Infants entering out-of-home care: Health, developmental needs and service provision.

BACKGROUND: There are rising numbers of infants entering out-of-home care due to child protection concerns. Research has found that infants entering care are at higher risk of developmental vulnerability and poor health problems. OBJECTIVES: To determine the prevalence of developmental vulnerability for children who entered care as infants, and the extent and likelihood of service provision in relation to their developmental vulnerability. PARTICIPANTS AND SETTING: This study includes children who entered care before the age of 1 year for the first time between May 2010 and October 2011 in New South Wales, Australia, and who received final Children's Court care and protection orders by 30 April 2013. METHODS: This is a prospective cohort study using interview data from the Pathways of Care Longitudinal Study (POCLS) as well as linked administrative child protection and health data. This study used standardised assessments (Age and Stages Questionnaire and the Brief Infant Toddler Social Emotional Assessment) included in the POCLS. Simple and multiple logistic regression analysis was conducted to investigate the likelihood of infants receiving professional services for developmental delays since placement. FINDINGS: A high proportion of children who entered care as infants were identified as developmentally vulnerable through health indicators (36 %) and standardised assessments (70 %). Only 17 % of infants in care received services for developmental delay, with 20 % and 15 % of those identified as developmentally vulnerable through standardised assessments and health-related variables receiving services, respectively. CONCLUSIONS: The findings point to the importance of developmental assessment of infants in care and the identification of developmental vulnerability and delays. The provision of early intervention services is essential for this group of high-risk infants and will be important in optimising their health, as well as social and emotional outcomes.

Infant and Pre-birth Involvement With Child Protection Across Australia.

Infants (<1 year old) are the age group in Australia with the highest rate of involvement with child protection. Many jurisdictions across Australia and internationally are implementing policies focused on prenatal planning and targeted support. This study investigates Australian trends in prenatal and infant child protection notifications, substantiations and out-of-home care; and the extent of over-representation of Aboriginal and Torres Strait Islander infants. Data was provided by the Australian Institute of Health and Welfare for the period 1 July 2012-30 June 2019. Univariate Poisson regression analysis was conducted, reporting the percentage change in the incidence rate ratios. All Australian jurisdictions who collect and approved release of prenatal notification data experienced increases in the rates of children with prenatal notifications, with a 4% (IRR: 1.04(1.04-1.05)) overall increase per year across Australia. Approximately 33% of children had substantiated prenatal notifications. Rates of infant notifications and entry to care in Australia increased overall by 3% (IRR:1.03(1.03-1.04)) and 2% per year (IRR:1.02(1.01-1.03)), respectively. With rising numbers of families reported prenatally and during infancy, greater evidence of the effectiveness of policies, interventions and outcomes for children and families is required.

How do Research Ethics Committee Members Respond to Hypothetical Studies with Children? Results from the MESSI Study.

Hypothetical scenarios were used to assess the influence of the sensitivity of the study topic, payments, and study methods on research ethics committee (HREC) members' approval of social research studies involving children. A total of 183 Australian HREC members completed an online survey. The higher the perceived sensitivity of the study topic, the less likely the study would be approved by an HREC member. HREC members were most likely to approve each of the hypothetical studies if no payment was offered. Payment was the most common reason for not approving the low risk studies, while risks were the most common reasons for not approving the more sensitive studies. Face-to-face interviews conducted at home with children elicited substantially higher rates of approval from HREC members with more sensitive study topics. Both HRECs and researchers may benefit from additional guidance on managing risks and payments for children and young people in research.

Human Research Ethics Committee Experiences and Views About Children's Participation in Research: Results From the MESSI Study.

As part of a larger study, Australian Human Research Ethics Committee (HREC) members and managers were surveyed about their decision-making and views about social research studies with child participants. Responses of 229 HREC members and 42 HREC managers are reported. While most HREC members had received ethical training, HREC training and guidelines specific to research involving children were rare. Most applications involving children had to go through a full ethical review, but few adverse events were reported to HRECs regarding the conduct of the studies. Revisions to study proposals requested by HRECs were mostly related to consent processes and age-appropriate language. One-third of HREC members said that they would approve research on any topic. Most were also concerned that the methodology was appropriate, and the risks and benefits were clearly articulated. Specific training and guidance are needed to increase HREC members' confidence to judge ethical research with children.

Cluster randomized controlled trial (RCT) to support parental contact for children in out-of-home care.

