An Integrative Data Analysis of Main and Moderated Crossover Effects of Parent-Mediated Interventions on Depression and Anxiety Symptoms in Youth in Foster Care.

Without preventative intervention, youth with a history of foster care (FC) involvement have a high likelihood of developing depression and anxiety (DA) symptoms. The current study used integrative data analysis to harmonize data across four foster and kinship parent-mediated interventions (and seven randomized control trials) designed to reduce youth externalizing and other problem behaviors to determine if, and for how long, these interventions may have crossover effects on youth DA symptoms. Moderation of intervention effects by youth biological sex, developmental period, number of prior placements, and race/ethnicity was also examined. Youth (N = 1891; 59% female; ages 4 to 18 years) behaviors were assessed via the Child Behavior Checklist, Parent Daily Report, and Eyberg Child Behavior Inventory at baseline, the end of the interventions (4-6 months post baseline), and two follow-up assessments (9-12 months and 18-24 months post baseline), yielding 4830 total youth-by-time assessments. The interventions were effective at reducing DA symptoms at the end of the interventions; however, effects were only sustained for one program at the follow-up assessments. No moderation effects were found. The current study indicates that parent-mediated interventions implemented during childhood or adolescence aimed at reducing externalizing and other problem behaviors had crossover effects on youth DA symptoms at the end of the interventions. Such intervention effects were sustained 12 and 24 months later only for the most at-risk youth involved in the most intensive intervention.

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 was 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, but 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.

Pathways to Preventing Substance Use Among Youth in Foster Care.

Substance use problems are highly prevalent among youth in foster care. Such problems in adolescence have long-lasting implications for subsequent adjustment throughout adulthood and even across generations. Although several programs have demonstrated positive results in reducing substance use in at-risk youth, few studies have systemically examined how such programs work for foster youth and whether they are effective for both genders. This study examined the efficacy of KEEP SAFE, a family-based and skill-focused program designed to prevent substance use and other related health risking behaviors among youth in foster care. We hypothesized that improving the caregiver-youth relationship would lead to later reductions in youths' involvement with deviant peers, which subsequently would lead to less substance use, and that this mechanism would work comparably for both genders. A sample of 259 youth (154 girls, ages 11-17 years) in foster care and their caregivers participated in a randomized controlled trial and was followed for 18 months post-baseline. Results indicated that the intervention significantly reduced substance use in foster youth at 18 months post-baseline and that the intervention influenced substance use through two processes: youths' improved quality of relationships with caregivers at 6 months post-baseline and fewer associations with deviant peers at 12 months post-baseline. This suggests that these two processes may be fruitful immediate targets in substance use prevention programs for foster youth. We also found little gender differences in direct and mediating effects of the intervention, suggesting KEEP SAFE may be effective for both genders in foster care.

Effects of the KEEP Foster Parent Intervention on Child and Sibling Behavior Problems and Parental Stress During a Randomized Implementation Trial.

Children in foster care are at risk for externalizing behavior problems, which can in turn increase the risk of changes in foster care placement. The KEEP (Keeping Foster Parents Trained and Supported) foster parent training intervention was designed to equip foster parents with strategies for managing externalizing behavior problems. The primary goals of this investigation were to (a) examine the effectiveness of the KEEP intervention in reducing child behavior problems, as delivered by a community agency; (b) determine if the effects of the KEEP intervention generalize to more than one child in the same home; and (c) examine the effectiveness of the KEEP intervention in reducing parental stress associated with child behavior problems. The data from 335 foster and kinship families with children between the ages of 5 and 12 years were analyzed to address these objectives. Families were randomly assigned to the intervention or control condition. The results indicated that the KEEP intervention was effective in reducing child behavior problems when delivered by a community agency. These results expanded prior research on the KEEP intervention, revealing that the intervention was effective in reducing the behavior problems of more than one child in the same household and in reducing parental stress levels associated with the behavioral issues of the focal child. Thus, the KEEP intervention model holds promise for reducing the behavior problems of children in foster care and reducing stress levels of foster and kinship caregivers as it is disseminated and implemented within similar child welfare settings.

