Care for Children
Mental Health Care for Children and Adolescents in Foster Care: Review of Research Literature
Prepared for Casey Family Programs by
John A. Landsverk, Ph.D. Child and Adolescent Services Research Center
Children’s Hospital – San Diego
Barbara J. Burns, Ph.D. Services Effectiveness Research Program
Department of Psychiatry and Behavioral Sciences School of Medicine
Duke University
Leyla Faw Stambaugh, Ph.D. Services Effectiveness Research Program
Department of Psychiatry and Behavioral Sciences School of Medicine
Duke University
Jennifer A. Rolls Reutz, M.P.H. Child and Adolescent Services Research Center
Children’s Hospital – San Diego
February, 2006
© Casey Family Programs 2006
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TABLE OF CONTENTS Overview ………………………………………………………………………………………………………1 I. Need for Mental Health Care ……………………………………………………………………….9 II. Use of Mental Health Care ………………………………………………………………………..15 Use of Mental Health Care ……………………………………………………………………16
Factors Associated with the Use of Mental Health Care…………………………….20
Summary ……………………………………………………………………………………………21
III. Evidence-Based Interventions and Promising Practices …………………………..22 What Is Evidence?……………………………………………………………………………….26
What Is the Evidence for Interventions Addressing PTSD and Abuse-related
Trauma, Disruptive Behavior Disorders, Depression, and Substance Abuse? 28
PTSD and Abuse-related Trauma………………………………………………………..28 Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)……………….34 Abuse-Focused Cognitive Behavioral Therapy for Child Physical
Abuse (AF-CBT) ………………………………………………………………………..35
Parent-Child Interaction Therapy (PCIT)………………………………………..36
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Child
Traumatic Grief ………………………………………………………………………….37
Cognitive Behavioral Intervention for Trauma in Schools …………………38 Child-Parent Psychotherapy for Family Violence (CPP-FV) ……………..39
Project 12-Ways/Safe Care for Child Neglect …………………………………39
Medication for Trauma………………………………………………………………..40
Disruptive Behavior Disorders ……………………………………………………………41 Parent Management Training ………………………………………………………41 Incredible Years…………………………………………………………………………42
Time Out Plus Signal Seat…………………………………………………………..42
Anger Coping, Problem Solving, and Assertiveness Training……………43
Anger Control Training with Stress Inoculation ……………………………….43
Rational Emotive Therapy (RET) ………………………………………………….43
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Medication for Disruptive Behavior Disorders …………………………………44
Depression………………………………………………………………………………………..45 Psychotherapy …………………………………………………………………………..46
Medication for Depression …………………………………………………………..48
Combined Psychotherapy and Medication……………………………………..48
Substance Abuse ………………………………………………………………………………49 Brief Interventions………………………………………………………………………49
Cognitive Behavioral Therapy (CBT) …………………………………………….49
Family-based Interventions………………………………………………………….50
Residential Treatment Centers …………………………………………………….52
Inpatient Treatment…………………………………………………………………….54
The 12-step Model ……………………………………………………………………..54
Medication for Substance Abuse ………………………………………………….55 Summary ……………………………………………………………………………………………55 Intensive Home and Community Based Interventions………………………….56 Treatment Foster Care………………………………………………………………..60
Multisystemic Therapy (MST) ………………………………………………………60
Intensive Case Management ……………………………………………………….61
Mentoring………………………………………………………………………………….62
Respite……………………………………………………………………………………..62
Crisis………………………………………………………………………………………..63
Day Treatment …………………………………………………………………………..64
Transition to Independence …………………………………………………………64
Family Therapy …………………………………………………………………………65
Family-based Education and Support ……………………………………………66
Therapeutic Group Homes…………………………………………………………..66
How Are Evidence-based Interventions Spreading? ……………………………………..67 Foster Care Initiatives…………………………………………………………………………..69 Treatment for Complex and Co-occurring Conditions………………………………..70 Test Evidence-based Mental Health Practices within Child Welfare ……………72
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IV. Legal Intervention …………………………………………………………………………………..73 V. Recommendations…………………………………………………………………………………..75 Appendix A: Resources and Registries for Identifying Evidence-based Interventions for
Children and Adolescents ………………………………………………………………………………78
Appendix B: Office for Victims of Crime Criteria for Evidence-based Treatments ……83
Appendix C: National Training Resources for Evidence-based Interventions …………85
References ………………………………………………………………………………………………..88
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OVERVIEW Introduction In Fall 2005, Casey Family Programs requested a review of the professional
literature to answer questions regarding the mental health needs of children in foster
care. The review was to include studies on the provision of mental health care, the
evidence base for mental health care, and related legal actions (e.g., class action
suits) taken on behalf of these children. This overview briefly summarizes the major
findings gleaned from the literature, and it outlines the challenges and implications
for those steps that have the potential to improve mental health care for these “high
risk” youth.
Need for Mental Health Care
The research literature here, which is based on studies across several states
plus one nationally representative survey, the National Survey of Child and
Adolescent Well-Being [NSCAW] (Leslie, Hurlburt, Landsverk, Barth, & Slymen,
2004; Burns et al., 2004)], suggests that between one-half and three-fourths of the
children entering foster care exhibit behavior or social competency problems that
warrant mental health care. There is also evidence that this high rate of need may
be anticipated as well for children who are served by child welfare while remaining in
their biological homes. This rate of mental health problems is significantly higher
than that which would be expected in community populations although it is more
comparable to that of children living below poverty level within these communities.
Furthermore, these service needs range across a number of domains, rather than
being concentrated in broad behavior problems alone. A noteworthy finding is the
high rate of developmental problems in children entering foster care prior to the age
of seven. In addition, some evidence suggests that the rate of developmental
problems may be somewhat lower in children who end up in kinship care compared
to children who are placed in non-relative foster care although this relationship
remains open to further, more definitive research. Finally, psychosocial functioning
of the children in foster care may not only affect their long-term functioning
outcomes, but also decisions regarding their continuity in or exit from living in foster
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care. For example, children with poorly treated mental health disorders may be less
likely to be reunified or adopted.
Below is the first of a series of text boxes that summarizes this review’s
recommendations based on the implications of the review for policy and services.
Use of Mental Health Care
Multiple local area studies across multiple states together with early data from
the NSCAW national study indicate that youth in the child welfare system use mental
health services at very high rates across all age groups, with the highest rates in late
adolescents who had been in out-of-home care for an average of six years. Studies
using Medicaid data confirm that this much higher rate for children in foster care is in
contrast to the relatively low rates seen children served by Aid to Families with
Dependent Children (AFDC).
The findings from the NSCAW study indicate that, despite these high rates in
comparison with community studies, three out of four youth in child welfare who
meet a stringent criterion for need were not receiving mental health care within 12
months after a child abuse and neglect investigation. More encouraging are the
results of the Casey Northwest Alumni study indicating that, over time, 80% do
receive some mental health services (Pecora et al., 2005). This finding needs to be
understood in light of national data from NSCAW.
Recommendation: Increase Access to Care
• Inform child welfare workers (CWW) about the importance of early
identification and treatment.
• Institute a standard protocol for screening and assessment to identify the need
for mental health care upon the child’s entry into the child welfare system.
• Educate CWWs about local resources and create a liaison with mental health
providers to facilitate rapid referrals into mental health services.
• Monitor referrals and follow-up with foster parents to ensure that youth receive
services.
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There is growing recent evidence that both clinical and nonclinical factors
affect mental health referral and utilization patterns for children in foster care. The
nonclinical factors implicated are type of maltreatment, racial/ethnic background,
age, and type of placement. The recent review of the race/ethnicity factor by
Garland, Landsverk, and Lau (2003) suggests that this nonclinical factor consistently
predicts lower use of mental health care for African American youth. Evidence from
a national study suggests that coordination between child welfare and mental health
agencies may increase the effect of clinical factors in the use of mental health care
and may decrease nonclinical factors such as race/ethnicity (Hurlburt et al., 2004).
Among youth in foster care who utilize “usual care” mental health services,
the great majority receive outpatient treatment, a small number is admitted to
hospitals, and many others are placed in group homes or residential treatment
centers. While it may be helpful to obtain, at a minimum, a diagnostic assessment
and long-term psychotherapy with a trusted professional who can offer support
about a troubling life history, there are more effective treatment approaches today.
Research suggests that there are effective brief clinic-based and group-based
models for children needing diagnostic-specific interventions. Research on more
comprehensive interventions for youth with more complex needs suggests that there
longer-term and intensive interventions that offer alternatives to institutional care for
many youth in foster care.
Recommendation: Move Beyond Usual Outpatient and Institutional Care
• Examine the evidence base for interventions to treat common clinical
conditions and more complex conditions experienced by youth in foster care.
• Assess the availability of evidence-based interventions at the local level and
national level to assure relevance and explore adaptations needed for youth in
foster care.
• Identify possible evidence-based interventions to meet mental health needs at
the local level.
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Evidence-Based Interventions and Promising Practices Children in foster care frequently experience several specific conditions that
require targeted treatment. The most prevalent conditions include PTSD and abuse-
related trauma, disruptive behavior disorders (including ADHD), depression, and
substance abuse. There is a strong evidence base for treating each of these
conditions with interventions that are largely behavioral or cognitive-behavioral and
that address symptoms, behavior, and functioning. Examples of such interventions
include Trauma-Focused Cognitive Behavior Therapy, the Incredible Years, Parent-
Child Interaction Therapy, and cognitive behavior therapy for depression. Such
interventions tend to be relatively brief, and most are more effective when a
caregiver is actively involved. A number are directed at the caregiver only,
particularly when the focus is on managing the child’s disruptive behavior. In fact,
dropping a child off at a clinic for individual therapy for most of these conditions is of
very limited value. Note: A caution about rapidly endorsing evidence-based
treatment. At present, these interventions are not uniformly available across the
country.
Youth with complex combinations of mental health conditions and the
functional impairment associated with long-term risks, such as multiple episodes and
types of maltreatment, other trauma (e.g., domestic violence and loss), and
instability of placements, will benefit from intensive home and community-based
services. Children in foster care often move on to “deep end” services in institutional
settings because of the failure to manage their behavior in the community. The
benefit of care in institutional settings is not well substantiated and may even be
deleterious due to close association with deviant peers, the risk of contagion, loss of
contact with family and peers, and other factors (Schaefer & Swanson, 1988;
Dishion, McCord, & Poulin, 1999).
Few recent studies have examined the effectiveness of group care models. There
are alternatives to the care and treatment of these youth today. Increasing the
availability of intensive home- and community-based services while youth are in
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foster care could benefit the children and prevent further movement away from
family and community. Those alternatives that could more effectively address the
needs of such youth tend to be intensive interventions that are long–term in nature.
