Adverse Childhood Experiences and Foster Care Placement Stability.

OBJECTIVES: To examine the impact of cumulative adverse childhood experiences (ACEs) on a child's foster care placement stability in Kansas. METHODS: Secondary data analysis was conducted by using a purposive cohort sample of 2998 children, from 6 to 18 years old, in Kansas's foster care system between October 2015 and July 2019. Multivariate hierarchical logistic regression models were used to examine the influence of cumulative ACEs on a child's placement stability. ACEs were measured at foster care intake and self-reported by the child. Placement stability variables were obtained through the state administrative database. RESULTS: Children in foster care with greater cumulative ACE exposure were significantly more likely to experience placement instability. Compared to children with 1 to 5 ACEs, when controlling for all other variables, children with ≥10 ACEs had an increased odds of experiencing placement instability by 31% (odds ratio: 1.31; P < .05); and children with 6 to 9 ACEs had a 52% (odds ratio: 1.52, P < .001) increased odds of experiencing placement instability. A child's race, biological sex, age at episode start, and whether they had siblings in foster care all significantly influenced placement instability. CONCLUSIONS: Findings from this study, in conjunction with previous research on ACEs and foster care, highlight the need to proactively address ACEs and trauma exposure at foster care entry.

Looked-after children and young people

This guideline covers how organisations, practitioners and carers should work together to deliver high-quality care, stable placements and nurturing relationships for looked-after children and young people. It aims to help these children and young people reach their full potential and have the same opportunities as their peers.

Investigating the Relationship between Trauma Symptoms and Placement Instability.

BACKGROUND: Placement stability while in foster care has important implications for children's permanency and well-being. Though a majority of youth have adequate placement stability while in foster care, a substantial minority experience multiple moves during their time in care. Research on correlates of placement instability has demonstrated a relationship between externalizing behaviors and placement instability. Likewise, evidence suggests higher levels of trauma are associated with increased externalizing behaviors. However, few studies have examined the relationship between trauma symptoms and placement instability. OBJECTIVE: The purpose of this study was to investigate whether children with clinically significant trauma symptoms had higher odds of placement instability. PARTICIPANTS AND SETTING: Administrative data collected as a part of a summative evaluation for a federally-funded trauma III grant project were used. The sample included 1,668 children ages 5 and older who entered foster care during a 30-month period in a Midwestern state and completed a self-reported trauma screen within 120 days of entering care. METHODS: Hierarchical logistic regression was conducted to examine the contributions of trauma symptoms scores to placement instability, above and beyond demographic characteristics and case characteristics. RESULTS: Results from the final analytic model, which controlled for demographic and case characteristics, showed that children with clinically significant trauma symptoms (i.e., scores ≥19) had 46% higher odds of experiencing placement instability (OR = 1.46, 95% CIs [1.16, 1.82], p = .001). Findings support the need to screen for and treat trauma symptomology among youth in foster care.

Parenting intervention outcomes for kinship caregivers and child: A systematic review.

BACKGROUND: Kinship foster caregivers often face serious challenges but lack adequate parenting capacities and resources. The importance of parenting interventions for kinship foster caregivers has been recognized, and researchers have assessed the effect of various parenting interventions on the caregivers and children. However, no systematic review has been conducted to summarize findings related to parenting interventions targeting kinship care. OBJECTIVES: This study systematically summarizes the effect of parenting interventions on kinship foster caregivers and their cared for children, and examines the intervention strategies and research methods used in order to provide a context in which to better understand effects of interventions. METHODS: From six academic databases, 28 studies were identified for review. A data template was used to extract the following information from each study: intervention targets, research design, settings, intervention description, outcome measures, and main results for each study. RESULTS: Various parenting interventions targeting kinship foster care families have been developed to improve parenting capacities and reduce parental stress. Most of the interventions had a positive impact on the outcomes of both caregivers and children, although the assessed outcomes often differed across studies. Parenting interventions improve caregivers' parenting competency, reduce parental stress, and advance child wellbeing. However, some interventions appear less promising in achieving targeted goals. DISCUSSION: The findings suggest that promoting evidence-based parenting interventions with a special focus on kinship care is important for child welfare. Future directions for research are also discussed in this study.

Suicide in Foster Care: A High-Priority Safety Concern.

