of creative bibliotherapy for the prevention and treatment of internalizing and externalizing behaviors, and the strengthening of prosocial behaviors in children (aged 5–16).MethodAn electronic search in seven major databases was conducted along with hand searches of key journals and bibliographies. Only randomized or cluster-randomized trials were included. Primary outcomes: internalizing behavior (e.g., anxiety and depression), externalizing behavior (e.g., aggression), and prosocial behavior (e.g., behavioral intentions and attitudes towards others). Secondary outcomes: parent–child relationship, peer relationship, educational attainment and reading ability.Results9180 records were located after removing duplicates. 9134 were excluded prior to screening. Of the 46 full-text articles assessed for eligibility, eight met the inclusion criteria and 38 were excluded. Meta-analysis was inappropriate due to study heterogeneity. Overall results suggest that creative bibliotherapy has small to moderate effect for internalizing behavior (δ range: 0.48–1.28), externalizing behavior (δ range: 0.53–1.09), and prosocial behavior (δ range: 0–1.2).ConclusionCreative bibliotherapy can have a small to moderate positive effect on child behavior. Although no definitive model of creative bibliotherapy emerges from the included studies, to some extent all interventions reflected CBT mechanisms. Further research is required to: 1) model the change processes taking place when children experience stories; 2) develop and pilot an intervention; 3) assess subgroup effects by gender, age, modality and literacy.     

Cost effectiveness of a school readiness intervention for foster children

ObjectiveMany young children in foster care suffer from emotional and behavior problems due to neglect and abuse. These problems can lead to difficulties in school, and functioning in school is linked to long-term health and development. Early intervention to reduce emotional and behavioral issues can help children successfully transition to school, which can improve long-term outcomes. However, communities need information on relative costs and benefits associated with programs to make informed choices. The objective of this study was to assess cost effectiveness, over 12 months, of the Kids in Transition to School (KITS) intervention compared to usual services available to children in a foster care control group (FCC).MethodRandomized controlled trial of 192 children in foster care entering kindergarten who were randomized to KITS (n = 102) or FCC (n = 90). KITS includes school readiness groups and parent training over 4 months. Main outcomes were days free from internalizing symptoms (IFD), days free from externalizing behavior (EFD), intervention costs, public agency costs, and incremental cost effectiveness.ResultsKITS significantly increased IFD and EFD compared to FCC. Average total cost of the intervention was $932 per family. The intervention did not significantly impact usual services. Average incremental cost effectiveness was $64 per IFD and $63 per EFD.ConclusionsThe cost of KITS is comparable to, or less than, similar programs, and the intervention is likely to provide significant emotional and behavioral benefit and improvement in school readiness for young children in foster care.     

The outcome of institutional youth care compared to non-institutional youth care for children of primary school age and early adolescence: A multi-level meta-analysis

ObjectiveThe outcome of institutional youth care for children is heavily debated. This multilevel meta-analysis aims to address the outcome of institutional youth care compared to non-institutional youth care for children of primary school age and early adolescence in economically developed countries. A gain of knowledge in this area may help the decision for referral of children to institutional youth care or other types of care (e.g., foster care or community-based care), and improve outcomes for children in youth care.MethodsOf 19 controlled studies (15.526 participants), 63 effect sizes of behaviour problems (externalizing, internalizing, and total), skills (social and cognitive) and delinquency were computed based on comparisons between institutional Evidence-Based Treatment (EBT), institutional Care As Usual (CAU), non-institutional EBT, and non-institutional CAU.ResultsInstitutional CAU showed a small-to-medium negative significant effect compared to non-institutional CAU (d = − 0.342). Furthermore, children in institutional care showed slightly more delinquent behaviour compared to children in non-institutional care (d = − 0.329). Significant moderating effects were also found for study design, year of publication and sex of the child.ConclusionsChildren receiving non-institutional CAU (mostly foster care) had slightly better outcomes than children in institutional CAU (regular group care). No differences were found between institutional and non-institutional care when institutional treatment was evidence-based. More research is needed on the conditions that make established treatment methods work in institutional care for (young) children.     

