Long-term impact of the Fostering Healthy Futures for Preteens program on suicide-related thoughts and behaviors for youth in out-of-home care: A randomized controlled trial.

Youth in out-of-home care are at high risk for suicide-related thoughts and behaviors (STB), yet there are no known efficacious interventions that reduce STB for this population. Fostering Healthy Futures for Preteens (FHF-P) is a 9-month community-based mentoring and skills training preventive intervention for children in out-of-home care. A randomized controlled trial enrolled 156 participants aged 9-11 years who were placed in out-of-home care over the prior year. Participants were 48.9% female, 54.1% Hispanic, 30.1% Black, and 27.1% American Indian. Follow-up interviews, conducted 7-12 years postintervention (85.2% retention rate), asked young adult participants, aged 18-22, to self-report lifetime STB as indexed by non-suicidal self-injury, suicidal thoughts, plans, and/or attempts. There was a nonsignificant reduction in the odds of STB for the intervention group at follow-up (OR = 0.74; CI, 0.32, 1.69). However, FHF-P significantly moderated the effect of baseline STB; control youth who reported baseline STB had 10 times the odds of young adult STB (OR = 10.44, CI, 2.28, 47.78), but there was no increase in the odds of adult-reported STB for intervention youth. Findings suggest that FHF-P buffers the impact of pre-existing STB on young adult STB for care-experienced youth. Further research is needed to identify mechanisms that may reduce STB in this population.

Engagement in a Preventive Intervention for Preadolescent Children in Foster Care: Considerations for Intervention Design.

Engagement in mental health-focused preventive interventions is understudied. Demographic, child, and system-level predictors of engagement were explored in a study with children in foster care (N = 222, Mage = 10.3) who participated in a 30-week intervention. Attendance and engagement in mentor visits and skills groups were rated weekly. Only 4 of 21 predictors showed bivariate associations with attendance/engagement: child sex, IQ, behavior problems, and trauma symptoms. SEM models with these three variables and a measure of adverse childhood experience (ACEs), were used to develop a model of engagement. Males had poorer mentor visit and group engagement. Group attendance was positively associated with trauma symptoms and negatively associated with ACEs. Group engagement was associated with higher IQ and fewer behavior problems. A contextually-sensitive intervention can result in high engagement for a vulnerable and diverse population, yet a few child factors still impacted engagement, and when identified could be ameliorated.Trial Registration ClinicalTrials.gov, Identifiers: NCT00809315 & NCT00810056.

Mentoring Children in Foster Care: Examining Relationship Histories as Moderators of Intervention Impact on Children's Mental Health and Trauma Symptoms.

Mentoring-based interventions show promise among children in foster care, but previous research suggests that some benefit more than others. Because children in foster care experience relationship disruptions that could affect mentoring effectiveness, we examined whether children's relational histories at baseline (i.e., relationship quality with birth parents, relationship quality with foster parents, caregiver instability, and previous mentoring experience) moderated the impact of a mentoring intervention on children's mental health, trauma symptoms, and quality of life. Participants included 426 racially and ethnically diverse children (age: 9-11; 52% male) who participated in a randomized controlled trial of the Fostering Healthy Futures program (FHF), a 9-month one-to-one mentoring and skills group intervention. Results showed that relationship quality with foster parents and prior mentoring experience did not moderate intervention impact. Relationship quality with birth parents and caregiver instability pre-program, however, moderated the effect on some outcomes. The impact on quality of life was stronger for children with weaker birth parent relationships and fewer caregiver changes. Likewise, the impact on trauma symptoms was stronger for those with fewer caregiver changes. Overall, FHF seems to positively impact children with varied relational histories, yet some may derive more benefits - particularly those with fewer caregiver changes pre-program.

Sexual and Reproductive Health Protective Factors among Adolescents with Child Welfare Involvement.