Suicide rates among youths in foster care are among the highest in the United States. Despite this fact, many foster-care agencies do not perform universal suicide-risk assessments as part of routine care. This commentary includes an argument for the importance of implementing universal suicide-risk assessments for youths in foster care. Important contextual information that prevents behavioral-health clinicians from implementing universal suicide screenings of youths in foster care is discussed. Several possible strategies for implementing universal suicide-risk assessments are offered; the pros and cons of each strategy are discussed. The perspectives of multiple stakeholders should be included in the consideration of universal suicide screening for youths in foster care, including behavioral-health providers, primary-care doctors, supervisors, directors of agencies, foster parents, and case managers. Although each of these stakeholders can improve suicide prevention, youths in foster care may not have regular access to each stakeholder. Case managers may be the optimal stakeholders for implementing universal suicide screening because of their frequent access to youths in foster care; therefore, case managers should receive training in suicide-risk assessment and prevention strategies.

Interventions and practice models for improving health and psychosocial outcomes of children and young people in out-of-home care: protocol for a systematic review.

INTRODUCTION: Children and young people placed in out-of-home care (OoHC) are often affected by a history of trauma and adverse childhood experiences. Trauma in early childhood can impact on children's health and psychosocial development, whereas early interventions can improve children's development and placement stability. Although several interventions and practice models have been developed to improve health and psychosocial outcomes for children and young people in OoHC, there remains a lack of rigorous research examining the impact of these interventions in OoHC settings, as there are no systematic reviews examining the impact these interventions and practice models have on the children and young people they serve. We aim to conduct a comprehensive systematic review to examine the effectiveness of interventions and practice models for improving health and psychosocial outcomes in children and young people living in OoHC and to identify relevant knowledge gaps. METHODS AND ANALYSIS: Major electronic databases including Medline, Medline in-process and other non-indexed citations, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Sociological Abstracts and all Evidence-Based Medicine Reviews incorporating: Cochrane Database of Systematic Reviews, American College of PhysiciansJournal Club, Database of Abstracts of Reviews of Effects,Cochrane Central Register of Controlled Trials, CochraneMethodology Register, Health Technology Assessment and National Health Service Economic Evaluation Database, will be systematically searched for any studies published between 2008 and 2018 of interventions and practice models developed to improve health and psychosocial outcomes for children and young people in OoHC. Two independent reviewers will assess titles and abstracts for eligibility according to prespecified selection criteria and will perform data extraction and quality appraisal. Meta-analyses and/or metaregression will be conducted where appropriate. ETHICS AND DISSEMINATION: This study will not collect primary data and formal ethical approval is therefore not required. Findings from this systematic review will be disseminated in a peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42019115082.

Improving Information Sharing for Youth in Foster Care.

There are ∼443 000 children in child protective custody (ie, foster care) in the United States. Children in protective custody have more medical, behavioral, and developmental problems that require health care services than the general population. These health problems are compounded by poor information exchange impeding care coordination. Health care providers often do not know which of their patients are in protective custody and are not privy to the critical social history collected by child protective services, including placement history and maltreatment history. Meanwhile, the custodial child protection agency and designated caregivers (ie, foster caregivers and kinship providers) often lack vital elements of the health history of children in their care, which can result in poor health care delivery such as medication lapses, immunization delay, and poor chronic disease management. In this case study, we address this critical component of health care delivery for a vulnerable population by describing a process of developing an information sharing system between health care and child welfare organizations in collaboration with child protection community partners. Lessons learned include recommended steps for improved information sharing: (1) develop shared community vision, (2) determine shareable information components, (3) implement and analyze information sharing approaches, and (4) evaluate information sharing efforts. A successful example of advocating for improvement of information sharing for youth in protective custody is explored to highlight these steps. In collaboration with child protective services, pediatricians can improve information sharing to impact both health care delivery and child protection outcomes.

Comprehensive Health Evaluation of the Newly Adopted Child.

Children who join families through the process of adoption, whether through a domestic or international route, often have multiple health care needs. Pediatricians and other health care personnel are in a unique position to guide families in achieving optimal health for the adopted children as families establish a medical home. Shortly after placement in an adoptive home, it is recommended that children have a timely comprehensive health evaluation to provide care for known medical needs and identify health issues that are unknown. It is important to begin this evaluation with a review of all available medical records and pertinent verbal history. A complete physical examination then follows. The evaluation should also include diagnostic testing based on findings from the history and physical examination as well as the risks presented by the child's previous living conditions. Age-appropriate screenings may include, but are not limited to, newborn screening panels and hearing, vision, dental, and formal behavioral and/or developmental screenings. The comprehensive assessment may occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children can be referred to other medical specialists as deemed appropriate. The Council on Adoption, Foster Care, and Kinship Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.