Concurrent child history and contextual predictors of children's internalizing and externalizing behavior problems in foster care

This study contributes to current research on the behavior problems of children in foster care by analyzing a more comprehensive set of concurrent child history and contextual predictors. Kinship home status and sibling status (i.e., whether the sibling is a biological sibling to the foster child) were evaluated as moderators of significant associations. Data were collected at the baseline of a foster parent training intervention program prior to any intervention services using parent phone interviews (N = 310, 51.6% male, M age = 7.57 years). Two linear hierarchical regressions were used to evaluate each set of predictors' association with behavior problems as well as each individual predictor's contribution. Results indicated that as a set, the contextual variables predicted a significant and unique amount of variability in the child's internalizing and externalizing behavior scores, whereas the child history variables did not. Specifically, the child's placement in a non-kinship home, being in a non-ethnically matched child-parent pair, higher parent stress scores, a greater number of prior group home placements, and higher internalizing behavior scores for the child predicted higher child externalizing scores. Higher parent stress scores, higher focal sibling externalizing behavior scores, and higher externalizing behavior scores for the child predicted higher internalizing scores for the child. The association between focal sibling externalizing behavior scores and child internalizing scores was moderated by kinship home status, such that there was a stronger association between the focal sibling's externalizing score and the child's internalizing score if the child was in a kinship compared to a non-kinship home. Implications for intervention services are discussed, particularly the importance of assessing the child's foster home environment when addressing the child's behavior problems.     

Caregiver–Adolescent Dyadic Disagreement and Problem Behaviors of Adolescents in the Child Welfare System

Parents and adolescents often provide different ratings of youths' behavior problems, yet few studies have examined such disagreement and its effect on later adjustment, especially among at‐risk adolescents. The purpose of this study was to investigate, among a sample of adolescents in foster care, whether the degree of caregiver–adolescent disagreement on adolescents' internalizing problems would be associated with adolescent externalizing problem behaviors over time. Two measures of adolescent caregiver agreement, the Pearson's r and intraclass correlations, were used with data drawn from a nationally representative study of children on foster care. Growth curve analyses of 180 adolescents revealed that the higher adolescent and caregiver agreement on adolescents' internalizing problems at Wave I, the slower the increase in externalizing problems over time.     

Changes in Externalizing and Internalizing Problems of Adolescents in Foster Care

Using a developmental psychopathology framework, this study aimed to examine changes in externalizing and internalizing problems of adolescents in foster care and to determine whether type of maltreatment, gender, and age influenced trajectories. Authors used 3 waves of data from the National Survey of Child and Adolescent Well‐Being. Growth‐curve analyses of 106 adolescents aged 13–16 in foster care revealed that externalizing and internalizing problems decreased over time. Adolescents, particularly boys, placed in foster care as a result of sexual abuse, physical abuse, or neglect demonstrated faster decreases in externalizing problems and, similarly but to a weaker degree, internalizing problems than did those placed in foster care as a result of other forms of maltreatment.     

Self-esteem: A mediator between peer relationships and behaviors of adolescents in foster care

Youth in foster care have been shown to be at risk for a range of negative behaviors. Developmental research has highlighted the important role that peer relationships can play in an adolescent's development. For youth in foster care, peer relationships can also play an important role in both youths' internal perception of themselves and their enacted behaviors. This study utilized National Survey of Child and Adolescent Wellbeing, a national secondary dataset to analyze the connection between peer relationships for youths in long-term foster care and their report of internalizing, externalizing, and delinquent behaviors (n = 188). Additionally, the self-esteem of adolescents was explored as a potential mediator between peer relationships and these behaviors. Preliminary analyses indicated that peer relationships had a significant association with all three of the identified behaviors: internalizing, externalizing, and delinquent behaviors of youths in foster care. Self-esteem was found to be a significant mediator between peer relationships and adolescents' report of their internalizing, externalizing, and delinquent behaviors. Clinical implications for therapeutic services that focuses on the adolescent's self-image and potential policy implications are discussed.     

Adaptation and Evaluation of a Nonviolent Resistance Intervention for Foster Parents: A Progress Report

Foster care faces serious challenges, such as behavioral problems in foster children and parental stress and ineffective parenting behavior in foster parents. The results of a pilot study that evaluated a training program for foster parents based on nonviolent resistance are described. In a pretest–posttest design, data were collected from 25 families. Significant reductions in externalizing, internalizing, and total problem behavior in the foster children and in parenting stress were found. Using a reliable change index, significant improvements in externalizing, internalizing, and total problem behavior were found in, respectively, 72, 44, and 80% of the cases. Most improvements proved to be clinically relevant. Effect sizes ranged from medium to large for problem behavior, and from small to medium for parenting stress.     