Major examples include intensive case management and home-based interventions
(e.g., multisystemic therapy, treatment foster care, crisis services, respite care,
mentoring, and several types of family therapy) in addition to special education
services in school or recreational and work opportunities in the community. The
critical challenge to creating such a continuum of care is to engage the relevant
other providers (e.g., schools, juvenile justice, Medicaid) in a joint endeavor.
Evidence-based interventions have been identified that have the potential to
address the mental health needs of youth in foster care, but they are delivered
largely by the mental health system. What may be more innovative is the provision
of specific mental health interventions within the child welfare system, and several
important studies are underway to test their applicability. Of real promise is the
statewide implementation of Parent-Child Interaction Therapy in an experimental
design in Oklahoma. A second important study will test the potential to adapt
treatment foster care principles and approaches to foster care parents (personal
communication, Patti Chamberlain, January 15, 2006). A third significant initiative
sponsored by the National Child Traumatic Stress Training Center will train clinicians
in 12 sites across the country to provide Trauma-focused Cognitive Behavior
Therapy (for child sexual and/or physical abuse). Another new initiative will field-test
rapid but more thorough mental heath references and training for both parents and
foster parents to better access effective mental health services
(http://www.kidsmentalhealth.org/Caseyproject.html). Further, other studies are
examining strategies for the dissemination of diagnostic-specific interventions and
the lessons learned from them will also be applicable to increasing the availability of
evidence-based practices for maltreated youth in child welfare.
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Legal Interventions Legal interventions through court actions with consent decrees and
settlements have become a frequent method for addressing problems in the foster
care system. A recent study (Kosanovich & Joseph, 2005) found that, within the past
decade, “there has been child welfare class action litigation in 32 states, with
consent decrees or settlement agreements in 30 of these (pg. 2).” Currently, 21
states operate “under court consent decrees, settlement agreements or are under
pending litigation brought against public child welfare agencies (pg. 6).”
While the litigation cases have addressed a wide range of child welfare
issues, the study investigators found that 20 of the 35 decrees have addressed
service provision, including 12 decrees explicitly dealing with mental health care. We
would note that 6 decrees addressed substance abuse problems and 7 decrees
among the 35 addressed the more generic treatment needs of children in foster
care.
Recommendation: Increase the Use of Evidence-Based Interventions in Child Welfare
• Track the progress of dissemination studies of mental health interventions in
foster care and clinical interventions relevant to the needs of these children to
determine readiness for large scale adoption.
• Learn from the challenges of intervention, adoption, and dissemination efforts
(e.g., stakeholder buy-in, the importance of policy and organizational factors,
and factors contributing to sustainability) prior to making policy decisions.
• Consider additional interventions for implementation within child welfare, in
contrast to those typically provided in the mental health system.
• For evidence-based interventions that require the expertise and resources of
the mental health system, develop a partnership between mental health and
child welfare with clearly explicated roles of each system, preferably with joint
child welfare and mental health and/or Medicaid funding.
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Limiting the number of decrees to those dealing with the narrow definition of
failure to provide treatment for the mental health needs of children in foster care may
underestimate the scope of this issue within the decrees. Many other issues may be
indirectly linked to provision of mental health care, such as training of caseworkers
and foster parents, education and independent living services for children in foster
care, parent-child visitation, minimizing disrupted placements and reduction in
number of placements, residential facility placement, and support and supervision of
foster parents. These latter issues may be especially linked to mental health care
because of the high prevalence of externalizing problems seen in children who are
involved in foster care and the findings that externalizing problems are best
addressed through parent-mediated interventions.
Finally, we would suggest that foundations such as the Casey Family
Programs have a vital role to play in efforts to improve mental health care for
children in child welfare, and we offer a small number of modest recommendations.
Recommendation: Use Evidence to Improve Practice and Policies in Child Welfare
• Consider the unique leverage points that Casey Family Programs can use to
assist initiatives to improve mental health care for children in foster care
through increased use of very promising interventions.
• Use the unique experience of Casey Family Programs to initiate and support
partnership dialogue between the child welfare system and the mental health
service system around efforts to integrate evidence-based interventions into
services for children in foster care.
• Provide leadership to the child welfare community as it works to improve
service delivery through the use of evidence about interventions that show
great promise for improving well-being outcomes for children in foster care.
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Summary This report has focused on the rapidly expanding research literature related to the mental health care of children in foster care. Great needs for mental health care
have been demonstrated in these children, and many efficacious interventions that
can be beneficial for children in foster care have been reviewed. Despite the
challenges of integrating the best interventions into the child welfare and mental
health service systems, which provide care for this population, there is enormous
promise in the robust efforts currently underway. Considerable focus and research
resources are being expended by federal agencies, including the National Institutes
of Health and the Administration for Children and Families. Foundations such as the
Casey Family Programs have an important role to play in these efforts to improve
mental health care for children in foster care.
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Mental Health Care for Children and Adolescents in Foster Care: Review of Research Literature
Overview This report was written in response to a request from Casey Family Programs
for a review of the literature on the mental health needs of children and adolescents
in foster care and on the treatment interventions for addressing these needs. Casey
Family Programs provided the following six questions to guide the review.
• What mental health treatment needs have been identified?
• What treatment interventions have been tried?
• What are the promising practice models?
• What interventions have been proven effective through evaluation and
research?
• How many studies have been done?
• How many lawsuits have been filed because of the failure to meet the mental
health needs of foster youth?
Encompassing these six questions, the review is organized in five sections:
1) the need for mental health care, 2) the use of mental health care, 3) evidence-
based interventions and promising practices, 4) system-level legal interventions
addressing mental health care, and 5) recommendations.
I. NEED FOR MENTAL HEALTH CARE
This report is based on a comprehensive but not exhaustive literature review.
It is comprehensive in that it covers most major issues involved in the provision of
mental health care for children and adolescents who experience foster care. It is not
exhaustive because it relies heavily on recent reviews with some updating but
without a thorough searching of extant literature. In particular, the sections on need
for and use of mental health care rely heavily on two review papers published within
the past three years: Landsverk, Garland, and Leslie (2002), “Mental Health
Services for Children Reported to Child Protective Services,” and Landsverk (2005),
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Improving the Quality of Mental Health and Substance Abuse Treatment Services for
Children Involved in Child Welfare.. In addition, the chapter “Evidence-based Mental
Health Interventions for Children in Child Welfare” in Beyond Common Sense: Child
Welfare, Child Well-Being, and the Evidence for Policy Reform by Wulczyn, Barth,
Yuan, Jones-Harden, and Landsverk (2005) informs the section on effective
research-based treatments and promising practices.
Reliable estimates, using standardized measures, of the need for mental
health care have become increasingly available over the past 15 years, both for
community populations and for the specialized population of children and
adolescents who have been involved with foster care (see Costello, Burns, Angold,
and Leaf, 1993, for a cogent discussion of four ways to estimate the need for mental
health services). From community studies, general estimates of this need range from
10 to 22% (Gould, Wunsch-Hitzig, & Dohrenwend, 1981; Offord et al., 1987; Costello
et al., 1988; Zahner, Pawelkiewicz, Defrancesco, & Adnopoz, 1992). Most recent
meta-analytic and epidemiological studies have narrowed the estimate for the
prevalence of psychiatric disorders among community youth to a range of 5-8% for
serious emotional disturbance, both psychiatric diagnosis and moderate to severe
levels of impairment (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1996;
Costello, 1999), and approximately 20% for any diagnosis with functional impairment
(Costello et al., 1996; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000).
All early studies that provide estimates from standardized measures for youth
in the child welfare system have focused on those placed in foster care. These
studies have shown that youth in foster care exhibit problems that require a mental
health assessment and/or intervention at a significantly higher rate than what would
be expected from either normative data or from community studies. Based on the
studies briefly reviewed below, this rate is likely to be five times greater
compared to community-based youth who are not involved in the child welfare
system.
Pilowsky (1995) completed a review of studies published from 1974 through
1994 that supports this conclusion, with the special note that externalizing disorders
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in particular may be more prevalent in the foster care population. Studies published
since the Pilowsky review confirm this widely accepted conclusion. In the state of
Washington, Trupin, Tarico, Low, Jemelka, and McClellan (1993) compared children
receiving protective services from child welfare with a criterion group of children in
the state’s most intensive mental health treatment programs and found that 72% of
the children in child welfare exhibited profiles of severe emotional disturbance
indistinguishable from the criterion group. In a Tennessee study of children over the
age of 4 years entering state custody, of whom 64% were under the supervision of
child welfare, Glisson (1994, 1996) found that 52% were in the clinical range of the
Child Behavior Checklist as determined by both the parent and teacher informant,
with 82% scoring in the clinical range of at least one of the three scales of
internalizing, externalizing, and total behavior problems. In another Tennessee study
of children in custody, Heflinger, Simpkins, and Combs-Orme (2000) found elevated
rates of aggressive, delinquent, and withdrawn behavior.
An important adjunct to the estimates based on standardized behavior or
diagnostic measures are studies that estimate problems in developmental
functioning. For example, in a study of 272 children entering foster care in
Connecticut before the age of 8 years, Horwitz, Simms, and Farrington (1994) found
that 53% showed developmental delays as determined by either the Connecticut
Infant/Toddler Developmental Assessment or the Battelle Developmental Inventory.
A number of recent studies have been conducted with children entering foster
care or having resided in foster care in California. Urquiza, Wirtz, Peterson, and
Singer (1994) conducted a comprehensive screening and evaluation of 167 children
between the ages of 1 and 10 years who were made dependents of the juvenile
court in Sacramento for reasons of child abuse and neglect. The researchers found
that 68% of the children displayed significant problems in one of four psychosocial
domains, as operationalized by a score 1.5 standard deviations below national
norms on one or more of four standardized assessment instruments.
Halfon, Mendonca, and Berkowitz (1995) reported on 213 young children with
a mean age of 3 years who were referred to a comprehensive health clinic after
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entering foster care in Oakland; the authors found that over 80% had developmental,
emotional, or behavior problems. They also found that children who were placed
after 2 years of age exhibited a higher rate of these problems than children placed at
an earlier age.
Clausen, Landsverk, Ganger, Chadwick, and Litrownik (1998) examined 140
children between the ages of 4 and 16 years entering foster care in three California
counties; they found that 54.4% met clinical or borderline criteria on one or more of
the narrow-band, broad-band, or total behavior problem scales of the Achenbach
Child Behavior Checklist, Parent Report Form, and that 62.6% met clinical or
borderline criteria on one or more of the narrow-band and social competency scales
as well. Only 23.0% were determined to fall in the nonclinical or borderline range on
both the behavior problem and social competency dimensions.