Youth with child welfare involvement experience disproportionate rates of sexual and reproductive health (SRH) risks and adverse outcomes. However, little is known about SRH protective factors among youth with child welfare involvement. This study examined whether birth control knowledge or SRH agency, norms, and expectancies differed by gender, age, race/ethnicity, or out-of-home care status among 245 youth, ages 12-15, with open child welfare cases due to maltreatment. Less than half of participants had received information on birth control or knew how to access birth control services; however, the majority reported high confidence in avoiding sex when not desired, strong peer norms for condoms, and few perceived benefits to unprotected sex. Males and younger adolescents had fewer protective attitudes and birth control knowledge, while Latinas had more protective attitudes. This study highlights the protective SRH attitudes already held by youth (ages 12-15) with child welfare involvement, as well as the need for early and gender-inclusive SRH education.

Fostering Healthy Futures Preventive Intervention for Children in Foster Care: Long-term Delinquency Outcomes from a Randomized Controlled Trial.

Child maltreatment and foster care placement are strong risk factors for delinquency and juvenile justice involvement, and there is substantial crossover between youth in the child welfare and juvenile justice systems. This study examines the long-term impact of the Fostering Healthy Futures (FHF) program, a 30-week mentoring and skills group preventive intervention for preadolescent maltreated children in foster care. Participants included 426 children recently placed in out-of-home care who were randomized to intervention or control conditions. Outcomes included both self-reported delinquency, measured at multiple time points between 6 months and 12 years post-intervention, as well as court records of delinquency charges, which were measured for 7 consecutive years beginning 3 months after the intervention began. Results from multilevel models indicated that the intervention group self-reported 30-82% less total and non-violent delinquency than the control group between ages 14 and 18. Court charges for total and violent delinquency in mid-adolescence were also 15-30% lower for the intervention group. These findings indicate that a mentoring and skills training program in preadolescence can reduce delinquency and justice involvement for children who are at high risk for these outcomes.

Assessing the Mental Health of Maltreated Youth with Child Welfare Involvement Using Multi-Informant Reports.

Researchers often question the validity of multi-informant assessments among adolescents with child welfare involvement. Yet, within other clinical populations, prior research finds that multi-informant reports have a discernable structure characterized by discrete patterns of agreement and disagreement. This structure "tracks" contextual displays of behavior and clinical severity. We examined the structure of multi-informant reports (i.e., adolescent, caregiver, teacher) of adolescent externalizing and internalizing problems in a sample of adolescents with a history of child welfare involvement. Across problem domains and informants, reporting patterns mirrored those observed in other clinical populations, and displayed characteristics robustly present in meta-analytic work on cross-informant correspondence. Specifically, informants agreed more on reports of externalizing problems than internalizing problems and caregiver-teacher dyads agreed more than adolescent-caregiver dyads. Overall, we found robust, replicable patterns of multi-informant reports among child welfare involved adolescents. These reporting patterns may facilitate use and interpretation of multi-informant evidence-based assessments among this population.

The Moderating Effect of Risk Exposure on an Efficacious Intervention for Maltreated Children.

The current study extends research on the impact of the Fostering Healthy Futures program (Taussig & Culhane, 2010), a 9-month mentoring and skills group preventive intervention for maltreated children, by examining whether the effect of Fostering Healthy Futures is moderated by children's baseline risk exposure (i.e., number of adverse childhood experiences). Participants included 156 racially and ethnically diverse children (ages 9-11, 50.7% female) recently placed in foster care due to maltreatment who were randomized to intervention or control conditions. Baseline and 6-month postintervention measures included a multi-informant index of mental health functioning and youth-reported symptoms of posttraumatic stress, dissociation, coping skills, social-acceptance, global self-worth, social support, and quality of life. A previously published, empirically derived risk index was used to assess level of exposure to 6 adverse childhood experiences (i.e., physical abuse, sexual abuse, removal from a single parent household, high level of exposure to community violence, and high numbers of caregiver and school transitions). Significant Intervention × Risk interactions were observed in regression models predicting 6-month postintervention symptoms of posttraumatic stress (ß = .38, p < .001) and dissociation (ß = .30, p < .01). Among children with low to moderate levels of risk, intervention participants evidenced fewer symptoms, whereas intervention participants with high levels of risk did not differ from the control group. The results of this study suggest that maltreated children exposed to high numbers of adverse childhood experiences may not experience the same reduction in trauma symptoms postintervention relative to children exposed to fewer adversities.

