Study Review

Mental health care interventions for children looked after

Mental health interventions that can be delivered in outpatient settings to children who are looked after.

Outcome Overall
effectiveness

This rating shows how effective the intervention is at achieving the evaluated outcome.

Click here for information about how effectiveness ratings are applied.

Strength of
evidence

This rating shows how confident we can be about a finding, based on how the research was designed and carried out.

Reduce or prevent behaviour problems Overall effectiveness: 1 (maximum 2) Strength of evidence : 1 (maximum 3)
Caregiver sensitivity and positive engagement Overall effectiveness: 1 (maximum 2) Strength of evidence : 1 (maximum 3)
Placement Stability Overall effectiveness: 1 (maximum 2) Strength of evidence : 1 (maximum 3)

Headline points

  • Children in foster care have high rates of adverse childhood experiences and are at risk for mental health problems. Accessing appropriate support can also be more challenging for children who are looked after.
  • This systematic review identified promising mental health interventions that can be delivered to children who are looked after (aged 0 to 12) in outpatient settings, addressing an existing gap in the literature.
  • The interventions reviewed demonstrated reductions in behaviour problems and increases in caregiver sensitivity, positive discipline, positive praise and use of reinforcement. However, these findings were based on a low strength of evidence.
  • Children and families who had access to mental health services were more likely to be reunited after foster care placement and had an increase in placement stability.
  • Further research is needed to identify which interventions work for whom and under which circumstances so that mental health interventions can be targeted appropriately.

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What is this?

This summary focuses on six mental health interventions:

  • Attachment and Biobehavioral Catch-up
  • Fostering Healthy Futures
  • Incredible Years
  • Keeping Foster Parents Trained and Supported
  • Parent-Child Interaction Therapy
  • Treatment Foster Care Oregon for Preschoolers

Two existing interventions (IY and Parent-Child Interaction Therapy) have been adapted for children in foster care. Three interventions focused on prevention (FHF, IY, TFCO-P) whereas access was based on the child’s age as opposed to a mental health diagnosis.

How is it meant to work?

  • Children looked after are significantly more likely to have experienced abuse and neglect, with many having experienced five or more adverse childhood experiences. Consequently, many children looked after are at risk of a range of mental health and developmental difficulties.
  • Research suggests that it may be particularly challenging to treat children with mental health difficulties who are looked after.
  • Additional challenges to receiving appropriate therapeutic help, faced by children looked after, include placement changes and interventions being directed toward parent-child pairs.
  • The interventions were based on a range of theoretical frameworks including behavioural, cognitive, psychodynamic and positive youth development. Some interventions included elements of behaviour management training and/or socio-emotional learning.

What are the evaluated outcomes?

  • Reduce or prevent behaviour problems
  • Caregiver sensitivity and positive engagement
  • Placement Stability

How effective is it?

Outcome 1: Reduce or prevent behaviour problems
Overall, interventions had a positive effect on reducing or preventing behaviour problems (for example internalising and externalising behaviours). This was based on low strength evidence from five studies involving 1,368 children.

Outcome 2: Caregiver sensitivity and positive engagement
Overall, interventions had a positive effect on caregiver sensitivity and positive engagement (for example positive praise). This was based on low strength evidence from four studies. These interventions were:

  • Attachment and Biobehavioural Catch-up
  • Incredible Years
  • Parent Child Interaction Therapy
  • Treatment Foster Care Oregon for Preschoolers

Outcome 3: Placement Stability
Overall, interventions had a positive effect on placement stability . This was based on low strength evidence from three studies. These interventions were:

  • Fostering Healthy Futures
  • Treatment Foster Care Oregon for Preschoolers
  • Keeping Foster Parents Trained and Supported

How strong is the evidence?

  • Four interventions were tested in randomised efficacy trials (determining whether an intervention produces the expected result under ideal circumstances) and three interventions were tested in randomised effectiveness trials (measuring the degree of beneficial effect under “real world” clinical settings).
  • Only Incredible Years was tested using both methods.

Three sources of potential bias were noted:

  1. First, reporting bias, where interventions were included with only one randomised controlled trial. To mediate reporting bias, this summary only reports findings for interventions with at least three studies.
  2. Second, publication bias, where there is a risk that only studies with positive findings are published.
  3. Third, developer bias, where many of the interventions had been evaluated by the person(s) who had developed the intervention.

Where has it been studied?