Landsverk, Litrownik, Newton, Ganger, and Remmer (1996) conducted a
study in San Diego County comparing children entering kinship care with children
entering non-relative foster care through the Parent Report Form of the Achenbach
Child Behavior Checklist. For children between the ages of 4 and 16 years, the
investigators determined that 43.2% in the kinship group and 51.9% in the non-
relative foster care group were in the borderline or clinical range on total behavior
problems. In the same study, they found that 60% of the children under age of 6.5
years and residing in kinship care were in the questionable or abnormal range on the
Denver Developmental Screening Test, Version Two (DDST II), as compared to
72% of the same-age children residing in non-relative foster placements. A more
recent study of 791 consecutive children in San Diego County entering the
emergency shelter/receiving facility found that 61.2%% were in the questionable or
abnormal range (currently termed the “suspect range”) on the DDST II (Leslie,
Gordon, Ganger, & Gist, 2002). Over two-thirds of these children (69%%) received a
developmental evaluation using the Bayley Scales of Infant Development II (Bayley-
II), with 34% scoring more than two standard deviations below the standard score on
at least one component of the Bayley II. Comparable with the findings from the
earlier study, children entering non-relative foster care placement were more likely to
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score in the suspect range (67%) as compared to children ending up in kinship care
(56%) or reunited with their biological parents (58%).
Two separate studies conducted in San Diego have used the NIMH
Diagnostic Interview Schedule for Children (DISC) for estimating rate of psychiatric
disorder based on separate versions of the Diagnostic and Statistical Manual. In a
study from the early 1990s, Madsen (1992) used the Diagnostic Interview Schedule
for Children (DISC), Version 3.2, with 59 children between the ages of 11 and 16
years in the early months of foster care; they found that 60% met criteria for one or
more DSM III-R diagnoses as determined by reports from either the parent or the
youth. In a more recent study conducted from 1997 through 1999 in San Diego,
Garland et al. (2000) reported on estimates for selected diagnoses using Version IV
of the DISC (Shaffer et al., 2000) with weighted samples drawn from five different
sectors of care, including 426 youth between the ages of 6 and 18 years who had
been declared dependents of the court. Two out of every five of these youth (41.8%)
met the criteria for one or more DSM IV diagnoses with at least a moderate level of
diagnostic-specific functional impairment. The largest proportion met the criteria for
disruptive disorders, with 22.2% meeting the criteria for oppositional defiant disorder,
16.1% for conduct disorder, and 20.8% for attention-deficit with hyperactivity
disorder. Considerably smaller proportions met the criteria for mood disorders
(5.2%) and anxiety disorders (8.6%). In the same study, Aarons, Brown, Hough,
Garland, and Wood (2001) reported that 19.2% of the adolescents aged 13-18 years
who were in child welfare custody met the criteria for a lifetime substance-use
disorder and 11.0% had met those criteria during the past year.
In a study of 406 17-year-old youths in foster care in Missouri, McMillen et al.
(2004) reported that 37% had met DSM-IV criteria for a psychiatric diagnosis in the
past year and 61% had met similar criteria for a lifetime disorder, with the highest
rates for disruptive disorders (CD and ODD), major depression, and ADHD. An
important new study from the Casey Family Programs interviewed 479 young adults
between the ages of 20 and 33 who had been placed in family foster care in Oregon
and Washington between 1988 and 1998 (Pecora et al., 2005). Using the Composite
International Diagnostic Interview (CIDI), the study estimated that 54.4% had met
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criteria for a DSM diagnosis within the previous year as compared to 22.1% for the
general population in the same age group. The highest rates were for PTSD (25.2%)
and major depression (20.1%).
While not the primary focus of this report, we would note that a limited but
growing empirical base suggests that estimates of need for mental health care may
be almost as high for youth involved with the child welfare system who remain with
their biological parents as for youth placed in foster care. For example, in a re-
analysis of the Great Smoky Mountains study data , Farmer et al. (2001) compared
three subgroups of children (age 9, 11, or 13 years at baseline) who were randomly
selected into their community sample: (1) children who had ever been in foster care
(N=132), (2) children who had been in contact with child welfare but who had never
been placed in out-of-home care (N=234), and (3) children living in poverty with no
known contact with child welfare (N=413). More than three out of four of these
children met the criteria for either a DSM III-R diagnosis, functional impairment, or
both, using the Child and Adolescent Psychiatric Assessment (CAPA) measurement,
with only small differences between the three groups (78% for the foster care group,
80% for the child welfare contact group, and 74% for the poverty group). These data
suggest that children provided services by child welfare while remaining in their
biological home may evidence equally high rates of mental health problems as those
observed in children placed in foster care.
The National Survey of Child and Adolescent Well-Being [NSCAW] is
providing the first nationally representative data on psychosocial functioning for
children involved in child welfare. In a study of mental health service use, Burns et
al.(2004) reported that “nearly half (47.9%) of the youths aged 2 to 14 years
(N=3,803) with completed child welfare investigations had clinically significant
emotional or behavioral problems (pg. 960)” as measured by the Achenbach CBCL.
However, these rates varied dramatically by placement setting, from a low of 39.3%
for youth in kinship foster care to a high of 88.6% for youth in group home or
residential treatment settings. In a separate NSCAW-based paper, Leslie et al.
(2004) reported that almost half (46.8%) of youth age 2 to 14 years who resided in
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foster care had clinically significant emotional or behavior problems as measured by
the CBCL.
Finally, two of the studies reviewed reported findings that suggest that
decisions about reunification may be affected by the psychosocial functioning of the
child in foster care. Horwitz, Simms, and Farrington (1994) found that children with
developmental problems were almost two times more likely to remain in foster care
than be reunified. Landsverk, Davis, Ganger, Newton, and Johnson (1996) found
that children with significant behavior problems, especially externalizing problems,
were one-half as likely to be reunified with their birth parent within 18 months of
foster care entry as were those without significant behavior problems.
Summary
The research literature based on studies across several states and a
nationally representative survey suggests that between one-half and three-fourths of
the children entering foster care exhibit behavior or social competency problems
warranting mental health services. Preliminary evidence indicates that this high rate
may also be anticipated for children served by child welfare but who remain in their
biological homes. The rate of problems is significantly higher than would be
expected in community populations, although more comparable with that of children
living below poverty level within these communities. Furthermore, these needs range
across a number of domains, rather than being concentrated in only broad behavior
problems. A noteworthy finding is the high rate of developmental problems in
children entering foster care prior to the age of 7 years. In addition, evidence
suggests that the rate of problems may be somewhat lower in children who end up
in kinship care as compared to children who are placed in non-relative foster care.
Finally, psychosocial functioning of the children in foster care may not only affect
their long-term functioning outcomes but also decisions regarding their continuity in
or exit from foster care.
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II. USE OF MENTAL HEALTH CARE
Since 1988, a growing body of studies has examined the use of mental health
care services for this special population. This section discusses findings from seven
studies that provide estimates of service use in six states, namely, California,
Tennessee, Washington, Pennsylvania, North Carolina, and Missouri. These rates
are compared to rates found in community samples. Early published findings from
the NSCAW study are also reviewed for the first national estimates of use of mental
health care by youth in foster care.
Use of Mental Health Care
Estimates regarding rates of mental health service use are difficult to
ascertain given the variations in definitions of mental health services, which range
from the traditional outpatient and inpatient modalities to the less traditional services
such as case management and therapeutic group homes. Despite these definitional
variations, a number of community studies using survey reports by parents and
youth have estimated that between 4 to 12% of children in community samples have
received mental health services (Offord et al., 1987; Zahner et al., 1992; Koot &
Verhulst, 1992).
Three studies of mental health service use by children in foster care used
Medicaid program claims data from the late 1980s and 1990s, one from California ,
one from the state of Washington, and one from Pennsylvania. The Medicaid data
from these three states are especially relevant because they have made all children
in foster care categorically eligible for the Medicaid program regardless of the
eligibility status of their biological parents. In the California study conducted by
Halfon, Berkowitz, and Klee (1992a, 1992b), Medi-Cal data (the name for the
Medicaid program in California) were examined for all paid claims involving children
under 18 years of age in the fee-for-service program in 1988. Rates of health care
utilization and associated costs were compared between the 50,634 children
identified in foster care and the 1,291,814 eligible children. While the children in
17
foster care represented less than 4% of the population of Medi-Cal eligible users,
they represented 41% of the users of reimbursed mental health services and
incurred 43% of all mental health expenditures. This over-representation among
mental health service users held for all age groups within the foster care population,
ranging from rates of 31% for children under the age of 6 years and 32% for children
between the ages of 6 and 11 years, to 49% for all users between the ages of 12
and 17 years. The investigators further determined that children in foster care had
an age-adjusted rate of mental health service utilization that was 15 times the overall
Medi-Cal population that served as the reference group. The investigators found that
this pattern of greater utilization was also true across many different types of mental
health services, with children in foster care accounting for 53% of all psychologist
visits, 47% of psychiatry visits, 43% of public hospital inpatient hospitalizations, and
27% of all psychiatric inpatient hospitalizations.
The second study (Takayama, Bergman, & Connell, 1994) using Medicaid
claims form data compared the health care utilization rates of 1,631 children in foster
care with those of a sample of 5,316 children from the population of children who
were AFDC recipients but not in foster care in 1990 This research focused on
children under the age of 8 years in Washington state, making it less inclusive than
the California study. Despite the younger age cohort studied, the findings were
comparable to those reported by Halfon and colleagues for California, with 25% of
the children in Washington foster care using mental health services as compared to
only 3% of the AFDC comparison group children. When the diagnoses were
examined for high-cost children, those whose 1990 health care expenditures
exceeded $10,000, (8% of foster children and 0.4% of AFDC children), the
prominent diagnoses for the children in foster care were mental disorders and
neurological conditions.
The third study (Harman, Childs, & Kelleher, 2000) compared use and costs
of mental health services between children in foster care and children identified
under the Supplemental Security Income (SSI) program (children qualify for SSI if
there is a medically determinable physical or mental impairment that results in
18
marked and severe functional limitations) in western Pennsylvania. This research
team found that:
children in foster care were 3 to 10 times more likely to receive a mental
health diagnosis, had 6.5 times more mental health claims, were 7.5 times
more likely to be hospitalized for a mental health condition, and had mental
health expenditures that were 11.5 times greater ($2082 vs. $181) than
children in the Aid to Families With Dependent Children (AFDC) program.
Overall, utilization rates, expenditures, and prevalence of psychiatric
conditions for children in foster care were comparable with those of children
with disabilities (p. 1114).