A Positive Youth Development Approach to Improving Mental Health Outcomes for Maltreated Children in Foster Care: Replication and Extension of an RCT of the Fostering Healthy Futures Program.

Preventing the negative impact of maltreatment on children's mental health requires interventions to be contextually sensitive, grounded in theory and research, and effective in reaching and retaining children and families. This study replicates and extends previous findings of the Fostering Healthy Futures (FHF) program, a 30-week mentoring and skills group intervention for preadolescent maltreated children in foster care. Participants included 426 children recently placed in out-of-home care who were randomized to intervention or control conditions. Outcomes measured 6-10 months postintervention included a multi-informant (child, caregiver, teacher) index of mental health problems as well as measures of posttraumatic stress symptoms, dissociative symptoms, quality of life, and use of mental health services and psychotropic medications. There were high rates of program initiation, retention, and engagement; 95% of those randomized to FHF started the program, 92% completed it, and over 85% of the mentoring visits and skills groups were attended. The FHF program demonstrated significant impact in reducing mental health symptomatology, especially trauma symptoms, and mental health service utilization. These program effects were consistent across almost all subgroups, suggesting that FHF confers benefit for diverse children. Results indicate that positive youth development programming is highly acceptable to children and families and that it can positively impact trauma and its sequelae.

Do sleep problems mediate the link between adverse childhood experiences and delinquency in preadolescent children in foster care?

BACKGROUND: Adverse childhood experiences (ACEs) are associated with multiple mental and physical health problems. Yet, mechanisms by which ACEs confer risk for specific problems are largely unknown. Children in foster care typically have multiple ACEs and high rates of negative sequelae, including delinquent behaviors. Mechanisms explaining this link have not been explored in this population. Impaired sleep has been identified as a potential mechanism by which ACEs lead to delinquency in adolescents, because inadequate sleep may lead to poor executive function and cognitive control - known risk factors for delinquency. METHODS: Interviews were conducted with 516 maltreated children in foster care, ages 9-11 years, and their caregivers regarding child exposure to ACEs, sleep problems, engagement in delinquent acts, symptoms of posttraumatic stress disorder, and current psychotropic medication use. ACEs data were also obtained from child welfare case records. RESULTS: After controlling for age, gender, race/ethnicity, placement type (residential, kin, foster), length of time in placement, posttraumatic stress symptoms, and current psychotropic medication use, sleep partially mediated the association between ACEs and delinquency. CONCLUSIONS: Although delinquency is likely multiply determined in this population, improving sleep may be one important strategy to reduce delinquency.

Adverse Childhood Experiences and Health-Risk Behaviors in Vulnerable Early Adolescents.

Adverse childhood experiences (ACEs) are associated with health-risk behaviors in general samples of adults and adolescents. The current study examined the association between ACEs and these behaviors among a high-risk sample of early adolescents. Five hundred and fifteen 9-11-year-old children placed in foster care due to maltreatment were interviewed about their engagement in violence, substance use, and delinquency. A multi-informant ACEs score was derived based on exposure to six adverse experiences. Regression analyses examined the relationship between ACEs and risk behaviors and the potential moderating effects of age, sex, and minority status. ACE scores were predictive of risk behaviors after controlling for age, sex, and minority status. Although males and older youth were more likely to engage in risk behaviors, none of the demographic characteristics moderated the ACE-risk behavior association. This study extends previous research by demonstrating an association between ACEs and risk behaviors in extremely vulnerable early adolescents.

Pregnancy Attitudes and Contraceptive Use among Young Adults with Histories of Foster Care.

