Quality improvement learning collaborative to examine foster care guidelines

Learning collaboratives (LC) are an important method of implementing quality improvement by serving as laboratories to translate research into practice and sharing knowledge. We created a Foster Care Learning Collaborative (FCLC) of 11 foster care health sites to share best practices on providing health services for children in foster care. Using a collaborative approach involving monthly conference calls, we invited each health site to present specific health care delivery issues for the purpose of developing collaborative quality improvement projects regarding the delivery of healthcare to children placed into foster care. For health sites providing primary care (n = 8 of 11 sites), we examined adherence to two American Academy of Pediatrics (AAP) guidelines for children entering foster care: a) the initial health screen, and b) the comprehensive medical evaluations. At least four distinct types of health care models that provide either direct primary care or administrative oversight for children in foster care were identified: 1) medical home sites (n = 3); 2) foster care evaluation/intake sites (n = 2); 3) specialized primary care sites (n = 1); and, 4) state administrative programs (n = 2). Data from the six direct primary care sites (n = 586 children) and two state administrative models (n = 3855 children) was collected. The time-frame for the initial health screen was adjusted to 7 days after entry and adherence (31%) was comparable among primary care sites. Adherence to AAP guidelines regarding completion of a comprehensive medical evaluation within 30 days of intake varied among medical homes (30%–86%), intake models (23%–33%), specialized primary care site (43%), and state models (43%–73%). No site was fully compliant with the AAP guideline for universal comprehensive medical evaluation within 30 days, and there is variation within and among care models. A foster care learning collaborative identified significant variability in adherence to a commonly accepted guideline for timely access to healthcare for children placed into foster care. The LC c model offers the opportunity to evaluate best practices, identify barriers to care, and provide objective feedback for improvement.     

The plans,goals, and concerns of pre-emancipated youth in foster care

This study focuses on the plans, goals, and concerns of foster care youth prior to leaving care. Participants were 179 pre-emancipated youth between the ages of 17 and 20 years old (M = 17.82, SD = 0.79) from a large metropolitan area in Southern California. Self-articulated immediate plans were grouped into 4 major categories and self-articulated life goals were grouped into 10 categories while also examining the prioritization of, estimated time frame for, and youth's sense of control over their life goals. Survey and interview data reveal the importance of educational and occupational life goals and their prioritization. Youth reported a high level of certainty in their immediate plans, but the youth were less explicit in describing their immediate plans for the year after foster care. Foster youth may have difficulty identifying concrete steps to make plans a reality despite their ideas for the future. Youths' worries and concerns about their post-emancipation plans and life goals typically centered around academics and finances. This study contributes to the limited literature on the life goals and plans for foster youth; these results reinforce the need for greater support in planning and goal setting prior to emancipation.     

Staff and youth views on autonomy and emancipation from residential care: A participatory research study

The use of participatory approaches in designing services is still relatively uncommon. In this study, we helped design a service to support the transition of youth from residential care to independent living by exploring the perspectives of staff and of youth regarding: (a) the concept and development of autonomy; and (b) key factors in developing this type of service. We gathered the data through 10 interviews with staff (n = 10) and 4 focus groups with youth (n = 21), and subjected the data to a thematic content analysis. Staff defined autonomy as self-regulation and self-care, and identified three paths to foster autonomy – a sense of normality, meaningful relationships, and planning for emancipation. The staff and youth identified the following important aspects in designing the service: achieving normality (e.g. limited number of residents), promoting youth capacity (e.g. skill-building activities), providing social support (e.g. trust and respect between residents), and assuring guidance and boundaries (e.g. supervision of youth).     

Youth with disabilities in the United States Child Welfare System

Existing literature suggests that youth with disabilities are known to be at increased risk of maltreatment in the form of abuse and/or neglect. Little is known, however, about the experiences of youth with disabilities who are living in foster care or who are supervised by child protection authorities. This study establishes a baseline estimate of the prevalence of youth with disabilities living in foster care, documents reasons for child protection system involvement, identifies placement types while youth are in care and explores case outcomes. This cross-sectional, exploratory study draws on data from the 2012 Adoption and Foster Care Reporting System (AFCARS) for foster youth in 50 states, the District of Columbia and Puerto Rico. A sample of youth with disabilities (N = 36.492) and a comparison group without disabilities (N = 601.539) were identified. Findings about demographics, reasons for child removal, foster care placements, permanency planning goals and case outcomes are presented. Findings have implications for the prevention the removal of youth from caregivers, the need for family supports to prevent foster care involvement, the promotion of community inclusion of foster youth while in foster care and the need for inter-system collaboration at the transitional age stage.     