Further insight into the use of mental health services by children in foster care
is provided by two additional studies within two separate states that shared
important design features. The investigations in Tennessee (Glisson, 1994, 1996)
and in San Diego County, California (Garland, Landsverk, Hough, & Ellis-Macleod,
1996; Landsverk et al., 1996; Leslie et al., 2000) both studied children entering
foster care and both used the Achenbach Child Behavior Checklist to determine the
need for mental health services.
The San Diego County study examined the need for mental health services in
a cohort of 662 children between the ages of 2 and 17 years at the first out-of-home
interview (approximately 5 to 8 months after entry into foster care). Need for services
was determined by a behavior problems score above the borderline cut point on the
Parent Report Form of the Child Behavior Checklist (Achenbach, 1991). Mental
health service utilization was based on reports by the substitute parent regarding
any service use for help with behavioral, social, school, or other adjustment
problems. In addition, the type of provider and frequency of visits were elicited from
the same informant. The study found that 56% of these children had used mental
health services within the period between entry into foster care and the first
interview. The proportion using mental health services ranged from 21% of the
children age 2 to 3 years, 41% of the children age 4 to 5 years, 61% of the children
age 6 to 7 years, and over 70% for children and adolescents over the age of 7 years.
These rates contrast sharply with the less than 10% of the same children for whom
19
there was evidence of mental health care utilization prior to entry into out-of-home
placement (Blumberg, Landsverk, Ellis-MacLeod, Ganger, & Culver, 1996). By far,
the largest proportion (60%) were being seen by a clinical psychologist. The
frequency of outpatient visits for all subjects receiving services (except those in
residential care) was relatively high with an estimated mean of 15.4 visits in 6
months. This suggests that the majority of subjects who received outpatient services
were in some type of ongoing treatment as opposed to an initial evaluation.
The Tennessee study followed a cohort of 600 children between the ages of 5
to 18 years who were randomly selected from approximately 2,000 children who
entered state custody in 24 Tennessee counties over the course of one year. Two-
thirds of the sample children were placed in the custody of the child welfare system.
The social workers for all of the 600 sample children reported that 14% had been
referred for mental health treatment after being placed in custody. No information
was included on the actual utilization of services.
A study of 17-year-old youths in out-of-home care in Missouri for an average
of six years reported especially high rates of both outpatient and inpatient mental
health services (McMillen et al., 2004). McMillen and his colleagues reported that
66% of the 406 youth were receiving some form of mental health services at the time
of the baseline interview, 83% reported mental health care within the past 12
months, and 94% had received mental health services within their lifetime. Use of
group home or psychiatric inpatient care was reported at very high levels, with 15%
having been in inpatient settings within the past 12 months (42% lifetime), and 60%
in group home care during the same time period (77% lifetime). This study also
reported that 3% of the youth had been in residential drug or alcohol treatment within
the past 12 months (8% lifetime). Comparably high rates (84% to 96%) of access to
“therapeutic services and supports” have been reported by Pecora and colleagues
(2005) for young adults age 20-33 years who had experienced an episode of family
foster care during their youth.
A North Carolina survey study generated estimates about the use of mental
health services for children in both in-home and out-of-home settings. Farmer et al.
(2001) in a re-analysis of North Carolina community youth in the Great Smoky
20
Mountain study (described in the prior section) found that 90% of youth reported use
of mental health services in both the group who had experienced foster care and the
group who had had contact with child welfare but had not entered foster care. This
was significantly higher than the 70% rate of use reported by youth living in families
with incomes below the poverty line.
National estimates of mental health service use for children involved with
child welfare have now been published from the NSCAW study. Burns(2004)
examined the use of specialty mental health services among children involved with
child welfare in both in-home and out-of-home settings and found that youth with
mental health needs (defined by a clinical range score on the Child Behavior
Checklist) were much more likely to receive mental health services than lower-
scoring youth, but that only one-fourth of such youth received any specialty mental
health care during the 12 months surrounding early involvement with the child
welfare service system. Leslie et al. (2004) examined an additional NSCAW cohort
that had been in out-of-home care for at least 12 months and found that over half of
the children age 2-15 years had received an outpatient mental health service since
the time of investigation leading to placement in foster care.
Factors Associated with Use of Mental Health Care
The studies discussed above also examined factors that were associated with
receipt of mental health care for youth residing in foster care. This report will
selectively review the most recent findings, especially those based on the NSCAW
study. Two published papers from the NSCAW national study both examined clinical
and nonclinical factors in reported use of mental health services. Examining mental
health care within 12 months of child abuse and neglect investigation, Burns and her
colleagues (2004) found that clinical need was related strongly (odds ratio = 2.7-3.5)
to receipt of mental health care across all age groups. Nonclinical factors were
moderated by age, with sexual abuse (versus neglect) associated with increased
use of mental health services among very young children (age 2-5 years). For 6-10-
year-olds, African American race and living at home reduced the likelihood of care,
while children aged 11 to 15 years were less likely to receive care if they were living
21
at home instead of out-of-home. Leslie and colleagues (2004) reported use of
mental health services within the past 12 months for youth in out-of-home placement
during that same period; they found that clinical need, older age, and history of
sexual abuse all predicted use of services, while African American children were
significantly less likely to have received care.
A very recent paper suggests that the geographic context may shape the
relationship between predictors and use of mental health care. Hurlburt et al. (2004)
used the NSCAW survey with child welfare participants from 92 geographic areas
(97 counties) to examine how patterns of specialty mental health service use might
vary as a function of the degree of coordination between local child welfare and
mental health agencies. After controlling for the usual predictors of use, including
need as measured by the Achenbach CBCL, age, type of placement, and
race/ethnicity, the investigators found that increased coordination between child
welfare and mental health agencies was associated with stronger relationships
between need and service use and decreased differences in rates of service use
between Caucasian and African American children. This is the first evidence that
“increases in interagency coordination may lead to more efficient allocation of
service resources to children with the greatest levels of need and to decreased
racial/ethnic disparities.” (Hurlburt et al., p. 1184).
Summary
Multiple local area studies across multiple states together with early data from
the NSCAW national study demonstrate very high rates of use of mental health
services by children in child welfare across all age groups, with the highest rates
shown in older adolescents who had been in out-of-home care for an average of 6
years. The studies using Medicaid data confirmed this much higher rate for children
in foster care, in contrast to the relatively low rates seen in children served by AFDC.
The rates of mental health service usage observed in the North Carolina study were
considerably higher than rates observed in the other states but that study did
indicate that children in both in-home and out-of-home settings were significantly
more likely to receive mental health services than children in families with incomes
22
below the poverty line. The findings from the NSCAW study indicated that despite
these high rates in comparison with community studies, three out of four youth in
child welfare who meet a stringent criterion for need were not receiving mental
health care within 12 months after a child abuse and neglect investigation. There is
growing recent evidence that both clinical and nonclinical factors affect mental health
referral and utilization patterns for children in foster care. The nonclinical factors
implicated are type of maltreatment, racial/ethnic background, age, and type of
placement. The recent review of the race/ethnicity factor by Garland, Landsverk, and
Lau (2003) suggests that this nonclinical factor consistently predicts lower use of
mental health care for African American youth. Evidence from a national study
suggests that coordination between child welfare and mental health agencies may
increase the effect of clinical factors and decrease nonclinical factors such as
race/ethnicity in use of mental health care (Hurlburt et al., 2004).
III. EVIDENCE-BASED INTERVENTIONS AND PROMISING PRACTICES
The prior sections of this report have used results from a growing body of
empirical research to demonstrate the substantial evidence for a high level of need
for mental health services and a high rate of use of mental health services for
children reported to child protective services, especially in the out-of-home setting of
foster care. A reasonable question to ask is whether the use of mental health
services ameliorates the mental health problems of this high-risk group.
Unfortunately, few studies have been conducted that provide an answer to this
question. We do not know enough about whether these services are effective in
reducing behavioral and emotional symptoms or enhancing functional outcomes in
children reported to child protective services. On a more positive note, children
involved with child welfare have been included with other children in studies of
selected interventions (e.g., cognitive behavioral therapy for sexual abuse treatment,
or treatment foster care). Emerging efforts to focus the development of interventions
23
on children in foster care (Fisher & Chamberlain, 2000) are encouraging and could
be increased.
However, other bodies of research suggest there may not be measurable
positive effects of “usual care” mental health services delivered in the type of
community settings to which children reported to child protective services are
referred. We briefly discuss the overall research findings in order to introduce the
issue of a gap between what is known from tightly controlled efficacy studies and the
treatment services that children receive in community-based settings.
A large body of efficacy trial research supports the conclusion that
psychotherapeutic interventions can produce large improvements in children’s
symptoms and functioning in non-child-welfare settings. (Similar evidence exists for
the efficacy of psychotropic medications for certain conditions such as attention
deficit hyperactivity disorder (ADHD), but that research will not be addressed here.)
Evidence to support this claim comes both from meta-analytic studies that review a
broad range of psychotherapeutic interventions in the research literature and from
criterion-based reviews of interventions for specific kinds of mental health disorders.
Extensive meta-analytic reviews of clinical trial studies (Casey & Berman,
1985; Weisz, Weiss, Alicke, & Klotz, 1987; Kazdin, Bass, Ayers, & Rodgers, 1990;
Weisz, Weiss, & Donenberg, 1992; Weisz, Weiss, Han, Granger, & Morton, 1995;
Kazdin & Weisz, 1998), conducted by different investigators and using somewhat
different review methodologies, have examined the effects of psychotherapeutic
interventions on symptoms and functioning across a large number of published
studies. Uniformly, these reports have concluded that psychotherapies for children
result in improved clinical outcomes. Depending upon the meta-analytic
methodology employed (weighted or unweighted least squares), the average
treatment effect size (defined as the difference between treatment and control
groups, after treatment or at follow-up, divided by the standard deviation of the
outcome measure) falls between .5 and .8. These effects are similar to those
reported in the meta-analytic literature on adult psychotherapeutic outcomes (Weisz
et al., 1992; Weisz et al., 1995). The conclusions of these meta-analyses remain
true, even when subjected to extensive re-analyses. For example, the positive
24
effects of psychotherapy exist across years within the same meta-analyses and in
meta-analyses spanning different years. Outcomes are more positive for domains
related to the target of the intervention but are not due to the use of outcome
measures that are unnecessarily close to the actual treatment process. Effects of
treatment are not limited to immediate post-treatment improvements but remain
relatively constant across follow-up periods of a year or more. Positive outcomes
appear across different problem categories and across different kinds of potential
outcome measures, including parental report and child self-report (Casey & Berman,
1985; Kazdin et al., 1990; Weisz et al., 1995). The conclusions of meta-analytic
studies are thus quite robust.