Predictors of externalizing behavior problems in early elementary-aged children: the role of family and home environments.

As children enter elementary school they display behavioral orientations that reveal potential developmental trajectories. Developmental transitions offer unique opportunities for examining developmental pathways and the factors that influence emerging pathways. The primary goal of this investigation was to examine characteristics of family and home contexts in predicting externalizing behavior problems among children transitioning into elementary school. Dimensions of the family and home environments of maltreated and nonmaltreated children (N = 177) were examined and used to predict externalizing behavior problems. Maltreatment was assessed using case file information, characteristics of the family and home environment were rated by interviewers, and externalizing behavior was assessed by mother's ratings on the Child Behavior Checklist. Relative to nonmaltreated children, the family environments of physically abused children were characterized by higher levels of negative social interactions. Also, in comparison to nonmaltreated children, the home environments of children who experienced neglect were characterized as less organized and clean. Hierarchical regression analyses revealed that physical abuse was the strongest predictor of externalizing behavior. After controlling for the contribution of physical abuse, mother's negative behavior toward the focal child, aggression between siblings, and the lack of an organized and clean home were each predictive of externalizing behavior.

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

PROBLEM: In order to obtain and maintain positive outcomes garnered from evidence-based practice (EBP) models, it is necessary to implement them effectively in "real world" settings, to continually monitor intervention fidelity to prevent drift, and to train new staff due to turnover. The fidelity monitoring processes that are commonly employed in research settings are labor intensive and probably unrealistic to employ in community agencies given the additional burden and cost that they represent over and above the cost of implementing the EBP. Efficient strategies for implementing fidelity monitoring and staff training procedures within the inner context of agency settings are needed to promote agency self-sufficiency and program sustainability. METHOD: A cascading implementation model was used whereby agencies who achieved proficiency in KEEP, an EBP designed to prevent placement disruptions in foster and kinship child welfare homes, were trained to take on fidelity management roles to improve the likelihood of program sustainability. Agency staff were trained to self-monitor fidelity and to train internal staff to achieve model fidelity. A web-based system for conducting fidelity assessments and for onsite/internal and remote program quality monitoring was utilized. RESULTS: Scores on fidelity ratings from streamed observations of intervention sessions showed no differences for foster parents treated by first generation interventionists trained by model developers compared to a second generation of interventionists trained by the first generation. CONCLUSION AND RELEVANCE TO CHILD WELFARE: Development of the local intra-agency capacity to manage quality intervention delivery is an important feature of successful EBP implementation. Use of the cascading implementation model appears to support the development of methods for effective monitoring of fidelity of the KEEP intervention, for training new staff, and ultimately for the development of internal methods for maintaining program sustainability and effectiveness.

Three collaborative models for scaling up evidence-based practices.

The current paper describes three models of research-practice collaboration to scale-up evidence-based practices (EBP): (1) the Rolling Cohort model in England, (2) the Cascading Dissemination model in San Diego County, and (3) the Community Development Team model in 53 California and Ohio counties. Multidimensional Treatment Foster Care (MTFC) and KEEP are the focal evidence-based practices that are designed to improve outcomes for children and families in the child welfare, juvenile justice, and mental health systems. The three scale-up models each originated from collaboration between community partners and researchers with the shared goal of wide-spread implementation and sustainability of MTFC/KEEP. The three models were implemented in a variety of contexts; Rolling Cohort was implemented nationally, Cascading Dissemination was implemented within one county, and Community Development Team was targeted at the state level. The current paper presents an overview of the development of each model, the policy frameworks in which they are embedded, system challenges encountered during scale-up, and lessons learned. Common elements of successful scale-up efforts, barriers to success, factors relating to enduring practice relationships, and future research directions are discussed.

Effectiveness of the KEEP Foster Parent Intervention during an Implementation Trial.