Program records as a source for program implementation assessment and youth outcomes predictors during residential care

This study used point card information from a residential program to generate treatment fidelity metrics and determine if the metrics predicted youth outcomes after six months in care. Youth outcomes included staff (n = 52) and youth (n = 143) ratings, youth conduct records kept by the residential program's teaching-family homes and school records. Treatment fidelity metrics included the program components: (a) percentage of positive interactions, (b) number of privileges earned, and (c) a skills taught to interactions ratio. The percentage of positive interactions averaged 90% per youth; 76% of the point cards indicated that privileges were earned; and a variety of life skills were typically taught to the youth (skills ratio = .61). The data from the treatment fidelity metrics supported that the program was implemented consistent with program expectations. The range of implementation quality for each measured component was then used to predict youth outcomes. Increased percent of positive interactions predicted significantly decreased externalizing behaviors as reported by staff (β = − 0.31, p < .001) and youth (β = − 0.30, p < .001), and significantly fewer incidents of non-compliance (Exp(b) = 0.93, p < .001) and school problems (Exp(b) = 0.91, p < .001) as indicated on the program records. The skills ratio indicated similar trends across outcomes, although non-significant at the p < .01 level. Permanent products may be helpful to develop program treatment fidelity metrics, which may be useful for monitoring implementation and may be associated with improved youth outcomes.     

From foster care to juvenile justice: Exploring characteristics of youth in three cities

Children placed in foster care are at risk for becoming involved with the juvenile justice system. This study documents the rates at which children involved with foster care enter the juvenile justice system (crossover or dually involved), and the factors associated with this risk. We utilize multiple birth cohorts and prospective, longitudinal data from birth to maturity separately in three major American cities. Analyses consider integrated administrative records from multiple birth cohorts representing populations in Cook County (Chicago; N = 26,003), Cuyahoga County (Cleveland; N = 10,284), and New York City (N = 13,065). Crossover rates ranged from 7 to 24%. African American males, and children who experienced congregate care were at highest risk for juvenile justice involvement. Older age at first foster care placement signaled progressively greater risk, as did more foster care spells for those first placed as infants. We discuss findings in terms of developmental theory, and as actionable intelligence to inform prevention, practice, and policy.     

Foster home licensing and risk of reentry to out-of-home care following family reunification

Family reunification without subsequent reentry is the primary permanency goal for children placed in foster care. While a number of placement-level factors have been examined for their effect on subsequent reentry to care, no study to date has considered foster care licensing. The current study uses statewide administrative data to construct a cohort of foster care youth who entered care between 2009 and 2012 and were reunified by the start of 2013 (N = 7752) to investigate the association between types of foster care and the probability of reentry to foster care up to two years following reunification. We focus specifically on the licensing status of foster homes, and employ propensity score analysis to address selection bias in placement type. A propensity-weighted cox proportional hazard model revealed that youth placed in licensed relative care (LRC) homes and licensed non-relative care (LNC) homes were more likely to reenter foster care than those youth placed in unlicensed relative care (URC) homes during their first spell of 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.     

The moderating role of length of stay in the relationship between cognitive dysregulation and peer attachment in adolescent boys and girls living in residential care

In Portugal, youth at risk tend to be placed in residential care for long periods of time, during which peers assume a status close to that of family. However, these adolescents often present deficits in emotional regulation, which can compromise the quality of their relationships with peers. Therefore, this study aimed to analyze the relationship between emotional dysregulation experienced by institutionalized adolescents and their own perception of peer attachment, testing whether the length of stay moderates this relationship, for boys and girls independently. Data was collected from a sample of 100 Portuguese adolescents (71 boys; 29 girls), aged 12–18, living in residential care for 43 months average (SD = 43.14). They responded to the Abbreviated Dysregulation Inventory, which measures cognitive, affective and behavioral dysregulation, and the peer version of the Inventory of Parent and Peer Attachment, which measures communication, trust and alienation.Only cognitive dysregulation accounted for the variability of perceived attachment to peers, in the total scale and in communication and trust. When the level of cognitive dysregulation reported by the adolescents is high, there is a positive effect of length of stay in the previous relationships, but only for boys.Results outline how length of placement contributes to youth at risk to reach certain outcomes. They also emphasize the need to develop specific interventions in residential care contexts to address specific characteristics such as gender differences, in order to continuously promote positive interactions with peers in these contexts.     