Whereas meta-analytic studies and review papers typically examine the
impact of psychotherapies generally or a class of treatments (e.g., Baer & Nietzel,
1991; Grossman & Hughes, 1992), alternative methods have been established to
determine whether specific psychotherapeutic interventions result in improved
outcomes for children. These methods involve establishing a set of criteria for
deciding whether sufficient evidence exists to label a psychotherapeutic treatment as
empirically supported (Task Force on Promotion and Dissemination of Psychological
Procedures Division of Clinical Psychology, 1995; e.g., Chambless & Hollon, 1998).
In a series of recent reviews, a number of different psychosocial interventions
fulfilled the criteria for either “probably efficacious” or ”well-established” (Chambless
et al., 1996; Birmaher, Ryan, Williamson, Brent, & Kaufman, 1996; Rogers, 1998;
Ollendick & King, 1998; Pelham, Wheeler, & Chronis, 1998; Brestan & Eyberg,
1998; Kazdin & Weisz, 1998; Kaslow & Thompson, 1998; American Academy of
Child and Adolescent Psychiatry, 1998), including treatments for depression and
conduct disorders, two of the most common problems presenting for care in public
mental health service systems (Rosenblatt, Rosenblatt, & Biggs, 2000). Therefore,
from both the meta-analytic perspective and the criterion-based perspective,
relatively clear evidence exists that psychosocial interventions can result in
moderate to large improvements in client outcomes both at the close of treatment
and over follow-ups of one year or more.
25
In contrast to the strong evidence demonstrating the efficacy of
psychotherapeutic interventions generally, and of specific treatments in particular,
evidence supporting the effectiveness of mental health treatment delivered in
community settings is quite weak. In a meta-analytic review of studies that
compared children receiving treatment in a community setting with children receiving
no treatment, Weisz, Donenberg, Han, and Weiss (1995) identified nine studies
sufficiently well designed for some conclusions to be drawn. Across the nine studies
reviewed, effect sizes for treatment relative to a no-treatment control ranged from -.4
to +.29, with an overall mean effect size of .01. Not surprisingly, this was not
significantly different from zero and amounted to no clinically important impact. A
closer review of the studies included in this meta-analysis reveals that a number of
studies provided relatively good tests of the impact of care delivered in community
treatment settings (e.g., Levitt, Beiser, & Robertson, 1959; Jacob, Magnussen, &
Kemler, 1972). The studies generally compared children receiving no treatment to
children receiving extensive treatment. Tests were conducted to confirm the
comparability of groups at baseline, and in some cases quite large sample sizes
were employed. An alternative view is that most of these studies were conducted
decades ago, did not utilize a controlled research design, and may not reflect
community care in the 21st century.
Over all, there is little evidence to suggest that measurable benefit in lowered
mental health symptom levels or increased functioning can be expected from the
receipt of “usual” mental health care in public mental health community settings that
serve children and adolescents who experience foster care. This has led to a sharp
focus on bringing therapeutic interventions into these settings that have better
potential for addressing the mental health problems of this clientele. A selective
review of these evidence-based interventions and promising practices is provided in
Section Three, which is directed toward the Casey Family Programs’ questions
about what mental health interventions have been evaluated. In the language of this
era with its focus on evidence-based medicine and evidence-based interventions,
the field is directed toward treatments/interventions that have been tested
empirically, usually in randomized clinical trials (RCTs), and have been shown to
26
demonstrate greater benefit (improved outcomes) for youth receiving the treatment
tested versus usual care or an alternative intervention.
In this section, three major questions are examined. “What is evidence?”
explores the criteria for evidence and how these vary as multiple professional
organizations have become engaged in examining evidence. Second, the question
“What is the evidence?” is pursued. To do so, the evidence for four of the most
common disorders (i.e., PTSD and abuse-related trauma, disruptive behavior
disorders, depression, and substance abuse) is presented. Then, since many youth
placed in foster care experience multiple disorders and difficulty functioning at home,
at school, and/or in the community, intensive home and community-based services,
which are applicable to these higher-risk youth are described and reviewed. The
third question asks about the status of evidence-based interventions in the practice
community, and it addresses the spread (or availability) of such interventions and
relevant experience with them in the foster care population.
What Is Evidence? The expectation that evidence even existed for child mental health
interventions was low until the extant scientific literature was pulled together for the
Surgeon General’s Report on Mental Health in 1999 (U.S. Department of Health and
Human Services, 1999). The surprising finding was that significant evidence existed
for the treatment of a number of common childhood disorders, even when stringent
criteria were applied. Since then, further treatment development research has
strengthened the potential to intervene effectively for trauma/PTSD, disruptive
behavior disorders, and depression, conditions that occur frequently in the foster
care population and in the general population, as well as interventions for more
complex or persistent conditions that are also common among youth in foster care.
Prior to 1999 and during the years since, multiple organizations have become
engaged in defining criteria for evidence and categorizing interventions on the basis
of “well established” at the highest level to “concerning treatment” (meaning
potentially harmful). The proliferation of criteria and lists of evidence-based practices
may have created confusion around understanding what works (i.e., is effective) and
27
does not work for youth with emotional and behavioral problems. A number of
registries, including those created by the federal government, vary in the quality of
evidence required, from multiple controlled trials to self-nominated “promising
practices” with some indication of benefit from uncontrolled studies. These registries
and reports offer additional information from federal and state agencies and
independent research organizations beyond the scope of what we have presented in
this report (see Appendix A for a listing of these resources and registries).
For this review, we have adopted a conservative approach by including those
interventions that (1) merit the highest standards of evidence while also commenting
upon several that may be deleterious or dangerous; (2) address the range of
common conditions, as the evidence permits; and (3) identify developmental, or at
least age-appropriate, interventions as feasible for pre-school, school age, and
adolescent youth. The major criteria relied upon here are those proposed by the
Division of Clinical Psychology of the American Psychological Association (Lonigan,
Elbert, & Johnson, 1998; Chambless & Hollon, 1998). To be identified as “well
established,” the following criteria were applied:
• At least two controlled group design studies or a large series of single-case
design studies
• Minimum of two investigators
• Use of a treatment manual
• Uniform therapist training and adherence
• True clinical samples of youth
• Tests of clinical significance of outcomes
• Functioning outcomes plus symptoms
• Long-term outcomes beyond termination
The major difference in the second level standard, “probably efficacious,” is
that a single investigator has conducted controlled studies on the intervention, in
contrast to the two or more controlled studies required for “well established.”
These criteria represent a high standard and are relatively easy to apply to the
scientific literature on diagnostic-specific psychosocial interventions. The APA
standards have not been applied officially in the recent published literature either to
28
diagnostic-specific interventions or to intensive home- and community-based
services. However, we have applied these standards for this report.
What Is the Evidence for Interventions Addressing PTSD and Abuse-Related Trauma, Disruptive Disorders, Depression, and Substance Abuse?
PTSD and abuse-related trauma Child abuse and neglect constitute the principal reason for children being
placed in foster care. Children who suffer from abuse and neglect often exhibit
physical, emotional, behavioral, and other symptoms (see Curie, 2002, for a
developmental review). Young children (up to age 5 years) are likely to experience
generalized fear that can manifest in various ways such as heightened arousal,
nightmares, clinging to caregivers, and/or a startle response to loud or unusual
noises. In school-aged children (6-11 years), general fearfulness may be
accompanied by guilt, aggression, social withdrawal, and loss of concentration. For
adolescents (age 12 to 18 years), symptoms may also include a decline in school
performance, rebellion at home or school, eating disturbances, and trauma-driven
acting out such as early sexual activity and other types of risk-taking. These
symptoms are in line with those associated with post-traumatic stress disorder
(PTSD) as defined by the DSM-IV (American Psychiatric Association, 1994). As
such, treatments provided to children with histories of abuse focus largely on
relieving PTSD symptoms. The effectiveness of these treatments has been
examined in recent reviews, and the findings will be presented in this section.
Four reviews of treatment for child abuse and neglect have been completed in
the last three years (Saunders, Berliner, & Hanson, 2002; Kolko & Swenson, 2002;
Chadwick Center for Children and Families, 2004; Chaffin & Friedrich, 2004). The
criteria used in these reviews to determine which treatments are effective broadly
follow the guidelines on “what is evidence” discussed earlier. The method for each
29
review is described briefly below to provide context for the main findings on which
interventions are best supported.
The primary aim of one review done by the Office for Victims of Crime [(OVC]
(Saunders et al., 2002) was to identify the treatments with the strongest research
evidence. A secondary aim was to more generally review and document the
research base for common treatments for children with abuse histories. These goals
necessitated a very comprehensive and specific set of criteria for classifying
interventions according to the type and quantity of evidence collected. The criteria
that were used (shown in Appendix B) prioritized experimental control up to the top
category (“well-established”), which requires evidence from RCTs. The full list of
treatments reviewed and the findings on their research support can be viewed at the
OVC website (http://www.musc.edu/cvc/guide1.htm).
The aim of the Kauffman report (Chadwick Center for Children and Families,
2004) was also to identify the leading interventions for children with abuse histories.
The OVC findings were reviewed, and a simplified classification scheme was
applied, which resulted in three interventions being labeled “best practices.” The
Kauffman guidelines also prioritized level of experimental control as the top marker
for reliable evidence. However, because the goals did not include review of a wide
array of common treatments as in the OVC report, fewer criteria were needed. To be
classified as a leading intervention, a treatment had to demonstrate a sound
theoretical basis and have a manual, acceptance in clinical settings, and at least one
RCT. The final report can be accessed through the Chadwick Center for Children
and Families website at http://www.chadwickcenter.com/kauffman.htm.
The remaining two published reviews took a slightly different approach (Kolko
& Swenson, 2002; Chaffin & Friedrich, 2004). Their aim was to present the most
rigorously researched and the most commonly provided interventions organized by
type of trauma history (e.g., physical abuse, sexual abuse, neglect). Although
specific criteria for classifying treatments in terms of research support were not
presented, the authors were more supportive of treatments that had been subjected
to controlled research from which positive findings emerged.
30
In addition to these four reviews, the National Child Traumatic Stress Network
(NCTSN) has compiled a list of treatments for child trauma, classified according to
the OVC guidelines. The NCTSN intervention list differs from that of the OVC report
because it includes treatment for all types of trauma, not just abuse and neglect. The
NCTSN list is available on the Internet at http://www.nctsnet.org and is slightly more
up-to-date than the other reviews presented here. That website also includes a fact
sheet for each treatment, which presents a summary of the treatment model and the
research that has been conducted on its effectiveness.