Externalizing behavior problems are highly prevalent among children in foster care, placing them at risk for placement disruptions and later personal and social maladjustment. The KEEP foster parent intervention was designed to equip foster parents and relative caregivers with the parenting skills necessary for managing challenging behavior problems. In prior research, the KEEP intervention was found to be effective in reducing child behavior problems. In the current study, the KEEP foster parent intervention was implemented in San Diego County during a three-year trial. The intervention was delivered by paraprofessionals employed by a local community agency (Social Advocates for Youth, San Diego) to 181 foster parent and relative caregivers of boys and girls between the ages of 5 and 12. The control group from an earlier effectiveness study of the KEEP intervention that was also conducted in San Diego County was utilized as a historical comparison group. Regression analyses were used to examine the effects of the intervention on reducing levels of child behavior problems at treatment termination. Consistent with the findings from the previous KEEP effectiveness study, the intervention was found to be effective in reducing child behavior problems when delivered by a community agency. Furthermore, the KEEP intervention was found to be effective in reducing child behavior problems among children displaying various levels of initial behavior problems.

The Relationship Between Critical Care Work Environment and Professional Quality of Life.

BACKGROUND: Professional quality of life is the quality a person feels in relation to work. For critical care nurses, it is composed of compassion satisfaction and compassion fatigue. Professional quality of life is affected by work environment. The American Association of Critical-Care Nurses (AACN) has identified 6 standards for a healthy work environment. OBJECTIVE: To explore which of the AACN healthy work environment standards have the strongest impact on professional quality of life in critical care nurses. METHODS: In an exploratory, cross-sectional survey of nurses working in 4 adult critical care units of a single health care facility, professional quality of life was assessed using the Professional Quality of Life Scale (ProQOL), and work environment was evaluated using the AACN Healthy Work Environment Assessment Tool. RESULTS: Participants reported compassion satisfaction and burnout levels as average and secondary traumatic stress levels as high. The composite average for all 6 AACN healthy work environment standards was good. A multiple regression analysis revealed true collaboration, effective decision-making, and authentic leadership as significant predictors of compassion satisfaction. Authentic leadership was the only predictor of burnout. Appropriate staffing, meaningful recognition, and authentic leadership were predictors of secondary traumatic stress. CONCLUSION: Authentic leadership is the strongest predictor of compassion satisfaction, burnout, and secondary traumatic stress. Therefore, improving leadership should be a priority in intensive care units seeking to improve nurses' professional quality of life.

Loneliness as a partial mediator of the relation between low social preference in childhood and anxious/depressed symptoms in adolescence.

This study examined the mediating role of loneliness (assessed by self-report at Time 2; Grade 6) in the relation between early social preference (assessed by peer report at Time 1; kindergarten through Grade 3) and adolescent anxious/depressed symptoms (assessed by mother, teacher, and self-reports at Time 3; Grades 7-9). Five hundred eighty-five boys and girls (48% female; 16% African American) from three geographic sites of the Child Development Project were followed from kindergarten through Grade 9. Loneliness partially mediated and uniquely incremented the significant effect of low social preference in childhood on anxious/depressed symptoms in adolescence, controlling for early anxious/depressed symptoms at Time 1. Findings are critical to understanding the psychological functioning through which early social experiences affect youths' maladjusted development. Directions for basic and intervention research are discussed, and implications for treatment are addressed.

Effects of a foster parent training intervention on placement changes of children in foster care.

Placement disruptions undermine efforts of child welfare agencies to promote safety, permanency, and child well-being. Child behavior problems significantly contribute to placement changes. The aims of this investigation were to examine the impact of a foster parent training and support intervention (KEEP) on placement changes and to determine whether the intervention mitigates placement disruption risks associated with children's placement histories. The sample included 700 families with children between ages 5 and 12 years, from a variety of ethnic backgrounds. Families were randomly assigned to the intervention or control condition. The number of prior placements was predictive of negative exits from current foster placements. The intervention increased chances of a positive exit (e.g., parent/child reunification) and mitigated the risk-enhancing effect of a history of multiple placements. Incorporating intervention approaches based on a parent management training model into child welfare services may improve placement outcomes for children in foster care.