"There are carers, and then there are carers who actually care"; Conceptualizations of care among looked after children and care leavers, social workers and carers.

BACKGROUND: Looked after children and care leavers (LACCL) are some of the most vulnerable and marginalized young people in our communities. Existing research demonstrates that this group often interprets care in terms of genuineness and tends to feel uncared for. Less work exists from the perspective of social workers and formal carers. OBJECTIVE: This study aims to explore how care is perceived and practiced among LACCL and those with a duty of care for them. We use a theoretical lens of care ethics to compare and contrast understandings in order to explore how they affect the delivery and receipt of care. PARTICIPANTS & SETTING: There were 44 participants from four local authorities in north-east England including nineteen LACCL aged 12-20, eight social workers, and nineteen formal carers. METHOD: Twenty-eight semi-structured 1:1 interviews, four dyad interviews and three focus group interviews. RESULTS: LACCL desired care that felt familial, went beyond minimum standards and involved understanding. Social workers had to manage LACCL expectations and build relationships by both rationing care according to role constraints whilst sometimes going 'above and beyond' statutory care. Carers conceptualized care in terms of dedication and discipline but felt limited in their ability to achieve care in this way. CONCLUSION: Bridging different conceptualizations of care is necessary to achieve integrated support for these vulnerable young people whilst also helping them to develop key skills for later adult life. A deeper understanding of frameworks of care has implications for social worker and formal carer training and practice.

Heuristic decision-making in foster care matching: Evidence from a think-aloud study.

Complex decisions are often based on heuristics, which are shortcuts or simple 'rules of thumb'. Since the matching decision in family foster care is often made in a less-than-ideal setting and riddled with uncertainty, heuristics are expected to be applied in that field of child and youth care on a daily basis. However, the use of heuristics in the matching decision has not been studied empirically until now. This research explores how decision-making heuristics are used by practitioners to determine which foster family is the best fit for a child. A number of 20 matching practitioners from the Netherlands were interviewed using vignettes and a 'think-aloud' methodology to generate an understanding of their reasoning. Two types of vignettes were created: hypothetical children and hypothetical foster families. The interviews were analyzed using a qualitative deductive content analysis focusing on key indicators of three classes of heuristics: recognition heuristics, one-reason heuristics, and trade-off heuristics. The results show that recognition heuristics did not play a decisive role in the matching process; practitioners considered more than one family before making a final decision. The findings for the one-reason heuristics reveal conjunctive decision-making rules; families were rejected based on one negative premise. The analysis of the trade-off heuristics demonstrates that the number of positive premises and the ratio between positive and negative premises predicted the matching decision. However, the total number of premises also predicted the matching decision, which might indicate confirmation bias.

Identifying effective interventions for promoting parent engagement and family reunification for children in out-of-home care: A series of meta-analyses.

BACKGROUND: An important obstacle for family reunification following child placement in residential care and other temporary out-of-home care services is the lack of engagement among parents. OBJECTIVE: The aim of this meta-analysis is to identify the most effective interventions to promote parental engagement and family reunification. METHOD AND PARTICIPANTS: Eight studies, for a total of 2996 families, were used to conduct two series of meta-analyses. Each study examined the effectiveness of a goal-oriented parental engagement intervention, relative to a control group made up of parents who received standard services. Six moderators were analyzed: type of clinical modality, number of clinical strategies, sources of motivation for intervention, focus on the child care staff-parent relationship, child care staff training, and strategies to promote access to intervention. RESULTS: Results indicate that parents exposed to goal-oriented engagement interventions showed greater engagement (effect size d = 0.71, CI: 0.35-1.07, p < 0.001) and likelihood of reunification (effect size OR = 2.49, CI: 1.22-5.10, p < 0.05) than parents who received standard services. In particular, moderator analysis showed that parents who specifically participated in a family-focused intervention showed the highest engagement in comparison to parents involved in other types of interventions or who received standard services (effect size d = 1.08, CI: 0.58-1.59, p < 0.001). No moderators significantly explained heterogeneity of studies on family reunification. CONCLUSION: Overall, the results underline the effectiveness of family-focused interventions to promote parental engagement. Nevertheless, greater knowledge on the mechanisms by which interventions can increase parents' engagement and family reunification is still needed.