Despite the fact that these reviews did not use identical criteria to classify
treatments in terms of their research support, each one prioritized experimental
control, and their results do converge to reveal a degree of expert consensus on the
leading candidates in the field. Three clear frontrunners emerged as the most well-
supported interventions for children with histories of abuse. These interventions
have been subjected to rigorous analysis in the form of RCTs. Each intervention is
described below, and the evidence for their effectiveness is briefly reviewed. Table 1
provides summary information for each treatment, including citations to controlled
treatment studies. Information on training materials and dissemination can be found
in the NCTSN fact sheets for all of the following treatments with the exception of
Project 12-Ways/Safe Care for Child Neglect.
31
Table 1. Well-established and probably efficacious interventions for child trauma
Intervention Target Population Controlled Studies (RCT* or quasi- experimental)
Main findings
Trauma Focused CBT Children (4-18 years) with
emotional and behavioral
disturbance related to
traumatic events, even if there
is no PTSD diagnosis
RCTs
Cohen & Mannarino (1996)
Cohen & Mannarino (1997)
Cohen & Mannarino (1998)
Cohen, Mannarino, & Knudsen (2005)
Cohen, Deblinger, Mannarino, & Steer
(2004)
Deblinger, Lippman, & Steer (1996)
Deblinger, Steer, & Lippman (1999)
Deblinger, Stauffer, & Steer (2001)
• Improvement in child PTSD,
depression, anxiety, behavior
problems, sexualized behaviors,
and feelings of shame and mistrust
• Decreased parental depression and
emotional distress about the child’s
abuse
• Improvement in parental child
support and parenting practices
Abuse-Focused CBT Physically abusive parents
and their children
RCTs
Kolko (1996a)
Kolko (1996b)
• Decreased parent use of physical
discipline
• Decreased parent anger problems
• Decreased child behavior problems
• Decreased child aggression
towards parent
• Decreased family conflict
Parent-Child Interaction
Therapy
Physically abusive parents
and their children age 4-12
RCTs
Chaffin et al. (2004) • Decreased parent physical abuse
• Reduced negative parent-child
32
years
Quasi-experimental
Eyberg, Boggs, & Algina (1995)
Borrego, Urquiza, Rasmussen, & Zebell
(1999)
Eyberg et al. (2001)
Boggs et al. (2004)
Timmer, Urquiza, Zebell, & McGrath
(2005)
interactions
• Maintenance of effects at long-term
follow-up (3 to 6 years after
treatment)
Child-Parent
Psychotherapy for
Family Violence
Children up to age 5 years
who have witnessed
traumatizing domestic violence
RCTs
Toth, Maughan, Manly, Spagnola, &
Cichetti (2002)
Cicchetti, Rogosch, & Toth (2000)
Lieberman, Van Horn, & Ghosh Ippen
(2004)
Lieberman, Weston, & Pawl (1991)
• Decreased PTSD symptoms
• Decreased behavior problems
• Decreased maternal avoidance
CB Intervention for
Trauma in Schools
(CBITS)
Children age 10-15 years who
have witnessed traumatic
events
RCTs
Stein et al. (2003)
Quasi-experimental
• Improvement in PTSD and
depressive symptoms
• Maintained improvements at 6-
month follow-up
33
Kataoka et al. (2003)
TF-CBT for Childhood
Traumatic Grief
Children who have
experienced both trauma and
loss of a loved one
Quasi-experimental
Cohen, Mannarino, & Knudsen (2004)
Cohen, Goodman, Brown, & Mannarino
(2004)
• Improvement in PTSD, grief
depression, anxiety, and behavior
problems in children
• Improvement in PTSD and
depression in parents
Project 12-Ways/Safe
Care for Child Neglect
Children who have suffered
neglect
Quasi-experimental
Gershater-Molko, Lutzker, & Wesch,
(2002)
Lutzker & Rice (1987)
Taban & Lutzker (2001)
Lutzker, Bigelow, Doctor, & Kessler
(1998)
• Improved assertion skills
• Improved job skills
• Improved home management skills
*RCT = Randomized clinical trial
34
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT addresses behavioral and emotional symptoms as well as the
negative thought patterns associated with childhood trauma. Treatment is
targeted at both the parent and the child. A PTSD diagnosis is not necessary;
rather, the child must exhibit behavioral or emotional problems related to a past
trauma experience. The model is clinic-based and short-term (results are
expected within 12-16 weeks). Some of the essential components of TF-CBT
include:
• Establishing and maintaining a therapeutic relationship with child and
parent
• Emotion regulation skills
• Connecting thoughts, feelings, and behaviors associated with the trauma
• Stress management skills
• Parenting skills training
• Personal safety skills training
• Coping with future trauma reminders
TF-CBT has been the focus of several RCTs. It has been compared to
non-directive play therapy and supportive therapies in children aged 3 to 14
years who have been subjected to multiple types of trauma (Deblinger et al.,
1996; Cohen & Mannarino, 1996; Cohen & Mannarino, 1997; Cohen &
Mannarino, 1998; Deblinger et al., 1999; Deblinger et al., 2001; Cohen et al.,
2004; e.g., Cohen et al., 2004; Cohen et al., 2005). TF-CBT has been linked to
improvements in PTSD symptoms, depression, anxiety, behavioral problems,
and feelings of shame and mistrust. Moreover, these improvements have been
maintained following treatment completion (Deblinger et al., 1999). When parents
are also involved in TF-CBT, research has shown that the positive effects for
children increase (Deblinger et al., 1996). This occurs through improvement of
parental depression, support of the child, emotional distress about the child’s
abuse, and parenting practices.
35
Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse
(AF-CBT)
AF-CBT was developed by Kolko and is fully described in Kolko and
Swenson (2002). AF-CBT is delivered in an outpatient setting to physically
abusive parents and their school-age children. Treatment is brief (12-18 hours)
and can be applied in either the clinic or the home. The model incorporates
aspects of learning/behavioral theory, family systems, and cognitive therapy.
Individual child and parent characteristics are targeted as well as the larger
family context. Both risks and sequelae associated with abuse are addressed
(e.g., parenting skills and beliefs, child behavioral and emotional problems).
Some essential components of AF-CBT are presented below. These
interventions can be directed at the child, the parent, or both.
• Instruction in specific interpersonal skills
• Instruction in specific intrapersonal skills (e.g., cognitive, affective)
• Promoting prosocial behavior
• Discouraging coercive/aggressive behavior at both individual and family
levels
• Coping skills
• Relaxation training
• Anger management
AF-CBT has been compared to family therapy and routine community
services (see Chalk & King, 1998, and Kolko & Swenson, 2002 for review). AF-
CBT led to decreases in parental anger and use of physical discipline and force
(Kolko, 1996a, 1996b). These changes occurred more quickly than similar
changes seen in family therapy and to a greater degree than seen in routine
community services. Over the follow-up period, both AF-CBT and family therapy
were superior to routine community services on decreasing child-to-parent
aggression, child behavior problems, and parental child abuse potential,
psychological distress, and drug use. Families in these two conditions
demonstrated more cohesion and less conflict.
36
Parent-Child Interaction Therapy (PCIT)
PCIT is a highly structured treatment model involving both parent and
child. Originally developed for children with behavioral problems, PCIT has been
adapted for physically abusive parents with children age 4 to 12 years. Treatment
is brief (12-20 sessions) and involves live-coached sessions where the
parent/caregiver learns skills while engaging in specific play with the child. The
overarching goal of PCIT is to change negative parent-child patterns. The time in
each session is usually divided between relationship-enhancing, positive
discipline, and compliance skills. Specific parent and child behaviors are tracked
and charted on a graph during each session, and the therapist provides feedback
to the parent on his or her mastery of the skills. Some of the specific components
of treatment include:
• Relationship-enhancing skills
• Positive discipline and compliance skills
• Homework sessions of 5-10 minutes daily to reinforce skills taught in
session
• Parenting skills
• Booster sessions following treatment completion
Studies of PCIT fall in two categories: (1) those involving children with
behavior problems regardless of whether they have any maltreatment history,
and (2) those involving children with a history of abuse regardless of whether
they have a diagnosable behavior problem. With respect to the first category,
several quasi-experimental studies have been conducted. These have
demonstrated improvement from pre- to post-treatment (Eyberg et al., 2001) and
significantly better outcomes for children and parents who completed treatment
versus families who were on the wait-list (Eyberg et al., 1995) or who did not
complete treatment (Boggs et al., 2004). These positive outcomes have been
maintained for as long as three to six years following treatment completion (Hood
& Eyberg, 2003).
With respect to the second category, one RCT and two quasi-
experimental studies have been conducted. The RCT randomly assigned
37
abusive parents and their children to PCIT, to enhanced PCIT (with additional
individualized services), or to a standard community-based parenting group
(Chaffin et al., 2004). PCIT and enhanced PCIT were similarly superior to the
parenting group at decreasing subsequent reports of physical abuse.
The most recent quasi-experimental study examined PCIT for biological
parent-child dyads with histories of maltreatment or at high risk for maltreatment
(Timmer et al., 2005). From baseline to post-treatment, these families showed
decreases in child behavior problems, parental stress, and risk for future abuse.
Another earlier study examined a single case of a child and parent at risk for
physical abuse (Borrego et al., 1999). The child’s behavior problems decreased
following treatment as did the mother’s stress. The number of positive parent-
child interactions also increased.
Given the fact that PCIT has garnered evidence for its effectiveness with
both children with behavior problems and children with abuse histories, it is
viewed as having great potential for children and families in foster care in which
these problems often overlap.
In addition to these well-established interventions, four others have
received support from controlled research and are cited or categorized as
supported interventions in the reviews listed above. These treatments are also
considered leading candidates, although the research lags slightly behind that of
the three candidates presented above. These interventions, described briefly
below, are included here to provide evidence for addressing types of trauma not
targeted by the interventions above.
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Child
Traumatic Grief
TF-CBT for Childhood Traumatic Grief is designed to help children
suffering from traumatic grief after experiencing the loss of a loved one in
traumatic circumstances. These children often have PTSD symptoms,
depression, anxiety, and/or behavior problems that prevent them from
successfully grieving their loss. The therapy model is calibrated for two age
38
groups: children up to 6 years, and children and adolescents over age 6 years.
Treatment is provided to both child and caregiver (together and alone) and
occurs over 12 to 16 sessions, focused at first on trauma and then on grief. The
model pays special attention to cognitive, behavioral, and physiological reactions
to the combination of trauma and bereavement, most notably sadness and fear
(see Brown, Pearlman, and Goodman, 2004, and Cohen and Mannarino, 2004,
for description). The components of the model are similar to those for TF-CBT
but with added focus on fear and sadness resulting from bereavement.
The evidence base for TF-CBT for Childhood Traumatic Grief is only just
emerging because the treatment is relatively new. Two open trials have focused
on children age 6 to 17 years who lost parents in the September 11, 2001
terrorist attacks. These trials have linked specific components of treatment to
targeted changes in symptoms over time (Cohen, Goodman, et al., 2004; Cohen,
Deblinger, et al., 2004 ). These findings, along with the success of TF-CBT for
child trauma, suggest that this intervention is a leading candidate for children
who are doubly exposed to trauma and bereavement.