Effects of kinship care on behavioral problems by child age: A propensity score analysis

When a child must be removed from the family home, placement with a relative is often sought because kinship care is the least restrictive and most family-like out-of-home placement. Although kinship care has become a preferred option in most U.S. child welfare systems, this preference is often based on “soft evidence” rather than rigorous evaluation of the risks and benefits of kinship care. Therefore, an evaluation of the impact of kinship care on child behavioral problems is needed to guide child welfare practice and policy. In addition, given that children of different ages and in different developmental stages are likely to have varying placement experiences, the evaluation of kinship care should explore the effect of kinship care on child behavioral problems across age groups. To fill these knowledge gaps, we compare the behavioral problems of 584 children in kinship care with those of 470 children in non-kinship care. Moreover, we examine the impact of kinship care on behavioral problems in 2 age groups: younger children (0 to 5 years) and older children (6 to 17.5 years). The analysis uses data from Waves 1 and 2 of the National Survey of Child and Adolescent Wellbeing, and applies propensity score methods to account for selection bias. Results show that older children in kinship care had significant lower levels of externalizing, internalizing, and total behavior problems. However, for younger children, the effects of kinship care on child behavioral problems did not reach statistical significance. The implications for practice, research and policy are discussed.     

Relationships of Sexual,Physical, and Emotional Abuse to Emotional and Behavioral Problems Among Incarcerated Adolescents

ABSTRACT

This study examined the relationships of sexual, physical and emotional abuse to emotional (internalizing) and behavioral (externalizing) problems among incarcerated girls and boys. Participants were youth who were remanded to the correctional facilities within a statewide juvenile correctional system in a southern state in the United States of America. Each participant completed a structured interview regarding abuse history, emotional and behavioral difficulties, and demographic characteristics. Multiple regression analyses indicated that girls were more likely than boys to internalize their problems. The only abuse variable that was positively and significantly associated with emotional problems was emotional abuse. Greater behavioral problems were significantly related to youths being younger in age, white ethnicity, history of sexual abuse, and history of physical abuse. There were overall gender differences for internalizing problems, but not for externalizing problems among incarcerated adolescents. Furthermore, physical and sexual abuses were related to externalizing problems but not to internalizing problems. Thus, different types of abuse appear to have different effects on adolescent behavior. Implications for future research and practice are discussed.     

Substance use in youth adopted from foster care: Developmental mechanisms of risk

Children who enter foster care are at unique risk for developing substance abuse due to experiencing early life stressors. A large body of research has revealed robust effects of various stressors on later substance use, implicating the role of early neurobiological changes that create chronic internalizing problems. However, less literature has investigated externalizing behavior as a mechanism underlying this relationship. Moreover, few studies have examined these mechanisms through a model of cumulative risk. The present study examined whether the prospective association between cumulative pre-adoptive risk (e.g., maltreatment, age at placement, foster placement instability, ever having lived with birth parent) and adolescent/young-adult substance use was mediated by childhood internalizing and externalizing problems in youth adopted from foster care. Participants included 82 adoptees, most with histories of prenatal substance exposure (72%). We tested parent-rated internalizing and externalizing problems across 5 years in childhood as simultaneous mediators of cumulative risk and level of substance use 11–15 years later. Bootstrapping mediation procedures, controlling for age, prenatal substance exposure, adolescent/young adult mental health symptomatology, and youth participation in follow-up, revealed a significant indirect effect of cumulative risk on substance use through childhood internalizing problems, but not externalizing problems. These results underline the importance of mitigating early risk for children in the child welfare system and call for targeting childhood emotion dysregulation to reduce likelihood of substance abuse among previously high-risk adoptees. Nevertheless, low rates of substance use overall in the present sample underscore the positive impact of adoptive placement on mitigating risk for substance abuse among foster youth.     