INTRODUCTION: This study examined pregnancy attitudes and contraceptive use among young adults with histories of foster care. METHODS: 209 female and male young adults, aged 18-22, with histories of foster care were interviewed about their intentions and feelings towards pregnancy. Respondents were then categorized as having pro-pregnancy (i.e., having positive pregnancy intentions and happy feelings about pregnancy), ambivalent (either intentions or happy feelings), or anti-pregnancy (no intentions and unhappy feelings) attitudes. Participants also reported their past-year contraceptive use, and the relationship between pregnancy attitudes and contraceptive use was subsequently explored for the overall sample, and by sex and history of pregnancy using Chi-square tests. RESULTS: Only 13.4% of participants had positive pregnancy intentions, though 41.9% reported that they would feel happy with a pregnancy. Over half (55.9%) of participants were anti-pregnancy, a third (32.8%) were ambivalent and 11.3% were pro-pregnancy. Compared to females, males were more likely to have positive pregnancy intentions (18.6% vs. 7.8%, p = .03) and to be pro-pregnancy (16.5% vs. 5.6%, p = .04). No differences in pregnancy attitudes were found as a function of pregnancy history. Consistent contraceptive use was significantly associated with pregnancy attitudes; 22.2% of pro-pregnancy participants reported consistent contraceptive use versus 52.9% of ambivalent and 62.2% of anti-pregnancy participants. DISCUSSION: In this exploratory study, few participants held pro-pregnancy attitudes and a high percentage of participants who were anti-pregnancy did not use contraception consistently. Although studies with larger samples examining this topic are needed, professionals should distinguish between young adults' intentions and feelings about pregnancy in an effort to better address contraceptive needs.

Mentoring Relationship Quality and Maltreated Children's Coping.

Coping strategies are believed to protect against the harmful effects of maltreatment on children's psychosocial outcomes. Caregivers are thought to be critical in helping children develop adaptive coping strategies, yet many maltreated children have poor and/or insecure relationships with their parents. A quality relationship with a caring, non-parental adult (e.g., a mentor), however, may be one strategy to promote healthy coping among maltreated children. Children (N = 154) in this study participated in a mentoring and skill-based program for maltreated preadolescents placed in foster care. Hierarchical regression was used to assess the association between children's reports of their relationship with their mentor at the end of the intervention and four coping strategies (i.e., Active, Support-seeking, Avoidance, and Distraction) 6 months following the intervention, while accounting for baseline coping strategies and other demographic factors. Above and beyond the covariates, better mentoring relationship quality was associated with children's greater use of Active and Distraction coping 6-month post-intervention. Mentoring relationship quality was not significantly associated with children's Avoidance or Support-seeking coping. The findings suggest that mentoring programs may be a fruitful approach to improving vulnerable children's coping skills. Healthy coping is hypothesized to protect against the harmful effects of maltreatment and to promote resilience in the face of multiple stressors (Banyard & Williams, ; Boxer & Sloan-Power, 2013; Cicchetti & Rogosch, 2009). It remains unclear, however, how best to promote positive coping among maltreated children, who are disproportionately exposed to numerous adverse childhood experiences (Raviv, Taussig, Culhane & Garrido, 2010). Theories of coping emphasize the importance of coping socialization through quality parent-child relationships (Kliewer et al., 2006; Skinner & Wellborn, ). Unfortunately, many maltreated children are exposed to poor quality and/or inadequate caregiving (Baer & Martinez, 2006), which may place them at risk for engaging in unhealthy or inappropriate forms of coping. It is reasonable to expect that positive relationships with other non-parental adults (e.g., mentors) would affect coping behaviors given the positive impact that quality relationships have on a myriad of emotional and behavioral child outcomes (DuBois, Portillo, Rhodes, Silverthorn & Valentine, 2011; Keller & Pryce, 2012; Thomson & Zand, ). Because children in foster care often transition in and out of schools and home environments, a quality relationship with a mentor (a consistent presence in the child's life) may be well suited to promote healthy coping strategies.

Mental Health Interventions for Children in Foster Care: A Systematic Review.