Improving Timeliness of Medical Evaluations for Children Entering Foster Care.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics (AAP) recommends children in foster care (FC) have an initial medical evaluation within 3 days of custody initiation; however, this vulnerable population often suffers from disjointed care. Our aim was to improve the mean time to initial foster care evaluation (TIE) from 32 to <7 days within 12 months for children in FC in Durham County, North Carolina. METHODS: This study was a time series, quality improvement project used to target interventions within an academic clinic and a community agency. Interventions were tested through multiple plan-do-study-act cycles. Control charts of the primary outcome, the TIE, were constructed. Charts were annotated with the dates of interventions, including workshops, performance feedback, integration of state forms, identification of appointments, development of an urgent appointment pathway, and empowerment of the scheduler. RESULTS: The mean TIE improved from 32 to 9 days within 12 months. Significant improvement in the following 2 process measures contributed to this: the time from custody initiation to the referral date improved from an average of 10 to 3 days, and the time from referral date to the initial evaluation improved from an average of 22 to 6 days. CONCLUSIONS: Improvement interventions and increased collaboration between medical and child welfare agencies can result in significant improvement of the TIE. However, despite improvement efforts, challenges remain in meeting the AAP 3-day TIE recommendation. We recommend further assessment of the AAP guideline as it relates to implementation feasibility and health outcomes of children in FC.

Improving Hospital-to-Home Transitions for Children Entering Foster Care.

BACKGROUND AND OBJECTIVES: Hospital-to-home transitions present safety risks for patients. Children discharged with new foster caregivers may be especially vulnerable to poor discharge outcomes. With this study, our objective is to identify differences in discharge quality and outcomes for children discharged from the hospital with new foster caregivers compared with children discharged to their preadmission caregivers. METHODS: Pediatric patients discharged from the Barbara Bush Children's Hospital at Maine Medical Center between January 2014 and May 2017 were eligible for inclusion in this retrospective cohort study. Chart review identified patients discharged with new foster caregivers. These patients were compared with a matched cohort of patients discharged with preadmission caregivers for 5 discharge quality process measures and 2 discharge outcomes. RESULTS: Fifty-six index cases and 165 matched patients were identified. Index cases had worse performance on 4 of 5 discharge process measures, with significantly lower use of discharge readiness checklists (75% vs 92%; P = .004) and teach-back education of discharge instructions for caregivers (63% vs 79%; P = .02). Index cases had twice the odds of misunderstandings needing clarification at the postdischarge call; this difference was not statistically significant (26% vs 13%; P = .07). CONCLUSIONS: Hospital-to-home transition quality measures were less often implemented for children discharged with new foster caregivers than for the cohort of patients discharged with preadmission caregivers. This may lead to increased morbidity, as suggested by more frequent caregiver misunderstandings. Better prospective identification of these patients and enhanced transition improvement efforts targeted at their new caregivers may be warranted.

Health Outcomes of Medically and Economically Vulnerable Adults: A Comparison of Former Foster Youth and Nonfoster Youth.

Medically and economically vulnerable adults experience various challenges that can impact their health. Within this vulnerable population, there may be individuals who are even more vulnerable, those who have a history of involvement with the foster care system. The purpose of this study was to evaluate the difference of reported health-related problems between adults with previous foster care experience and other vulnerable adults. Physical, mental, and relational health was evaluated in this study. Practice and policy implications for mental health and medical professionals are discussed.

Health care quality measures for children and adolescents in Foster Care: feasibility testing in electronic records.