BACKGROUND: There is an identified need to improve the evidence-base in relation to contact visits for children in the out-of-home-care (OOHC) system, to ensure optimal outcomes. OBJECTIVE: The aim of this cluster randomized controlled trial (RCT) was to test the effectiveness of a contact intervention for parents having supervised contact with children in long-term OOHC. PARTICIPANTS: 183 study children in 15 clusters (OOHC services) and their parent(s) were randomized to the intervention (8 clusters, 100 children) and control groups (7 clusters, 83 children) in three Australian jurisdictions. SETTING: The manualized intervention consisted of increasing the preparation and support provided by caseworkers to parents before and after their contact visits. METHOD: Interviews were conducted with carers, parents and caseworkers of the study children at baseline and nine months post-randomization. Interviews included standardized assessment tools measuring child and adult wellbeing and relationships, carer and caseworker ability to support contact, and contact visit cancellations by the parent. RESULTS: Compared with controls, the intention-to-treat (ITT) analyses showed that fewer visits were cancelled by parents in the intervention group at follow-up (-10.27; 95 % CI: -17.04 to -3.50, p = .006). In addition, per-protocol (PP) analyses showed higher caseworker receptivity to contact (6.03; 95 % CI: 0.04-12.03, p = .04), and higher parent satisfaction with contact (7.41; 95 % CI: 0.70-14.11, p = .03) in the intervention group at follow-up. CONCLUSIONS: While the intervention did not have an effect on child wellbeing, as measured by the SDQ, the trial reports significant positive findings and demonstrates the benefits of the kC kContact intervention in providing support to parents to attend contact visits. The findings of the current study provide an important contribution to knowledge in an area where few RCTs have been completed, notwithstanding the null findings.

Couple and family therapies for post-traumatic stress disorder (PTSD).

BACKGROUND: Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD. OBJECTIVES: The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings. SEARCH METHODS: We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018. SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures. MAIN RESULTS: We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses. AUTHORS' CONCLUSIONS: There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.

Tensions and contradictions in family court innovation with high risk parents: The place of family drug treatment courts in contemporary family justice.

Parental substance misuse is a leading factor in child abuse and neglect and frequently results in court-mandated permanent child removal. Family drug treatment courts, which originated in the USA and are only found in adversarial family justice systems, are a radical innovation to tackle this problem. Unlike ordinary court, they treat parents within the court arena as well as adjudicating, and in this way they seek to draw a new balance between parental needs and the child's right to timely permanency. Family drug treatment courts have spread to England, Australia and Northern Ireland and international research has found they have higher rates of parental substance misuse cessation and family reunification and lower foster care costs than ordinary courts. Yet their growth has been far from straightforward. In the USA they have not kept pace with the rise of criminal drug treatment courts and in England and Australia their numbers remain small. The central purpose of this article is to explore why the family drug treatment movement has not achieved wider impact and to consider opportunities and challenges for its future development. To address these questions we draw on evidence and experience from the USA, England and Australia. We discuss the operational challenges, tensions between children's needs for stability and parental timescales for recovery, the impact of wider economic and political change, and issues in data evaluation. We conclude that despite the promise of family drug treatment courts as a new paradigm to address risky parenting, effecting systemic change in the courts is extremely difficult.

Infant removals: The need to address the over-representation of Aboriginal infants and community concerns of another 'stolen generation'.

OBJECTIVES: The removal of a child from their parents is traumatising, particularly in Aboriginal communities where a history of child removals has led to intergenerational trauma. This study will determine where disparities in child protection involvement exist among Aboriginal and non-Aboriginal children and characteristics associated with infant removals. Challenges faced by child protection and other agencies, and opportunities for overcoming these, are discussed. METHODS: Data from both the Australian Institute of Health and Welfare and linked Western Australian government data was used to examine disparities between Aboriginal and non-Aboriginal children in the child protection and out-of-home care system. RESULTS: Nationally, Aboriginal children are ten times more likely to be placed in out-of-home care than non-Aboriginal children and this disparity starts in infancy. Infants were removed from parents with high levels of risk. Aboriginal infants were at increased risk of being removed from women with substance-use problems and had greater proportions removed from remote, disadvantaged communities than were non-Aboriginal infants. CONCLUSIONS: Aboriginal infants have a high rate of removal. Although there are many complexities to be understood and challenges to overcome, there are also potential strategies. The disparity between Aboriginal and non-Aboriginal infant removals needs to be seen as a priority requiring urgent action to prevent further intergenerational trauma.

Children in Social Research: Do Higher Payments Encourage Participation in Riskier Studies?

The MESSI (Managing Ethical Studies on Sensitive Issues) study used hypothetical scenarios, presented via a brief online survey, to explore whether payment amounts influenced Australian children and young people to participate in social research of different sensitivity. They were more likely to participate in the lower sensitivity study than in the higher at all payment levels (A$200 prize draw, no payment, $30, or $100). Offering payments to children and young people increased the likelihood that they would agree to participate in the studies and, in general, the higher the payments, the higher the likelihood of their participating. No evidence of undue influence was detected: payments can be used to increase the participation of children and young people in research without concerns of undue influence on their behavior in the face of relatively risky research. When considering the level of payment, however, the overriding consideration should be the level of risk to the children and young people.

Prenatal reporting to child protection: Characteristics and service responses in one Australian jurisdiction.