Children in foster care have high rates of adverse childhood experiences and are at risk for mental health problems. These problems can be difficult to ameliorate, creating a need for rigorous intervention research. Previous research suggests that intervening with children in foster care can be challenging for several reasons, including the severity and complexity of their mental health problems, and challenges engaging this often transitory population in mental health services. The goal of this article was to systematically review the intervention research that has been conducted with children in foster care, and to identify future research directions. This review was conducted on mental health interventions for children, ages 0 to 12, in foster care, using ERIC, CINAHL, PsycINFO, PubMed, ProQuest's Dissertation and Theses Database, Social Services Abstracts, and Social Work Abstracts. It was restricted to interventions that are at least "possibly efficacious" (i.e., supported by evidence from at least one randomized controlled trial). Studies were evaluated for risk of bias. Ten interventions were identified, with diverse outcomes, including mental health and physiological. Six interventions were developed for children in foster care. Interventions not developed for children in foster care were typically adapted to the foster context. Most interventions have yet to be rigorously evaluated in community-based settings with children in foster care. Little research has been conducted on child and family engagement within these interventions, and there is a need for more research on moderators of intervention outcomes and subgroups that benefit most from these interventions. In addition, there is not consensus regarding how to adapt interventions to this population. Future research should focus on developing and testing more interventions with this population, rigorously evaluating their effectiveness in community-based settings, determining necessary adaptations, and identifying which interventions work best for whom.

Student Satisfaction With an Innovative Internship.

This article describes an internship program designed specifically to meet graduate students' training needs within the context of their work in a prevention program for children in foster care. An internship based on a strong model of intern recruitment and supervision, structured inclusion of interns in a supportive agency culture, a manualized orientation, and an ongoing didactic program, was hypothesized to result in a positive experience for interns. Results of anonymous surveys administered to 102 interns over a 9-year period assessing their internship experience are presented and discussed. Recommendations are made for development of internship training sites.

Dissociative symptoms and academic functioning in maltreated children: a preliminary study.

Research has identified numerous negative sequelae of child maltreatment that may adversely impact academic functioning (AF). There is limited research, however, on the relationship between specific trauma symptoms, such as dissociation, and poor AF. This cross-sectional study examined the association between dissociative symptoms and multi-informant reports of AF in a sample of maltreated youth with a history of out-of-home care. Participants included 149 youth and their caregivers and teachers. Dissociative symptoms were measured based on youth report, whereas AF was assessed using (a) standardized measures of academic achievement, (b) youth-report measures of school membership and perceived academic competence, (c) caregiver reports of youths' performance in school, and (d) teacher reports of student grades. Results of multiple regression analyses suggested that dissociative symptoms were generally related to poorer AF after IQ, age, gender, and the total number of school and caregiver transitions were controlled. Implications for school personnel are discussed.

Sources and Types of Social Supports and Their Association with Mental Health Symptoms and Life Satisfaction among Young Adults with a History of Out-of-Home Care.

Young adults with a history of out-of-home care report poorer mental health and life satisfaction compared to non-care-experienced peers. Social support is a known protective factor for mental health. There is limited evidence, however, on the relationship between sources (e.g., family members) and types (e.g., information) of social support and mental health symptoms and life satisfaction in this population. Reporting cross-sectional survey data from 215 young adults aged 18-22 years with a history of out-of-home care, the current study conducted descriptive, bivariate, and linear regression analysis to examine the different sources and types of support young adults receive and their relation to mental health symptoms and life satisfaction. Participants had high levels of support from family members, friends, and other adults. Most participants had informational support, but less than half had consistent material support. Regression analyses demonstrated that having enough informational and material support were associated with fewer mental health symptoms. Having family support and material support were associated with greater life satisfaction. Further longitudinal research is needed to understand the trajectory between social supports and mental health functioning and life satisfaction.

Anger and Attention Problems as Mechanisms Linking Maltreatment Subtypes and Witnessed Violence to Social Functioning Among Children in Out-of-Home Care.