Suffering in silence: why a developmental psychopathology perspective on selective mutism is needed.

A developmental psychopathology perspective is offered in an effort to organize the existing literature regarding the etiology of selective mutism (SM), a relatively rare disorder in which a child consistently fails to speak in 1 or more social settings (e.g., school) despite speaking normally in other settings (e.g., home). Following a brief description of the history, prevalence, and course of the disorder, multiple pathways to the development of SM are discussed, with a focus on the various genetic, temperamental, psychological, and social/environmental systems that may be important in conceptualizing this unusual childhood disorder. The authors propose that SM develops due to a series of complex interactions among the various systems reviewed (e.g., a strong genetic loading for anxiety interacts with an existing communication disorder, resulting in heightened sensitivity to verbal interactions and mutism in some settings). Suggestions are provided for future longitudinal, twin/adoption, molecular genetic, and neuroimaging studies that would be particularly helpful in testing the pathways perspective on SM.

Hostile attributional tendencies in maltreated children.

The hostile attributional tendencies of maltreated children in elementary school across key relationship figures (i.e., parents, teachers, and peers), the relation between children's hostile attributional tendencies and the frequency and severity of maltreatment, and the role of children's hostile attributions of their parents in mediating the relation between maltreatment and children's hostile attributions of unfamiliar peers were examined. The sample consisted of 44 maltreated and 56 nonmaltreated children (females = 51) of mixed ethnicity. Subjects were administered a 20-item measure of attributional processes. The results indicated that relative to nonmaltreated children, physically abused boys were more likely to attribute hostile intentions to a variety of relationship figures, including their parents, an unfamiliar teacher, their best friend, and unfamiliar peers. A positive relation was also found between the frequency of physical abuse and hostile attributional tendencies among males. Finally, support was found for the role of children's hostile attributions of their mothers in mediating the relation between physical abuse and children's hostile attributions of unfamiliar peers. The results support a link between physical abuse and hostile attributional tendencies in children in early elementary school.

Social information processing skills in children with histories of heavy prenatal alcohol exposure.

Based on caregiver report, children with prenatal alcohol exposure have difficulty with social functioning, but little is known about their social cognition. The current study assessed the social information processing patterns of school-age children with heavy prenatal alcohol exposure using a paradigm based on Crick and Dodge's reformulated six-stage model. Fifty-two children (aged 7-11) with and without heavy prenatal alcohol exposure were tested using a structured interview measure of social information processing involving 18 videotaped vignettes of children in group entry and provocation situations. Alcohol-exposed children displayed maladaptive processing patterns on the goal, response generation, and response evaluation steps in group entry situations, and encoding, attribution, response evaluation, and enactment steps during provocation situations. Children with heavy prenatal alcohol exposure also had difficulty on the Test of Problem Solving, and performance correlated with social information processing measures. Such difficulties may lead to problems in social functioning and warrant early intervention.

Peer rejection and social information-processing factors in the development of aggressive behavior problems in children.

The relation between social rejection and growth in antisocial behavior was investigated. In Study 1,259 boys and girls (34% African American) were followed from Grades 1 to 3 (ages 6-8 years) to Grades 5 to 7 (ages 10-12 years). Early peer rejection predicted growth in aggression. In Study 2,585 boys and girls (16% African American) were followed from kindergarten to Grade 3 (ages 5-8 years), and findings were replicated. Furthermore, early aggression moderated the effect of rejection, such that rejection exacerbated antisocial development only among children initially disposed toward aggression. In Study 3, social information-processing patterns measured in Study 1 were found to mediate partially the effect of early rejection on later aggression. In Study 4, processing patterns measured in Study 2 replicated the mediation effect. Findings are integrated into a recursive model of antisocial development.