BACKGROUND: Preventive quality measures for the foster care population are largely untested. The objective of the study is to identify healthcare quality measures for young children and adolescents in foster care and to test whether the data required to calculate these measures can be feasibly extracted and interpreted within an electronic health records or within the Statewide Automated Child Welfare Information System. METHODS: The AAP Recommendations for Preventive Pediatric Health Care served as the guideline for determining quality measures. Quality measures related to well child visits, developmental screenings, immunizations, trauma-related care, BMI measurements, sexually transmitted infections and depression were defined. Retrospective chart reviews were performed on a cohort of children in foster care from a single large pediatric institution and related county. Data available in the Ohio Statewide Automated Child Welfare Information System was compared to the same population studied in the electronic health record review. Quality measures were calculated as observed (received) to expected (recommended) ratios (O/E ratios) to describe the actual quantity of recommended health care that was received by individual children. RESULTS: Electronic health records and the Statewide Automated Child Welfare Information System data frequently lacked important information on foster care youth essential for calculating the measures. Although electronic health records were rich in encounter specific clinical data, they often lacked custodial information such as the dates of entry into and exit from foster care. In contrast, Statewide Automated Child Welfare Information System included robust data on custodial arrangements, but lacked detailed medical information. Despite these limitations, several quality measures were devised that attempted to accommodate these limitations. CONCLUSIONS: In this feasibility testing, neither the electronic health records at a single institution nor the county level Statewide Automated Child Welfare Information System was able to independently serve as a reliable source of data for health care quality measures for foster care youth. However, the ability to leverage both sources by matching them at an individual level may provide the complement of data necessary to assess the quality of healthcare.

Evaluation of institutional foster care services for children and adolescents in Recife. / Avaliação dos serviços de acolhimento institucional de crianças e adolescentes no Recife.

This study aimed to evaluate the structure and process of institutional foster care services for the protection of children and adolescents who are victims of neglect and/or violence in Recife. A semi-structured questionnaire was applied to those responsible for the services. Variables frequency were calculated and the following implementation level classification system adopted: critical, when compliance was less than 40% of the recommended standards; inadequate, 40-59%; acceptable, 60%-89%; adequate and excellent, 90-100%. The qualitative analysis consisted in interviews with one manager from the Judiciary and three managers from the Executive. Of the five philanthropic institutions investigated, two had an excellent standard structure; two were acceptable and one inadequate. Among public institutions, one was considered inadequate and the others acceptable. Regarding the process, one institution was found to be excellent and the others acceptable. The content analysis identified that the greatest challenges to introduction of the measures envisaged in the Child and Adolescent Statute are drug use, family geographical remoteness, lack of integration with other institutions and staff turnover.

O objetivo do estudo foi avaliar a estrutura e o processo dos acolhimentos institucionais para proteção de crianças e adolescentes vítimas de abandono e/ou violência no Recife. Foi aplicado um questionário estruturado aos responsáveis pelos serviços, e então calculadas as frequências das variáveis e estabelecida a seguinte classificação do grau de implantação: crítico, quando a adequação à norma preconizada for inferior a 40%; inadequado, de 40-59%; aceitável, de 60%- 89%; adequado e ótimo, de 90-100%. Para análise qualitativa foram realizadas entrevistas com um gestor do poder judiciário e três do executivo. Das cinco instituições filantrópicas, duas apresentaram estrutura padrão ótimo, duas, aceitáveis, e uma, inadequada. Dentre as instituições públicas, uma municipal foi considerada inadequada e as demais, aceitáveis. Com relação ao processo, uma instituição apresentou padrão ótimo e as outras, aceitáveis. A análise de conteúdo permitiu observar que os maiores entraves para a realização das medidas previstas pelo Estatuto da Criança e de Adolescente decorrem do uso de drogas, distanciamento geográfico da família, falta de integração com outras instituições e rotatividade dos profissionais.

Is more better? Examining whether enhanced consultation/coaching improves implementation.

It is extremely challenging to implement evidence-based interventions in community-based agencies with sufficient quality, fidelity, and intensity to produce desired changes in practice and outcomes. This is particularly difficult to do within the confines of existing service providers' time, personnel, and resource constraints. Over the past 15 years, Together Facing the Challenge (TFTC) has been developed, tested, and disseminated in an effort to address this set of issues to improve treatment foster care (TFC). Data from the initial randomized trial showed improved practice and outcomes in TFTC compared to usual TFC. These initial results came from study-led training and follow-up consultation. Subsequent dissemination activities suggested potential need for more intensive support for TFTC supervisors to produce more consistent and sustained implementation of the model. The current randomized trial extends this work by comparing the previously tested standard consultation versus enhanced consultation that incorporated more of a coaching approach. Initial results suggest that enhanced coaching/consultation was associated with improvements in the small- to medium-effect size range. Results are promising, but require additional work to more fully understand how and whether to enhance supports as agencies implement new evidence-based approaches. (PsycINFO Database Record

Fostering Change.

Senate Bill 11, authored by Sen. Charles Schwertner, MD (R-Georgetown), and passed into law, launched a series of major reforms of Texas' troubled foster care system.