Cultural adaptation considerations of a comprehensive housing outreach program for indigenous youth exiting homelessness.

Generalist health interventions that aim to reduce chronic health disparities between Indigenous and non-Indigenous populations can be culturally adapted to better meet the needs of Indigenous people in Canada; however, little is known regarding best practices in implementing these adaptations. The present study first provides a review of the research process used to adapt a previous evidence-based housing initiative for Indigenous youth in Northwestern Ontario. Second, it includes an overview of the adaptations that were made and the associated rationale for such adaptations. Third, it examines the experiences of participants and staff involved in the cultural adaptation of the Housing Outreach Program Collaborative (HOP-C), a health intervention re-designed to improve physical and mental health outcomes, wellbeing, and social support for formerly homeless Indigenous youth as they secure housing. Qualitative feedback from interviews with 15 participants and eight program staff, in addition to one focus group with an additional six frontline workers, described perceived outcomes of the program's cultural adaptations. Modifications to the overall program structure, specific roles within the program (including counseling services, peer mentorship, cultural services, and case management), and adaptations to general implementation within the health organization providing the intervention were described by participants and staff as effective and helpful adaptations. The focus of Indigenous values at an organizational level led to consistent adaptations in counseling and case management to best meet the unique needs of the youth involved. Based upon participant interviews, recommendations to future adaptations are provided.

Ecological disruptions and well-being among children in foster care.

Bronfenbrenner's framework highlights the importance of considering ecological systems to understand child well-being. Children entering foster care often experience disruption across systems. Yet, prior research has focused on specific disruptions linked to outcomes. This longitudinal study examined the impact of multiple ecological disruptions (i.e., changes in or separation from siblings, friends, school, church, community) on children's internalizing symptoms and externalizing behaviors over time. This study included 211 children between the ages of 6 and 13 years (M = 10.23, SD = 2.37; 55.0% female; 57.3% African American). Children entered foster care for up to four reasons: Neglect (73.9%), physical abuse (29.4%), dependency (10%), and/or sexual abuse (9.5%). Most of the children experienced a change in school (64.0%), 46.9% were separated from siblings, 25.1% lost friends, 12.8% experienced community disruptions, and 10.0% were separated from church. Hierarchical Linear Modeling was employed to examine the association between ecological disruptions and longitudinal internalizing symptoms and externalizing behaviors, while controlling for baseline internalizing and externalizing, demographic variables (i.e., child age, gender, and race), and maltreatment severity. Maltreatment severity, along with school and community disruptions related to the presence of internalizing symptoms. Loss of friends was associated with the absence of externalizing behaviors, while community disruption was associated with the presence of externalizing behaviors. This study suggests that maintaining children's connections to their school and community is important for well-being. Under certain circumstances, separation from friends may relate to improved behavioral functioning. Future research should explore additional and interacting facets of children's ecological systems and related outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Subjective housing stability in the transition away from homelessness.

Housing stability is a complex concept to measure. One set of factors under consideration are those based on a personal or subjective sense of stability. We explore the variables associated with subjective stability and explore how subjective stability relates to housing stability across time. We use data from longitudinal, mixed methods research with 85 young people exiting homelessness. We find that subjective stability is a meaningful construct that can be validated through qualitative and quantitative data. The construct is primarily linked to indicators of environmental and social wellbeing. Subjective stability is also one of the only variables with a significant relationship to T2 housing stability. Qualitative analysis is used to explore these relationships in more detail. We conclude that subjective stability can provide holistic insight into the complex life circumstances influencing housing stability. However, this strength introduces complexity in that subjective stability appears to be developed in comparison with past experiences, as well as feelings of forward momentum on goals beyond housing.

Profiles of Maltreatment in the Child Welfare System: Predicting Mental Health Outcomes and Examining Age as a Moderator.