Internalizing and externalizing behavioral problems of American Indian children in the child welfare system

Children involved in the child welfare system display elevated or clinically significant behavioral problems. However, there is a dearth of literature on the behavioral problems of American Indian children following child welfare involvement. Grounded in Patterson's Family Adjustment and Adaptation Response theory, this study fills that gap. Baseline, 18-month, and 36-month follow-up data from the National Survey of Child and Adolescent Well-being were utilized. The sample (n = 3498) consisted of American Indian, African American, and Caucasian children ages 2–16 at baseline (M = 8.13 years old, SD = 3.85) and 51.7% were female. Nearest neighbor propensity score matching analyses were used to estimate the effect of race on clinically significant internalizing and externalizing behavioral problems. Findings suggest that although externalizing behavioral problems do not differ based on race after controlling for other important factors, internalizing behavioral problems do differ. American Indian children are more likely to display clinically significant internalizing behavioral problems.     

Foster parents' emotional investment and their young foster children's socio-emotional functioning

Emotional investment may be defined as a willingness to accept and become committed to a child, and being aware of influencing the child's development. Research in this field is limited, and has shown that commitment in particular is associated with foster children's socio-emotional functioning. Our aim was therefore to investigate 60 foster parents' acceptance, commitment and awareness of influence to their early placed foster children at 2 years, as well as to investigate the association between these three concepts and the foster children's social-emotional functioning (externalizing, internalizing, dysregulation and competence) at 2 (T1) and 3 (T2) years of age. The caregivers were interviewed with “This is My Baby”, and completed the questionnaire “Infant-Toddler Social and Emotional Assessment”. Results showed that on average the foster parents were rated quite high on emotional investment. Linear regressions, including one predictor and one outcome variable, revealed associations between emotional investment and foster children's socio-emotional functioning. Moreover, in regressions including all three predictors, commitment significantly negatively predicted externalizing behavior in the foster children at T1, while acceptance significantly negatively predicted dysregulation at T2. Lastly, among others for externalizing, the coefficient of commitment was significantly higher at T1 than at T2. Our results indicate a possible short-term influence of commitment on externalizing- and a possible long-term influence of acceptance on dysregulation behavior in foster children. We will therefore highlight the clinical importance of emotional investment in foster care, in order to help the young foster child towards a healthy social-emotional functioning.     

Risk and protective factors for residential foster care adolescents

Based on Jessor's (1998) Problem Behavior Theory, this study investigated the relationship between risk and protective factors and adolescent psychopathology and adjustment. For this purpose, adolescent girls (n = 69) and boys (n = 71) living in residential foster homes in the city of Tehran, responded to an adapted version of the Adolescent Health and Development Questionnaire, Jessor, 1998) and their foster home caregivers rated the adolescents' internalizing/externalizing problems and prosocial behavior with the Strengths and Difficulties Questionnaire (SDQ, Goodman, 2001). This study identified several influential aspects at the levels of the individual, foster home, peers and community that serve as a direct risk and protective factors, and also documented indirect pathways of gender, individual, foster home, peers and community influence.Three main patterns, protective, protective and enhancing, and protective but reactive seemed to characterize most of the risk by protective factor interactions. The risk and protective factors associated with foster home adolescents' mental health are broadly in line with previous published findings. Based on the present findings, the extension of universal intervention programs designed within the framework of PBT and which address multiple targets seems justified to be used with foster care home adolescents.     

Environmental Correlates of Cognition and Behavior in Children with Fetal Alcohol Spectrum Disorders

ABSTRACT

The physical, cognitive, and behavioral correlates of Fetal Alcohol Spectrum Disorders (FASD) have been well-researched. However, there is minimal investigation of the non-biological correlates of cognition and behavior in this population. The association between foster care placement history and cognitive and behavioral functioning was explored using archival data from 136 children with FASD. Significant cognitive and behavioral abnormalities were found in the overall sample. Children with one foster care placement performed significantly better on measures of verbal intelligence, mathematics achievement, and impulse control and endorsed fewer symptoms of internalizing disorders compared to children who were never removed from their biological home. Children with multiple foster home placements generally fell between the other two groups on assessment measures. It may be important to consider placement history of children with FASD when attempting to understand their cognitive and behavioral abnormalities.     

Acculturation Risk and Protective Factors and Mental Health Symptoms in Immigrant Latino Adolescents

Abstract

The aim of this investigation was to map factors that predicted internalizing, externalizing, social, and total behavioral problems in immigrant Latino adolescents. Interviews were conducted with 100 foreign-born Latino adolescents. Multiple regression analyses revealed two risk factors, perceived discrimination and parent-adolescent conflict, which were significant predictors of adolescent internalizing, externalizing, and total problems. Interaction terms indicated that adolescents who were highly involved in Latino culture and who experienced high parent-adolescent conflict were at risk for internalizing problems. Familism was a protective factor associated with lower levels of internalizing and total problems. However, the effect of familism was mediated by parent-adolescent conflict.     