A randomized controlled trial of the effectiveness of the youth crime prevention program ‘New Perspectives’ (NP): Post-treatment changes and moderator effects

ObjectivesNew Perspectives (NP) aims to prevent that youth at onset of a criminal career will develop a more persistent criminal behavior pattern. The study aim was to examine whether NP was effective relative to care as usual in preventing and reducing (persistent) delinquency. Moreover, we examined improvements in secondary outcomes (e.g., peer and parent relationships and cognitive distortions) and other outcomes (e.g., substance use and self-esteem).MethodsAt-risk youth (N = 101) aged 12 to 19 years were randomly assigned to the intervention group (NP, n = 47) or control group (‘care as usual’, n = 54). The effects of the NP intensive phase (3 months after program start) and aftercare phase (6 months after program start) were analyzed.ResultsNP and care as usual did not differ on any of the outcome measures at both post-test occasions. The effects of NP were the same for boys and girls, different age groups, and ethnic groups.ConclusionsThe overall null-effects are discussed, including implications for further research, policy, and practice.     

Concurrent reductions in psychotropic medication,assault, and physical restraint in two residential treatment programs for youth

Over the past decade, the level of clinical needs of youth in residential treatment has increased significantly. Youth in out-of-home settings typically experience higher levels of psychotropic medication use than their peers living at home, even when controlling for the severity of clinical issues. The purpose of the current study was to examine the effects of an approach to clinically reassess psychotropic medication utilization for youth residing in residential treatment settings while also observing the impact on the youth's need for physical containment. Medication changes were based on a data-informed process, using input from a multi-disciplinary treatment team. Data for 531 youth who were consecutively admitted to one of two non-affiliated intensive residential treatment programs, one in the Midwest and one in New England, was analyzed. Over half of these youth (n = 292, 55%) had their medications reduced during their stay and only 14% (n = 76) were prescribed more medication at discharge than they had been taking at admission. The remainder either saw no change during their stay (n = 104, 20%) or were never on medication at any time (n = 59, 11%). From admission to discharge there was a 62% decrease in the number of assaultive incidents as well as a 72% decrease in the use of physical restraints. These results support the view that residential treatment can provide a treatment milieu that allows for thoughtful reassessment of the clinical basis for behavioral disorders in children that can achieve the dual goals of medication reduction and behavioral stabilization.     

Criminal conduct subgroups of “aging out” foster youth

Subgroups of adolescents drawn from the Midwest Study of the Adult Functioning of Former Foster Youth were identified on the basis of cluster analysis of self-reported criminal behavior: Cluster 1: No Criminal Activity (n = 204), Cluster 2: Moderate Criminal Conduct (n = 300), Cluster 3: Extensive Criminal Involvement (n = 87), and Cluster 4: Group Fighting (n = 139). Logistic regression analysis revealed higher proportions of foster youth with alcohol and drug diagnoses, male gender, out of school status, and limited caregiver closeness in each of the groups in which there was evidence of significant criminal conduct (Clusters 2, 3, & 4) in comparison to the no criminal activity group (Cluster 1). The same variables contributed to discrimination between the cluster subgroup with the most serious and pervasive pattern of criminal conduct (Cluster 3) and the two with less extensive criminal involvement (Clusters 2 & 4). Current findings and those of G. R. Cusick, M. E. Courtney, J. Havlicek & N. Hess (2010), help in identifying the differing needs of youth aging out of the child welfare system and should be useful in informing development of targeted interventions.     

Youth participation in foster youth advisory boards: Perspectives of facilitators

Foster youth advisory boards (YAB) have the objective of promoting foster youth participation in decisions that are made about their lives. There is currently little known about how youth participation is conceptualized or implemented within or across boards. This qualitative study explored youth participation from the perspectives of 42 primary YAB facilitators in 34 states. The study's findings are derived from telephone interviews. A thematic analysis identified four primary approaches to youth participation, which we labeled as being, ‘Adult-Led’ (n = 2); ‘Adult-Driven Youth Input’ (n = 14); ‘50–50 Youth-Adult Partnership’ (n = 16); and ‘Youth-Led’ (n = 2). Within each of these approaches to youth participation, we present findings that explore facilitators' conceptualizations of youth participation, the strategies and program activities they use to enact youth participation, and the strengths and limitations of each of the approaches. Our discussion explores implications for YAB program activities, youth participation in child welfare systems, and future research.     

Development & maintenance of social support among aged out foster youth who received independent living services: Results from the Multi-Site Evaluation of Foster Youth Programs

This study uses secondary data from the Multi-Site Evaluation of Foster Youth Programs, a randomized controlled trial of four independent living programs for youth in foster care. The subject of this investigation is the Life Skills Training Program (LST) of Los Angeles County, CA. We had three interrelated aims: (1) Evaluate the effectiveness of the LST program as compared to services as usual on the change in social support over time; (2) Examine the differences over time in social support by race and ethnicity among LST participants; and (3) Investigate the explanatory value of prosocial activities, educational involvement, current living arrangement, employment, victimization experiences, placement instability, and behavioral health symptomology on changes in social support over time among LST participants. We employed multilevel longitudinal modeling to estimate growth in social support over three time points (baseline, first follow-up, and second follow-up) among 482 youth (n = 234 LST; n = 248 control). We found a significant reduction in social support across the three time points. But, there was no difference in the social support trajectory between the LST and control groups. In addition, no racial/ethnic difference in the social support trajectory was detected. Results underscore the need to critically examine how independent living programming is intended to increase social support and whether modifying these practices can improve promotion and maintenance of social support for youth who age out of foster care.     