This longitudinal study explored the unique profiles of maltreatment among youth in the child welfare system and examined their relation to mental health outcomes over time. We additionally examined the moderating role of age. Participants included 316 youth in the foster care system (age range: 6-13 years). Data were collected through the Department of Children and Family Services upon youths' entry into foster care, then quarterly for the duration of care. A latent profile analysis identified five profiles of maltreatment, categorized as primary neglect (PN), neglect and physical abuse (PA), complex trauma, complex trauma with severe sexual abuse (SA), and neglect with SA. A hierarchical general linear model applied to the data revealed that all four classes predicted higher internalizing symptom trajectories compared with the PN reference class, event rate ratios (eRRs) = 1.19-1.37, but none of these associations were significantly moderated by age. Membership in the two classes categorized by complex trauma predicted higher externalizing behavior trajectories as compared to the PN reference class, eRRs = 1.11-1.13. The relation between membership in the neglect with SA class and externalizing behaviors was moderated by age, eRR = 0.83. Finally, membership in all four classes predicted higher posttraumatic stress symptoms as compared with the reference group, eRRs = 1.84-2.45, and with all associations moderated by age, eRRs = 0.51-0.53. These findings provide insight into the maltreatment experiences of youth in the child welfare system and have important implications for treatment needs.

Adaption and implementation of the Housing Outreach Program Collaborative (HOP-C) North for Indigenous youth.

There is a high prevalence of Indigenous youth experiencing either precarious housing or homelessness in northwestern Ontario. Given that Indigenous pathways to homelessness can differ from non-Indigenous youth, interventions that address homelessness must also adapt to meet diverse needs. The Housing Outreach Program Collaborative (HOP-C) is a tertiary prevention intervention designed to provide congruent housing and peer and mental health supports for youth experiencing homelessness in Toronto, Ontario. Less is known regarding its adaptability to adequately serve Indigenous youth in northwestern Ontario. This study assessed the preliminary effectiveness and feasibility of an adaptation of the HOP-C North program for transitional aged Indigenous youth exiting homelessness in Thunder Bay, Ontario. Participants completed premeasures (n = 15) and postmeasures (n = 8) as well as qualitative interviews regarding their experiences in the program. Qualitative interviews were also conducted with staff (n = 14) engaged in implementing the program. After completing the HOP-C North program, participants reported improvements in a number of outcomes, including increased educational enrollment, attainment of employment, reduced hospitalizations, and increased engagement in clinical mental health services. Specific program aspects that participants found helpful included increased program flexibility, accessibility, emphasis on relationships, relevance of programming, fostering participant autonomy, and an adaptive approach to program implementation. These findings suggest that the HOP-C North model, when adapted, is a helpful program for Indigenous youth. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trialing the feasibility of a critical time intervention for youth transitioning out of homelessness.

Little is known regarding the specific types of service models and collaborations that are necessary to support diverse populations of youth in transition out of homelessness. Transitional supports addressing the complex needs of this population are needed to stabilize the array of housing arrangements that youth access. This study was a pilot randomized controlled trial of one such critical time intervention, called the Housing Outreach Program-Collaboration (HOP-C). HOP-C is a multicomponent, multidisciplinary intervention that provides 6 months of mental health and peer support, along with transitional case management to youth who have transitioned into some form of stable housing out of homelessness. In this trial, 65 youth were randomized to receive HOP-C plus treatment as usual or transitional case management plus treatment as usual. Outcome assessments were completed by 30 treatment and 28 control participants. The findings suggest that this intervention is feasible with mental health, employment or education, and housing metrics favoring HOP-C with odds ratios ranging from 2.28 to 3.18 and better subjective housing stability. Other indicators showed less change. HOP-C appears feasible and should be tested in a fully powered trial, providing the intervention for a duration longer than 6 months. Overall, these data suggest the potential benefit in fostering city-level, multidisciplinary teams sourced from several organizations to support youth transitioning out of homelessness. Pragmatic trial method considerations for this population are also addressed as are the ethical considerations pertinent to engaging highly marginalized youth in clinical trials. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Impact of Emergency Shelter Utilization and Kinship Involvement on Children's Behavioral Outcomes.

Youth in child welfare often experience emergency shelter care, a type of congregate setting, while a permanent placement is arranged. The present longitudinal study explored the impact of initial emergency shelter placement on long-term externalizing behavior (i.e., aggression, delinquency) and internalizing symptom (i.e., anxiety, depression) trajectories, and whether kinship involvement moderated the effect of shelter placement on behavioral outcomes. The sample consisted of 282 youths (55.3% male) with an average age of 9.90 years ( SD = 2.37); 36.9% experienced an emergency shelter placement. Data were collected from the Illinois Department of Children and Family Services. Caseworkers completed the Child and Adolescent Needs and Strengths, which measured youths' behavioral outcomes. Results suggested that shelter care was not associated with externalizing behavior trajectories. However, shelter care was associated with internalizing symptoms among children with less kinship involvement. Results from this study suggest that best practices for shelter care should leverage kinship involvement.