Externalizing problems in young foster children: Prevalence rates,predictors and service use

Objective

Examining the prevalence of externalizing problems, their predictors and mental health service use for these problems by foster children and foster parents in a representative group of foster children aged 3 to 12 in Flanders.

Method

Survey data were collected on 212 foster children, who had been in the foster family for approximately four months. Foster parents filled out a Child Behavior Checklist to measure foster children's externalizing problems. Foster care workers reported on several potential risk variables for externalizing problems and on foster children's and foster parent's mental health service use. Predictors of externalizing problems were identified from a large number of variables using the method of purposeful selection of variables in linear regression.

Results

40.6% of the foster children had externalizing problems. Foster children who were placed because of behavioral problems had more externalizing problems. Only 20.9% of the foster children with externalizing problems and only 13.9% of their foster parents received professional help.

Conclusions

This study showed that externalizing problems are prevalent in this young foster care population, that it is hard to predict which foster children had externalizing problems, and that foster children and their foster parents rarely receive services for these problems. These findings call for a standard protocol of assessment of foster children's externalizing problems. Moreover, from a preventive viewpoint, guidelines are needed to systematically link young foster children with externalizing problems and their foster parents to appropriate services.     

Co-development of internalizing and externalizing behavior problems during early childhood among child welfare-involved children

Using parallel-process latent growth curve modeling, we examine developmental trajectories of internalizing and externalizing behavior problems and identify early risk factors for behavior problems among 329 child welfare-involved children followed from age 2 years to 5 years. Data are drawn from the National Survey of Child and Adolescent Well-Being II. On average, internalizing behavior problems remained stable, while externalizing behavior problems decreased over time. Higher initial levels of internalizing behavior problems were associated with higher initial levels of externalizing behavior problems. Rates of change also had positive cross-domain relationships. Child neglect, exposure to intimate partner violence (IPV), insecure caregiver-child attachment, and caregiver mental health problems were associated with higher initial levels of internalizing and externalizing behavior problems. Exposure to IPV, out-of-home care, and caregiver drug use predicted rates of change in behavior problems. Our findings highlight the importance of comprehensive assessment and treatment for co-occurring internalizing and externalizing behavior problems in young children involved in the child welfare system. Results also indicate the need for identifying and addressing early risk factors to prevent early onset and continued development of behavior problems in high-risk children.     

Socioemotional functioning across the transition to lower secondary school: The role of temperament and relationships with mothers and teachers

This Finnish longitudinal study investigated the role of relationships with mothers (n = 631) and teachers (n = 56), and adolescents' (n = 848; 53.9% girls, 46.1% boys) temperament in the development of the adolescents' socioemotional functioning during the transition to lower secondary school (Grade 6 to Grade 7; age in Grade 6: M = 12.32, SD = 0.36). The results showed that mother–adolescent closeness predicted a higher level and teacher–adolescent closeness predicted a smaller decrease in prosocial behavior. Teacher–adolescent conflict predicted a higher level, and mother–adolescent conflict predicted an increase in externalizing problems. Only temperament predicted internalizing problems. In addition, relationship quality both mediated and moderated some of the associations between temperament and socioemotional functioning.     

Compliance and Internalization in Preschool Foster Children

Child compliance and internalization are socio-cognitive developmental processes which are critical for children's social outcomes in multiple arenas. These developmental processes are found to be compromised in maltreated children. The current study was designed to add to the extremely limited literature on compliance and internalization in maltreated children in foster care. Compliance and internalization tasks were administered to preschool foster children, videotaped and later coded. Through parent-report questionnaires completed by the foster parents and observations of the foster home, the relation of compliance/internalization to child behavior problems, foster care experiences, and the foster home environment was examined. Findings revealed that most children showed committed compliance, but over 50% of children exhibited “deviation” behaviors in the internalization task. HOME acceptance scores (via observation of parent and child in home setting) significantly contributed to children's compliance levels but did not significantly contribute to their internalization. Internalization was related to children's externalizing behavior problems. These findings are considered in the context of future research and practice with respect to young children in foster care.