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.     

Extracurricular activity participation and educational outcomes among older youth transitioning from foster care

This study examined factors associated with extracurricular participation and whether participation in extracurricular activities is associated with completing high school and attending college among a sample of older youth transitioning from foster care (n = 312). Results indicated that better self-reported grades and greater educational aspirations were associated with extracurricular participation. Participation in extracurricular activities was associated with graduating from high school, but not starting college by age 19. Consistent with provisions of the Preventing Sex trafficking and Strengthening Families Act of 2014, results suggest that efforts that make extracurricular participation a normative aspect of the developmental experience of foster youth are important for their educational well-being.     

Development of an innovative process evaluation approach for the Families Improving Together (FIT) for weight loss trial in African American adolescents

This study demonstrates how a multi-theoretical, multilevel process evaluation was used to assess implementation of the Families Improving Together (FIT) for weight loss intervention. FIT is a randomized controlled trial evaluating a culturally tailored, motivational plus family-based program on weight loss in African American adolescents and their parents. Social Cognitive, Self Determination, Family Systems theories and cultural tailoring principles guided the conceptualization of essential elements across individual/family, facilitator, and group levels. Data collection included an observational rating tool, attendance records, and a validated psychosocial measure.ResultsAttendance records (0 = absent, 1 = present, criteria = ≥70%) indicated that 71.5% of families attended each session. The survey (1 = false, 6 = true, criteria = ≥4.5) indicated that participants perceived a positive group climate (M = 5.16, SD = 0.69). A trained evaluator reported that facilitator dose delivered (0 = no, 1 = yes, criteria = ≥75%) was high (99.6%), and fidelity (1 = none to 4 = all, criteria = ≥3) was adequate at facilitator (M = 3.63, SD = 0.41) and group levels (M = 3.35, SD = 0.49). Five cultural topics were raised by participants related to eating (n = 3) and physical activity (n = 2) behaviors and were integrated as part of the final curriculum.DiscussionResults identify areas for program improvement related to delivery of multi-theoretical and cultural tailoring elements. Findings may inform future strategies for implementing effective weight loss programs for ethnic minority families.     

Aggressive behaviors among Korean children in out-of-home care: The role of placement characteristics

Using data from the Korean Panel Study on Children in Out-of-Home Care, this study examined the impact of placement characteristics on aggressive behaviors among children in out-of-home care by placement type. The sample was divided into three groups based on placement type: institutional care (n = 118), group homes (n = 95), and foster care (n = 212). Results from hierarchical multiple regression analyses indicated that the length of stay in out-of-home care significantly influenced aggressive behaviors amongst children in institutional care, such that increased duration of out-of-home care decreased the level of aggressive behaviors. Perceptions of stigma/discrimination also significantly influenced aggressive behaviors displayed by children in institutional and foster care. Children with a higher perception of stigma/discrimination were more likely to exhibit severe aggressive behaviors than were their counterparts. On the other hand, placement characteristics had no significant influence on aggressive behaviors of children in group homes. The study findings suggest that children's mental health problems and disabilities should be considered during the placement procedure and interventions focusing on decreasing stigmatization should be developed and provided for children in out-of-home care.     

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.     

Heterogeneity among adolescent mothers and home visiting program outcomes

Despite the challenges of early parenting, many adolescents navigate motherhood successfully, underscoring an overlooked heterogeneity among adolescent mothers. The present study used Latent Class Analysis (LCA) to identify subgroups of adolescent mothers (n = 704) enrolled in a randomized controlled trial (RCT) evaluation of a home visiting program for young parents. The model incorporated demographic and background characteristics, as well as indicators of psychological vulnerability. Analyses revealed four distinct subgroups: (a) non-Hispanic high vulnerability (n = 209, 30%); (b) Hispanic high vulnerability (n = 98, 14%); (c) non-Hispanic moderate vulnerability (n = 241, 34%); and (d) Hispanic moderate vulnerability (n = 156, 22%). Mothers in the two high vulnerability subgroups exhibited the poorest personal and parenting functioning outcomes measured approximately two years postpartum, particularly in terms of child maltreatment (non-Hispanic high vulnerability) and depressive symptoms (Hispanic high vulnerability). Analyses revealed positive effects of the home visiting program within specific latent classes on such outcomes as healthy baby at birth, high school or GED attainment, and repeat birth.