Thirty-seven studies were conducted in the USA, one study was conducted in the UK and one study was conducted in Romania. Therefore, the generalizability to a UK setting is limited, and practitioners should consider the different national contexts when applying these interventions to their own practice.

Who does it work for?

  • Children were aged from 0-12 years
  • Incredible Years:
    – Associated with a reduction in physical aggression for boys and where children had clinically significant behaviour problems at baseline, reductions in the intensity of behaviour problems were found at follow-up.
    – Linares et al., 2006 found increased use of positive praise at the end of the intervention and at three months follow-up with a sample of 64 foster children, compared with services as usual.
    – This intervention also found improved co-parenting between biological parents and foster carers on completion of the intervention.
  • Parent Child Interaction Therapy:
    – Associated with reductions in both internalizing and externalising behaviours.
    – Timmer et al., 2006 and Mersky et al., 2015 reported reductions in foster carer distress, total stress and child-related stress and increased use of praise and positive parenting practices along with reductions in negative parenting practices.
  • Fostering healthy futures:
    – In a study of 110 foster children, children who received this intervention reported fewer placement changes, increased permanency and less residential placements.
    – In a further study with 700 foster children, placement stability was not moderated by severity of neglect, suggesting that children with severe neglect histories can still continue to benefit from gaining access to Fostering Healthy Futures.
  • Treatment Foster Care Oregon for Preschoolers:
    – Reported a reduction in the impact of behaviour problems on placement disruption.
    – In two studies with 90 foster carer-child dyads in the first study and 52 foster carer-child dyads in the second study, participation in this programme was associated with increased permanence.
    – For further details see Treatment Foster Care summary.
  • The Keeping Foster Parents Trained and Supported:
    – This intervention was associated with decreased placement disruption when caregivers were highly engaged with the child.
    – Further, in a study of 700 foster children aged between 5 and 12 years, KEEP was associated with an increase in positive exits from care.
  • The authors note the lack of findings on what moderates intervention outcomes and which sub-groups benefit the most from mental health interventions in community settings.
  • There is also limited evidence on engagement, retention and attendance rates.
  • By focusing on interventions that could be delivered in outpatient settings, findings were weighted towards children in foster or kinship care rather than those in group homes or residential settings.

When, where and how does it work?

  • Interventions also varied in the components they included. Some interventions included behaviour management, play therapy and some form of therapeutic intervention.
  • The review lacked further detailed information concerning the implementation of each intervention.
  • Whilst adapting interventions to the foster care context improves access to mental health support for this population, it does not inform how well these interventions may have performed without adaptation. The study does not address the extent of adaptation necessary to achieve expected outcomes.

What are the costs and benefits?

No economic analysis was included in the review.

How is it implemented?

  • Interventions varied considerably in delivery setting, characteristics and duration.
  • Duration of interventions varied from ten weekly sessions to weekly sessions over a period of twelve months.
  • Interventions varied in delivery settings including community settings, mental health settings and in child welfare agencies.
  • The age ranges of the children varied from 0-12 years.
  • Interventions were delivered in community settings, mental health settings and in child welfare agencies.
  • Interventions were focused on either the child only, caregiver only, or caregiver and child. Four interventions included group elements
  • Characteristics of the six interventions varied as they were based on different theoretical frameworks.

Who can deliver it?

  • The specific skills required to deliver the interventions are not listed in the review.

What are the training and supervision requirements?

  • No training or supervision requirements are given in the review

What supports good implementation?

  • Methods for maintaining fidelity are unclear.
  • It is unclear which interventions in the review used a manualized approach. However, the authors highlight that without manualization of the adaptations to the interventions needed to meet the needs of children looked after, it is difficult for providers to know how to use these adaptations, and how much adaptation is needed.
  • Without manualisation of such adaptations, it is difficult for providers to know how to use or implement these adaptations. The authors note that testing how much adaptation is needed and disseminating information around how best to implement these adaptations is necessary.

In summary...

  • Children looked after face additional barriers to receiving appropriate mental health support.This review sought to address an existing gap in the research on mental health care and young people in child welfare settings.
  • The review finds positive outcomes from six interventions. These benefits include reductions in behaviour problems and increases in caregiver positive engagement as well as placement stability.
  • However, these findings were based on a low strength of evidence.
  • All interventions included in the review were adapted to suit the needs of young people who are looked after to increase access. The review does not include details of how interventions were adapted.
  • More research is needed to determine which interventions work for whom, under which circumstances so that mental health interventions can be targeted appropriately.

Further resources