More than four walls and a roof needed: A complex tertiary prevention approach for recently homeless youth.

This article examines the feasibility of a complex intervention designed to facilitate the transition of youth out of homelessness. It is intended to contribute to efforts to build out the youth homelessness intervention literature, which is underdeveloped relative to descriptive characterizations of risk. The 6-month intervention examined here, referred to as the Housing Outreach Program-Collaboration (HOP-C), is comprised of transitional outreach-based case management, individual and group mental health supports, and peer support. The intervention was delivered through a multiagency, interdisciplinary collaboration. Feasibility was assessed using a mixed methods design that included prepost intervention metrics and the study site was a large Canadian urban center. A total of 31 youth participated in the study with 28 completing the intervention. Overall, implementation and youth engagement was successful though patterns and intensity of engagement were quite variable. While prepost, self-report metrics improved modestly, substantial gains were observed in employment, education, and mental health service connectedness. Qualitative themes focused on the benefits of a flexible, multicomponent approach, close attention to seamless delivery and common factors, and supporting youth in the balance of isolation versus independence. These findings suggested that this tertiary prevention approach is feasible and warrants further investigation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Father involvement in child welfare: Associations with changes in externalizing behavior.

Nonresident fathers can have a significant impact on children's behavioral outcomes. Unfortunately, the impact of nonresident father involvement on the behavioral outcomes of children with child welfare involvement has received scant attention in the literature, a limitation the current study sought to address. A sample of 333 children in state custody in Illinois between the ages of six and 13 participated and were assessed using the externalizing behavior scale of the Child and Adolescent Needs and Strengths (CANS) at regular intervals throughout their time in care. Father involvement was measured through a review of case files and interviews with child welfare workers. Growth trajectories were fit to children's externalizing behavior across time and were predicted using Time 1 characteristics. Father involvement, total non-father relative involvement, and gender (girls) was associated with lower baseline externalizing behavior and the African American children in the sample experienced higher baseline externalizing behavior. However, only Time 1 father involvement predicted slope trajectories after controlling for Time 1 externalizing behavior; more father involvement was associated with lower externalizing behavior trajectories. These results suggest that even in the unique and stressful context of child welfare, father involvement can be protective regarding children's externalizing behaviors.

Emergency shelter care utilization in child welfare: Who goes to shelter care? How long do they stay?

Emergency shelter care for children entering foster care is widely used as a temporary first placement, despite its contraindications. However, little research has examined predictors of utilization (e.g., entry into care, length of stay in care). A sample of 123 children (ages 6-13) entering foster care was studied to explore the variables associated with an initial placement in shelter care versus kinship care and variables associated with children staying less than 30 days in the shelter versus 30 days or longer. After applying a classification tree analysis (CTA via Optimal Data Analysis), results indicated that variables across the child's ecology--specifically the microsystem, mesosystem, and exosystem--were associated with increased emergency shelter utilization, including older age, entering as a dependency case, more relatives and fictive kin with barriers to involvement in the child's life, and the child welfare agency serving the child. These results suggest that although emergency shelter care utilization may be determined by a complex interaction of variables across the child's ecology, policy and programmatic attention to some of these risk factors might be effective in limiting utilization so that children can enter care with a more long-term, family-based placement.

Change Trajectories: Children's Patterns of Improvement in Acute-Stay Inpatient Care.

This study estimated classes of children's acute-stay psychiatric acuity trajectories in terms of shape (i.e., linear, quadratic, cubic) and rate of change (slope). A total of 788 children served on three child units (ages 4-12) were studied. The Children's Acuity of Psychiatric Illness (CAPI) was completed each weekday by trained frontline staff on the milieu. Latent class growth analysis was applied to the data, and seven acuity trajectory classes provided the most parsimonious fit. Four classes evidenced a significant quadratic term, one class a significant linear term, and two classes did not evidence a significant change in acuity. The classes varied in survival time to rehospitalization, in pre-treatment community service use and rates of seclusion, restraint, and emergency medications during the episode. Overall, the results suggest that acute-stay patients may have distinct and identifiable psychiatric acuity change patterns during their episodes and that some may experience non-linear (i.e., quadratic) acuity trajectories.