Prenatal reporting to child protection services has been enacted into most jurisdictions across Australia and in other countries, its aims being to intervene early and provide supports which will either identify or prevent the need for a baby to be taken into care and protection once born. Despite indications that there are increasing numbers of prenatal reports, little is known about the characteristics of those reported, the timing and reasons for reports, service responses, and the impacts of being reported. This study is one of the first to use administrative data to examine the characteristics of two samples from one Australian jurisdiction: (i) data from casefiles of 38 cases reported in 2012-13, and (ii) administrative data from 117 cases reported prenatally in 2013. These data showed that women who were reported to child protection services in relation to their pregnancy were predominantly disadvantaged, and were likely to be reported relatively late in their pregnancy due to 'future risk concerns'. Approximately two-thirds of those reported were provided with some prenatal support, as recorded by the child protection system, generally of limited duration. Twelve percent of the babies born to the larger cohort of women were removed within 100days of their birth. It is likely that longer term supportive interventions are needed, to reduce the risk factors evident in women reported during pregnancy, and to improve their ability to safely care for their children. Information on the short and long-term impacts from rigorous evaluations and longer-term intervention trials are also vital to ensure that prenatal reporting and interventions are, in fact, improving outcomes for infants and families.

KContact, an enhanced intervention for contact between children in out-of-home care and their parents: protocol for a cluster randomised controlled trial.

BACKGROUND: When children are unable to safely live at home with their parents, contact between these children and their parents is considered, in most cases, important for maintaining children's sense of identity and relationships with their parents. However, the research evidence on contact is weak and provides little guidance on how to manage contact and when it is beneficial or potentially harmful. The evidence in relation to contact interventions with parents and their children who are to remain in long-term care is the most limited. A small number of studies have been identified where interventions which were therapeutic, child-focused and with clear goals, particularly aimed at preparing and supporting parents, showed some promising results. This trial aims to build on the existing evidence by trialling an enhanced model of contact in multiple sites in Australia. METHODS/DESIGN: This study is a cluster randomised controlled trial of an enhanced contact intervention with children in long-term care who are having supervised contact with their parents. Intervention sites will implement the kContact intervention that increases the preparation and support provided to parents in relation to contact. Baseline and follow-up interviews are being conducted with parents, carers and agency workers at intervention and control sites. Follow-ups interviews will assess whether there has been an increase in children's emotional safety and a reduction in distress in response to contact visits with their parents (the primary outcome variable as measured using the Strength and Difficulties Questionnaire), improved relationships between children and their parents, improved parental ability to support contact, and fewer contact visits cancelled. DISCUSSION: By increasing the evidence base in this area, the study aims to better guide the management and supervision of contact visits in the out-of-home care context and improve outcomes for the children and their families. TRIAL REGISTRATION: Trial registered on 7 April 2015 with the Australian New Zealand Clinical Trials Registry ACTRN12615000313538.

The nature and extent of child protection involvement among heroin-using mothers in treatment: high rates of reports, removals at birth and children in care.

INTRODUCTION AND AIMS: A substantial proportion of women in treatment for substance use problems are mothers of dependent children, but only a small number of studies have explored the nature and extent of their child protection involvement with substance-using mothers themselves. DESIGN AND METHODS: A large sample of mothers on the opioid treatment program (OTP) in Sydney, Australia, were interviewed. This paper describes their characteristics, the extent and nature of their involvement with the child protection system, the parenting-related interventions provided and their views of their own parenting. RESULTS: The 171 mothers were disadvantaged and marginalised and had 302 children under the age of 16 years, 99 of whom were in out-of-home care. Nearly half the children in care (n = 42) had been removed at the time of their birth, and half (n = 49) had been removed from a mother who was on an OTP at the time. Among the younger children (age 1-2 years), higher proportions had been removed at birth than among the older children. None of the 32 mothers who had a child removed at birth and then gave birth subsequently retained care of their new baby. Women often chose to enter treatment (63.6%) for child-related reasons (35%) and attempted to shield their children from their substance use. Few health services were provided to them outside the availability of OTP. DISCUSSION AND CONCLUSIONS: Entering treatment presents an opportunity for improving outcomes for these women and their children and to reduce future involvement with the child protection system.

Mothers in methadone treatment and their involvement with the child protection system: a replication and extension study.

OBJECTIVES: Although a high level of involvement with the child protection system has been identified in families where parental substance use is a feature, not all such parents abuse or neglect their children or have contact with the child protection system. Identifying parents with substance-use histories who are able to care for their children without intervention by the child protection system, and being able to target interventions to the families who need them the most is important. This study interviewed a relatively large sample of mothers about their histories, their children and their involvement with the child protection system. We hypothesized that mothers in opioid pharmacological treatment who are involved with child protection services are different in characteristics to those mothers who are not involved. METHODS: One hundred and seventy-one women, with at least one child aged under 16 years, were interviewed at nine treatment clinics providing pharmacological treatment for opioid dependence across Sydney, Australia. RESULTS: Just over one-third of the women were involved with child protection services at the time of interview, mostly with children in out-of-home care. Logistic regression analyses revealed that factors which significantly increased the likelihood of the mother being involved with the child protection system were: (1) having a greater number of children, (2) being on psychiatric medication, and (3) having less than daily contact with her own parents. CONCLUSIONS: This study replicates and extends the work of Grella, Hser, and Huang (2006) and the limited literature published to date examining the factors which contribute to some substance-using mothers becoming involved with the child protection system while others do not. The finding that mental health problems and parental supports (along with the number of children) were significantly associated with child protection system involvement in this study, indicates a need for improved interventions and the provision of treatment and support services if we are to reduce the involvement of the child protection system with these families.