Cognitive Behavioral Intervention for Trauma in Schools (CBITS) CBITS is a group intervention focused on building skills for children
suffering symptoms of PTSD, depression, and anxiety related to trauma. Some of
the skills taught include relaxation, social problem solving, challenging upsetting
thoughts, and processing traumatic memories and grief. CBITS is commonly
used for children age 10 to 15 years who have experienced or directly witnessed
a traumatic event, including violence. One RCT compared early intervention
CBITS to late intervention CBITS (Stein et al., 2003). Children who received
CBITS earlier following trauma (the early intervention group) demonstrated more
positive responses to outcome than those who received the intervention later.
Both groups improved over time. A second quasi-experimental study involving
198 Latino immigrant children compared CBITS to a wait-list control group,
revealing greater improvement in the CBITS group (Kataoka et al., 2003).
39
Child-Parent Psychotherapy for Family Violence (CPP-FV)
CPP-FV is an individual psychotherapy model for infants, toddlers, and
preschoolers who have witnessed domestic violence or display symptoms of
violence-related trauma such as PTSD, defiance, aggression, multiple fears, and
difficulty sleeping. The treatment incorporates aspects of psychodynamic,
attachment, trauma, cognitive-behavioral, and social-learning theories. Treatment
is delivered in a dyad and targets the child-parent relationship and the individual
child’s functioning. Typically, treatment is delivered for one hour per week for
approximately 12 months. Randomized trials have compared CPP-FV to non-
intervention control groups as well as other interventions, e.g.,
psychoeducational home visitation, standard community treatment (Lieberman et
al., 1991; Cicchetti et al., 2000; Toth et al., 2002). Findings have shown better
outcomes for children who received CPP-FV compared to children receiving
other control or comparison treatments. The outcomes that have been measured
include behavior problems, symptoms of traumatic stress, and maternal
avoidance (mother avoiding the child).
Project 12-Ways/Safe Care for Child Neglect Project 12-Ways/Safe Care is focused on child neglect. Like abuse,
neglect is a form of maltreatment that places children at risk for mental health
problems. This is why Project 12-Ways is included here, despite the fact it is
technically considered prevention. The intervention targets the ecology in which
the child and family live and is based on behavioral principles (Lutzker, Van
Hasselt, Bigelow, Greene, & Kessler, 1998). Parents are taught skills in safety,
bonding, and health care. The intervention often incorporates video modeling and
is used for both prevention and treatment. The evidence has been reviewed by
Chaffin and Friedrich (2004) and Kolko and Swenson (2002) and consists of as
many as 60 program evaluations and quasi-experimental studies, some of which
are listed in Table 1. These evaluations have shown improvement in both
interpersonal (social interactions, assertion skills) and functional (job training,
home management skills) domains for parents.
40
These seven leading interventions are presented in Table 1 along with
summary information regarding the target population, outcomes, and references
for the controlled studies on each intervention. Many other treatments that are
often provided to children in foster care are not included because the research on
their effectiveness is either less promising or still emerging. Examples include
Cognitive Behavior and Dynamic Play Therapy, Eye Movement Desensitization
and Reprocessing, Physical Abuse-Informed Family Therapy, and others. Some
treatments may be harmful, such as Corrective Attachment Therapy. This
treatment features holding therapy, a type of physical restraint, which has led to
physical injury in several reported cases. Readers are encouraged to visit the
websites of the NCTSN (http://www.nctsnet.org) and the OVC
(http://www.musc.edu/cvc/) for more information on these treatments.
Medication for Trauma
Pharmacological intervention is another option for children with histories of
abuse. When medication is prescribed, this is usually done “off-label,” (i.e., the
medication has not yet been explicitly endorsed for treatment of this population),
and it is combined with behavioral treatment. One highly controlled, randomized
study compared TF-CBT plus placebo to TF-CBT plus SSRI (sertraline/Zoloft) for
children 10 to 17 years with PTSD related to sexual abuse (Cohen, 2005). The
study found a significant effect for sertraline over and above the effects of TF-
CBT alone in remitting PTSD symptoms. These very preliminary findings suggest
that a combination of TF-CBT and SSRI treatment may be a promising topic for
future research. Some caution is warranted here, however, as the sample size
for this study was small (n=20 for each group).
Further research should be conducted on the potential utility of medication
for maltreated children. Until more evidence is available on the efficacy of SSRIs
for maltreated children, and until the current controversy surrounding the suicide
risk of certain SSRIs in children moves towards resolution, caution should be
taken in writing such prescriptions.
41
In summary, several treatments appear to be effective at improving
outcomes for children who experience trauma-related symptoms related to a
history of abuse. These treatments have been chosen and described by
independent review teams. Research on these interventions has also shed light
on some common characteristics of effective treatments for children who have
experienced trauma. Specifically, treatment is more effective when it is brief and
when parents are involved. These findings are promising and give hope that
children who receive evidence-based treatment for child abuse and neglect can
have significantly improved lives.
Disruptive Behavior Disorders The evidence base on treatment for disruptive behavior disorders has
been reviewed by Brestan and Eyberg (1998); Farmer, Compton, Burns, and
Robertson (2002); and Weisz (2004). The discussion below follows from these
reviews. Two models (Parent-Child Interaction Therapy [PCIT] and Multisystemic
Therapy [MST]) that are evidence-based for disruptive behaviors are described in
other sections because PCIT has also been evaluated for trauma and MST as an
intensive home-based intervention will be described in a later section on
community-based treatment. Table 2 presents the well established and probably
efficacious treatments that were identified through review.
Parent Management Training
Parent management training programs were originally developed by
Gerald Patterson at the Oregon Social Learning Center in the 1960s. These
programs are based on the principles of operant conditioning, i.e., rewarding
positive behaviors and ignoring or punishing deviant behaviors. Intervention is
usually targeted for preschool-age children. Treatment is short term and teaches
parents behavioral management skills. Compared to psychodynamic therapy and
no-treatment controls, parent management training has produced superior
outcomes for children with conduct disorder. Patterson’s work has spawned
42
intervention development by a number of investigators (e.g., Chamberlain, Reid,
Dishion, Forehand & McMahon, Webster-Stratton, Eyberg).
Table 2. Well-established and Probably Efficacious Interventions for Disruptive Behavior Disorders
Target age Intervention
Preschool
Parent Management Training
Incredible Years
Parent-Child Interaction Therapy (age 2-8 years)
Time Out plus Signal Seat
School age Anger Coping
Problem Solving Skills Training
Adolescent
Multisystemic Therapy
Assertiveness Training
Rational Emotive Therapy
Anger Control Training with Stress Inoculation
Incredible Years
Incredible Years, an intervention developed by Webster-Stratton and with
roots in parent management training, also teaches behavior management skills
to parents of preschool-age children with behavior problems (see Farmer et al.,
2002, for review). Videotapes depicting parent-child vignettes are shown to
parents in a group setting, and subsequent discussion is guided by a therapist.
Parents attend approximately 12 two-hour sessions. Incredible Years has been
subjected to at least seven randomized trials where improved parenting skills
have been achieved.
Time Out plus Signal Seat
Time-Out plus Signal Seat is a self-instructive parenting intervention, also
based on operant conditioning and targeted for preschool-age children. A manual
presents parents with specific instructions on using positive reinforcement and
43
time-out. The signal seat, on which the child sits during the time-out, is wired to
produce a noise if the child leaves the seat. In a study comparing the intervention
to wait-list control for children 2 to 7 years, those in the treatment group
demonstrated fewer negative behaviors (Hamilton & MacQuiddy, 1984).
Anger Coping, Problem Solving, and Assertiveness Training
These interventions are most often provided in schools and are intended
to help children and adolescents with behavioral problems to learn skills to cope
in challenging situations. Controlled studies have been conducted in both school
and clinical settings, comparing these types of programs to usual school services
and parent management training (e.g., Huey & Rank, 1984; Lochman, Lampron,
Gemmer, & Harris, 1989; Kazdin, Siegel, & Bass, 1992). These studies suggest
that learning these skills can help children to control negative behaviors.
Assertiveness training in particular has shown positive findings with African
American adolescents (Feindler, Marriott, & Iwata, 1984). Positive results have
been maintained up to one-year post-treatment.
Anger Control Training with Stress Inoculation This intervention targets both anger management skills and coping skills.
The therapist’s goal is to help adolescents understand the causes and
consequences of anger. The stress inoculation component exposes the
adolescent to a trigger situation so that the child can practice his or her control
and coping skills in a constructive environment. Treatment is provided by a
therapist, in a clinical or school-based setting, over approximately 10 one-hour
sessions. Controlled studies have supported its efficacy with 12- to 18-year-olds
displaying delinquency or disruptive classroom behavior (Schlichter & Horan,
1981; Feindler et al., 1984).
Rational Emotive Therapy (RET)
44
RET incorporates cognitive components similar to that of CBT, including
training in moral reasoning. This treatment is relevant for youth with conduct
disorder because their moral reasoning and judgment skills are often
underdeveloped. Treatment is short term and provided by a therapist in weekly
sessions. Fonagy, Target, Cottrell, Phillips, and Kurtz (2002) have written the
most recent review of RET for children with behavioral problems. They found that
the only controlled studies in this area were conducted at least 20 years before
(Block, 1978; Arbuthnot & Gordon, 1986). One study (Block) included both
Hispanic and African American adolescents. Comparison groups received client-
centered therapy or no treatment. In these studies, adolescents who received
RET demonstrated higher school achievement and fewer disruptive behaviors.
These positive results were maintained at six-month follow-up in the Block study
and one-year follow up in the Arbuthnot and Gordon study.
Medication for Disruptive Behavior Disorders
The research evidence for psychopharmacological intervention for
disruptive behavior disorders in children and adolescents was most recently
reviewed by Fonagy et al. (2002) and Pappadopulos, Guelzow, Wong, Ortega,
and Jensen (2004). What follows is a brief review of the evidence.
Stimulants are commonly used to treat behavior problems when they are
comorbid with attention deficit hyperactivity disorder (ADHD). Meta-analysis has
suggested that these drugs can have positive effects for children with both
diagnoses (Steiner, Saxena, & Chang, 2003). However, one highly controlled
RCT of methylphenidate (Ritalin) found that children with behavior problems but
not ADHD experienced increases in disruptive behaviors when treated with
methylphenidate (Klein et al., 1997). More research is needed for children with
behavioral problems who do not have comorbid ADHD.