Does the Hospital Predict Readmission? A Multi-level Survival Analysis Approach.

Time to psychiatric rehospitalization was predicted for a sample of 1473 Medicaid-insured youth in Illinois in 2005 and 2006. A multi-level model statistical strategy was employed to account for the fact that youth days to rehospitalization were nested within hospital and to test the hypothesis that hospitals would vary significantly in return rates, controlling for individual-level (e.g., symptom, demographic) variables. Hospitals did not vary significantly in days to rehospitalization. At the individual-level, level of externalizing behavior and residential treatment placement predicted a faster return to the hospital. These results support the perspective that hospital outcomes are best operationalized using variables tied more directly to the inpatient episode (e.g., LOS, reductions in acuity).

Confirmatory factor analysis of the Behavior Rating Inventory of Executive Functioning (BRIEF) in children and adolescents with ADHD.

The Behavior Rating Inventory of Executive Functioning (BRIEF) is a parent report measure designed to assess executive skills in everyday life. The present study employed a confirmatory factor analysis (CFA) to evaluate three alternative models of the factor structure of the BRIEF. Given the executive functioning difficulties that commonly co-occur with attention-deficit/hyperactivity disorder (ADHD), the participants included 181 children and adolescents with a diagnosis of ADHD. The results indicated that an oblique two-factor model, in which the Monitor subscale loaded on both factors (i.e., Behavioral Regulation, Metacognition) and measurement errors for the Monitor and Inhibit subscales were allowed to correlate, provided an acceptable goodness-of-fit to the data. This two-factor model is consistent with previous research indicating that the Monitor subscale reflects two dimensions (i.e., monitoring of task-related activities and monitoring of personal behavioral activities) and thus loads on multiple factors. These findings support the clinical relevance of the BRIEF in children with ADHD, as well as the multidimensional nature of executive functioning.

The Protective Effect of Kinship Involvement on the Adjustment of Youth in Foster Care.

Child maltreatment and family dysfunction (e.g., conflict) can have a long-term deleterious impact on youth well-being. Using a child welfare sample, this study examined whether dysfunction in the nuclear family of origin was associated with adjustment problems, including internalizing and externalizing behavior problems, beyond the effect of child maltreatment, and whether extended family (kinship) involvement protected against youth's adjustment problems. Participants included 171 children and adolescents (mean age = 10.15; 50.3% female) who entered foster care due to child maltreatment. Results indicated that greater dysfunction in the nuclear family of origin and child maltreatment were independently associated with greater internalizing and externalizing behavior problems. Results also showed that kinship involvement was protective against externalizing behavior problems. Moreover, kinship involvement buffered the association between dysfunction in family of origin and internalizing behaviors only at low levels of family dysfunction. These results support policies that encourage the involvement of extended and noncustodial family members in the lives of maltreated youth following their entry into foster care.

Measuring children's response to inpatient treatment: use of practice-based evidence.

OBJECTIVE: The study tested the feasibility of using practice-based evidence to improve children's treatment response to inpatient care in psychiatric hospitals. METHODS: A total of 524 children (aged four to 12 years) who were patients at three psychiatric hospitals with child units were studied between October 1, 2009, and October 1, 2010. The Acuity of Psychiatric Illness, Child and Adolescent Version (CAPI), a reliable and valid measure of risk behaviors, symptoms, and functioning, was completed each weekday by trained frontline staff on the milieu. RESULTS: Growth curve modeling via hierarchical linear modeling was used, and linear trajectories were fit to children's CAPI scores over days in care. Trajectories of CAPI acuity scores varied significantly among the children, and changes in scores (slope of the trajectories) were predicted by several clinical variables at intake. These variables included externalizing behavior, such as aggressive behavior toward others and objects and sexual aggression, and internalizing symptoms, such as self-mutilation behaviors and suicidal ideation or gestures. Further, moderation analyses revealed that the hospital unit serving the youths moderated the effect of intake clinical characteristics on the trajectories of acuity scores. CONCLUSIONS: Regular measurement of psychiatric acuity using a reliable and valid measure has the potential to monitor an episode of care in real time and provide data that can be used to improve treatment. This approach may hold promise as a method to promote accountability across hospital systems and to identify the core competencies and deficits of hospitals in addressing specific problems presented at intake.