Research has consistently shown that child maltreatment and witnessed violence lead to disrupted patterns of social functioning, yet the mechanisms underlying these pathways remain unclear. This cross-sectional study evaluated whether anger and/or attention problems mediated the links from abuse, neglect, and witnessed violence to peer problems and aggressive behavior. Participants included a diverse sample of 470 children (ages 8-11; 52.1% boys) living in out-of-home care. Subtype and severity of maltreatment exposure were coded using Child Protection Services' intake reports and court records. Witnessed violence and anger were assessed using child-reports, and caregivers provided ratings of attention problems and social functioning. Indirect effects were tested using a series of structural equation path analysis models. Results indicated that anger fully mediated the links from witnessed violence to both peer problems and aggressive behavior. Further, attention problems fully mediated the links from physical abuse and physical neglect to both peer problems and aggressive behavior. These findings highlight the need for interventions to target anger regulation and attentional control among children in out-of-home care in order to mitigate their risk for social maladjustment.

Attention Problems Mediate the Association between Severity of Physical Abuse and Aggressive Behavior in a Sample of Maltreated Early Adolescents.

Empirical evidence has accumulated documenting an association between childhood physical abuse and aggressive behavior. Relatively fewer studies have explored possible mediating mechanisms that may explain this association. The purpose of the current study was to examine whether caregiver- and youth-reported attention problems mediate the association between physical abuse severity and aggressive behavior. A sample of 240 maltreated early adolescents (ages 9-11) and their caregivers were interviewed within 14 months of being removed from the home. Results from multiple regression analyses indicated that caregiver- and youth-reported attention problems were partial mediators of the association between physical abuse severity and aggressive behavior. These associations were significant even after controlling for children's intellectual functioning, sex, age, and severity of other maltreatment types. Possible explanations for the detrimental impact of physical abuse on behavior are discussed, along with the implications of the current study's results for interventions aimed at reducing early adolescent aggressive behavior.

Do youth in out-of-home care receive recommended mental health and educational services following screening evaluations?

For children in out-of-home care, a significant gap exists between those who need services and those who receive them. Screening all children in out-of-home care is recommended to reduce this gap. This study was designed to determine if recommendations from mental health and educational screening evaluations were related to service implementation for youth in out-of-home care. Screening evaluations were completed with 171 maltreated youth (ages 9 to 11) in out-of-home care within the prior year. Written reports summarizing the findings were provided to children's caseworkers. Service utilization was assessed at baseline (T1; before screening reports were completed) and follow-up (T2; 9-12 months later) interviews. For children not already receiving services at T1, logistic regression analyses tested the association between T1 recommendations for services and new service implementation by T2. Mental health (youth-report) and educational (teacher-report) outcomes were analyzed separately. Screening evaluations identified 22% of children with unmet mental health needs and 36% with unmet educational needs at T1. Children who received a recommendation for new services (i.e., all of those with unmet needs) were more likely to receive mental health (OR=2.50, p=.06) and/or educational (OR=3.54, p=.04) services by T2 than children who did not receive recommendations for services. While recommendations increased the odds of receiving services, almost half of the children with unmet mental health needs did not receive services, and 84% of children with unmet educational needs did not receive services by T2. Much work remains to ensure youth receive needed services.

Interventions to prevent child maltreatment and associated impairment.

Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown. Two specific home-visiting programmes-the Nurse-Family Partnership (best evidence) and Early Start-have been shown to prevent child maltreatment and associated outcomes such as injuries. One population-level parenting programme has shown benefits, but requires further assessment and replication. Additional in-hospital and clinic strategies show promise in preventing physical abuse and neglect. However, whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. A specific parent-training programme has shown benefits in preventing recurrence of physical abuse; no intervention has yet been shown to be effective in preventing recurrence of neglect. A few interventions for neglected children and mother-child therapy for families with intimate-partner violence show promise in improving behavioural outcomes. Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care; enhanced foster care shows benefits for children. Future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.