Methodological background of decision rules and feedback tools for outcomes management in psychotherapy.

Systems to provide feedback regarding treatment progress have been recognized as a promising method for the early identification of patients at risk for treatment failure in outpatient psychotherapy. The feedback systems presented in this article rely on decision rules to contrast the actual treatment progress of an individual patient and his or her expected treatment response (ETR). Approaches to predict the ETR on the basis of patient intake characteristics and previous treatment progress can be classified into two broad classes: Rationally derived decision rules rely on the judgments of experts, who determine the amount of progress that a patient has to achieve for a given treatment session to be considered "on track." Empirically derived decision rules are based on expected recovery curves derived from statistical models applied to aggregated psychotherapy outcomes data. Examples of each type of decision rule and of feedback systems based on such rules are presented and reviewed.

Person--job match among frontline staff working in residential treatment centers: the impact of personality and child psychopathology on burnout experiences.

Prior research has shown that the personality variables extraversion and neuroticism predict burnout among frontline staff working in residential treatment centers. This study tested the hypothesis that the effect of personality on burnout would be moderated by the psychiatric characteristics of the youth served on the milieu. Two hundred and three frontline staff working in 21 residential treatment centers in Illinois serving troubled youth completed surveys regarding opinions about their jobs, the Big Five Inventory (BFI), a youth presenting problems scale for the entire milieu, and the Maslach Burnout Inventory (MBI). Results indicated that the effect of neuroticism on burnout is moderated by psychosis and posttraumatic stress disorder (PTSD); high and moderate milieu ratings of psychosis and PTSD showed a positive relationship between neurosis and burnout, while low ratings of these conditions showed no relationship. These findings suggest that the optimal work setting is a function of the interaction between specific personality characteristics and specific work environments, with implications for personnel selection and future research on person-environment fit.

Trauma resilience among youth in substitute care demonstrating sexual behavior problems.

OBJECTIVE: The purpose of this longitudinal study was to examine the relationship between several proposed protective factors and trauma symptoms among highly vulnerable youth in the child welfare system. METHODS: Participants were 142 youth identified with a sexual behavior problem and their caregivers. Two waves of data were collected for each participant an average of 18 months apart. Foster parents reported on perceived level of support from the child welfare agency, youth involvement in club activities, and perception of youths' interpersonal and emotional competence. Youth provided self-reports of their sexual and physical abuse experiences, trauma symptoms at both time 1 and time 2, and ratings of parenting practices. RESULTS: Youth with higher rates of sexual abuse showed more negative affect and higher levels of sexual and non-sexual rumination at time 2, controlling for time 1 scores. Boys and youth who experienced better parenting practices displayed lower negative affect. Youth with higher levels of emotional and interpersonal competence showed lower levels of non-sexual rumination. Moderation analyses revealed that youth with more significant sexual abuse histories whose foster parents did not feel supported by their child welfare caseworkers had higher levels of sexually ruminative thoughts. Finally, the results revealed that only youth without sexual abuse histories experienced the benefits of club involvement in terms of lower sexual rumination scores. CONCLUSIONS: This study demonstrated that youth with significant vulnerabilities can still exhibit a degree of protection from trauma symptomatology in the presence of a wide range of personal and social variables. These findings support the efforts of stakeholders to promote strengths at the level of the individual, family, and broader social network and community.

Evaluating psychiatric hospital admission decisions for children in foster care: an optimal classification tree analysis.

This study explored clinical and nonclinical predictors of inpatient hospital admission decisions across a sample of children in foster care over 4 years (N = 13,245). Forty-eight percent of participants were female and the mean age was 13.4 (SD = 3.5 years). Optimal data analysis (Yarnold & Soltysik, 2005) was used to construct a nonlinear classification tree model for predicting admission decisions. As expected, clinical variables such as suicidality, psychoticism, and dangerousness predicted psychiatric admissions; however, several variables that are not direct indications of acute psychiatric distress, such as the presence of family problems and the location of the hospital screening, impacted decision making in a subsample of cases. Further analyses indicated that the model developed in Year 1 reliably and consistently predicted admission decisions (with 64%-68% overall accuracy) across the next 3 years. Policy, research, and clinical implications are discussed.

Empirically and clinically useful decision making in psychotherapy: differential predictions with treatment response models.

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.