Antipsychotics such as risperidone have also been used to treat behavior
problems in children and adolescents. Results from two recent RCTs suggest
that risperidone may be effective, compared to placebo, for reducing disruptive
behaviors (Turgay, Binder, Snyder, & Fisman, 2002; Aman, De Smedt, Derivan,
45
Lyons, & Findling, 2002). These improvements were maintained up to one year
post-treatment. However, caution is warranted in interpreting these results. First,
the children in the first study had IQs ranging from 36 to 84. Second, in both
studies, negative side effects such as weight gain, headache,
somnolence/drowsiness, and vomiting were reported by as many as 52% of
those receiving risperidone.
Mood stabilizers such as lithium have also been studied in RCTs with
children exhibiting behavior problems. Lithium, in particular, has shown positive
results compared to placebo in reducing aggression (Geller et al., 1998; Malone,
Delaney, Luebbert, Cater, & Campbell, 2000). In addition, two RCTs of
divalproex (Depakote) have shown significant reductions in disruptive behaviors
(Donovan et al., 2000; Steiner, Petersen, Saxena, Ford, & Matthews, 2003). As
with antipsychotics, negative side effects have also been reported with mood
stabilizers (e.g., vomiting, ataxia, enuresis, fatigue, weight gain).
Finally, research on SSRIs for children with behavior problems has begun
to emerge. One quasi-experimental study involving 12 youths in outpatient
treatment demonstrated positive effects for citalopram (Celexa) (Armenteros &
Lewis, 2002). Because SSRIs can cause behavioral disinhibition, caution has
been stressed in the use of SSRIs for this population. Although early findings are
promising, it is clear that more research is needed to determine the safety and
efficacy of SSRIs for children with disruptive behavior disorders.
Depression Depression is another common mental health consequence for children
who have been abused and neglected. Both psychosocial and
psychopharmacological interventions have been studied. Weisz, Hawley, and
Doss reviewed the evidence on psychosocial treatments for child mental health
disorders in 2004. Research on medication was reviewed by Pappadopulos et al.
in the same 2004 volume. Interventions that have received the strongest
research support are summarized below. For more detail, see Weisz et al. and
Pappadopulos et al..
46
Psychotherapy
The leading psychotherapy treatment models for depression are Coping
with Depression and Interpersonal Therapy for Adolescents. Self-control training,
relaxation therapy, and cognitive behavior therapy have also received support
from controlled research.
Coping with Depression is a course, originally designed for adults, that
has been calibrated for use with adolescents. The course consists of 16 two-hour
sessions focusing on topics such as monitoring moods, relaxation training,
developing social skills, decreasing anxiety, and conflict resolution. Coping with
Depression is usually delivered in a group setting, and there is an optional parent
component where parents are taught similar content in fewer sessions. Three
large controlled trials with children have produced positive results for Coping with
Depression compared to wait-list control (Lewinsohn, Clarke, Hops, & Andrews,
1990; Clarke, Rohde, Lewinsohn, Hops, & Seeley, 1999; Kaufman, Rohde,
Seeley, Clarke, & Stice, 2005).
Interpersonal Therapy for Adolescents (IPT-A) has also received support
from controlled research trials. IPT-A is a brief treatment that targets several
interpersonal problems that often underlie depression. Two RCTs have been
conducted, one of which was focused on Puerto Rican adolescents (Rosselló &
Bernal, 1999; Mufson, Weissman, Moreau, & Garfinkel, 1999). In both studies,
IPT-A was superior to wait-list control in reducing depressive symptoms and
increasing social functioning. In addition, in the study involving Puerto Rican
youth, IPT-A was equal to CBT in reducing symptoms and superior to CBT in
improving general functioning (Rosselló & Bernal, 1999).
Kaslow and Thompson (1998) reviewed the evidence base for self-control
therapy. This treatment incorporates cognitive and behavioral techniques to help
the child monitor his or her mood and activity, manage aversive events, and
develop his or her own self-reinforcement patterns. Treatment is time-limited and
can be delivered in either an individual or group setting. Self-control therapy has
been compared to behavioral problem-solving therapy and wait-list control (Stark,
47
Reynolds, & Kaslow, 1987). In this study, children in both intervention groups
improved significantly more than children on the wait-list. Enhanced self-control
therapy (with increased number of sessions and monthly family meetings) has
also shown superior results to traditional counseling (Stark, Rouse, & Livingston,
1991).
Relaxation therapy was compared to CBT and self-modeling in one RCT
(Kahn, Kehle, Jenson, & Clark, 1990) and to CBT in another (Reynolds & Coats,
1986). In these studies, relaxation therapy decreased depression and anxiety as
well as increased self-esteem among junior high and high school students.
Relaxation therapy is also commonly included as a component of group-based
therapy such as Coping with Depression for adolescents.
The results for CBT are mixed (see Burns, Hoagwood, and Mrazek, 1999,
and Fonagy et al., 2002, for review). CBT has demonstrated positive results in
controlled studies (Reynolds & Coats, 1986; Brent et al., 1997), including one
with Puerto Rican youth (Rosselló & Bernal, 1999). Two other studies have
suggested no superior effects for CBT compared to control groups (Vostanis,
Feehan, Grattan, & Bickerton, 1996; Clarke et al., 2002). Samples have included
children with subclinical symptom levels, and sample sizes have been small. In
addition, the little long-term follow-up research that has been conducted has not
produced promising results (Wood, Harrington, & Moore, 1996). Some research
suggests that monthly booster sessions following treatment completion can help
reduce relapse (Kroll et al., 1996). Finally, two meta-analyses using different
methods have found positive outcomes for CBT (Reinecke, Ryan, & DuBois,
1998; Harrington, Whittaker, Shoebridge, & Campbell, 1998). Future controlled
research on CBT for children and adolescents with depression should help to
clarify its potential role in treating this population.
Medication for Depression
The use of psychotropic medication to treat child and adolescent
depression has increased over the last decade. RCTs comparing SSRIs to
placebo for child and adolescent depression have produced significant, positive
48
findings in four studies (Emslie et al., 1997; Strober et al., 1999; Keller et al.,
2001; Wagner et al., 2003) and positive but not statistically significant findings in
one study (Simeon, Dinicola, Ferguson, & Copping, 1990). Tricyclic
antidepressants have not shown similar positive results (see Hazell, O’Connell,
Heathcote, and Henry, 2002, and Fonagy et al., 2002, for review). In these
studies, medication is typically prescribed to children in the intervention group in
low doses with close monitoring for approximately 12-16 weeks.
Combined Psychotherapy and Medication
A more recent multi-site trial (n=433) has examined the combined effects
of psychosocial treatment and medication for child and adolescent depression.
The Treatment for Adolescents with Depression Study (TADS) was an RCT with
four conditions: (1) SSRI alone, (2) CBT alone, (3) combined SSRI and CBT, and
(4) placebo (Treatment for Adolescents with Depression Study (TADS) Team,
2005a).1 Adolescents who received combined SSRI and CBT showed the most
improvement. Those who received SSRI alone experienced greater improvement
than those who received CBT alone. The TADS was the first and only study to
examine a combined medication and psychotherapy model in comparison to
medication or psychotherapy alone. Although the initial results are promising,
more research is needed to replicate these results and to clarify their meaning
over time and for diverse child mental health needs.
As with the use of medication for child trauma, the main message on the
use of pharmacological intervention for children with depression is one of
cautious optimism. Because of the risk of an increase in suicidal symptoms,
close medical monitoring in the early weeks of treatment with an SSRI is critical.
Substance Abuse Children in the foster care system who suffer from PTSD, behavioral
disorders, and/or depression often experience problems related to substance use
during adolescence. These problems include early substance use (prior to age
49
14 years) and/or heavy use of substances in the mid- or late-adolescent period.
Below, three treatment approaches with supporting evidence are reviewed
broadly (brief interventions, cognitive behavior therapy, and family-based
interventions). In addition, the evidence for residential treatment centers,
inpatient treatment, the 12-step model, and medication is briefly reviewed to
provide information on these commonly used interventions.
Brief Interventions
Brief interventions are used to reduce harmful consumption of alcohol,
tobacco, and other drugs. These are shorter in tenure than more traditional
interventions and are primarily intended to address an adolescent’s motivation to
attend treatment. A recent review of brief interventions (Tait & Hulse, 2003)
identified 11 studies involving more than 3,000 adolescents. Most studies
included motivational interviewing, the leading brief intervention model. Three
studies included health education programs. Generally, these brief interventions
have shown small to moderate effects. Specific improvements have included
decreases in consumption as well as related problems and consequences, and
increased treatment engagement (Tevyaw & Monti, 2004). Results have been
stronger for those with heavier substance use or lower motivation at intake.
Cognitive Behavioral Therapy (CBT)
CBT has been adapted for substance abuse. In the adapted model, the
therapist helps the client to identify high-risk situations that trigger substance use
and to develop strategies to avoid or handle these situations in order to maintain
sobriety. Other components of treatment include coping skills, self-efficacy,
relapse prevention, and operant conditioning principles. Models of CBT for
substance use are short- or moderate-term in length (5 to 12 sessions) and have
been applied in both individual and group formats (see Waldron and Kaminer,
2004, for review).
1 For a detailed description of the study’s methodology, see TADS (2005b).
50
Evidence for CBT as a treatment for substance abuse has emerged from
several recent randomized trials. These trials demonstrate positive outcomes for
both group-based and individual CBT and for both short- and moderate-term
models (Waldron, Slesnick, Brody, Turner, & Peterson, 2001; Liddle, 2002;
Dennis et al., 2004). The adolescents participating in these trials have mainly
been from inner-city areas, and their problems have centered around alcohol and
marijuana use. The comparison conditions have included other effective models
such as family therapy and motivational interviewing. Little is known about the
maintenance of positive effects over the long term. One study found continued
improvement over a nine-month follow-up (Kaminer, Burleson, & Goldberger,
2002), while another found maintenance of effects but leveling off of
improvement at a six-month follow-up (Liddle). A third study found high rates of
relapse and reports of continued substance abuse and other problems at a 12-
month follow-up (Dennis et al.).
Family-based Interventions
Family-based treatments recognize the role that the family environment
often plays in the development, continuation, and successful recovery of
substance use problems in adolescents. These treatments typically address
family conflict, parenting practices, and neighborhood factors that contribute to
and/or exacerbate the problem. Several family therapy models have been
effective in treating adolescent substance abuse in controlled clinical trials.
These models include Brief Strategic Family Therapy (BSFT), Functional Family
Therapy (FFT), Multisystemic Therapy (MST), and Multidimensional Family
Therapy (MDFT). Liddle (2004) and Diamond and Josephson (2005) have most
recently reviewed the evidence for family-based treatments, separated by
disorder.
The evidence for BSFT and FFT comes primarily from studies described
later in this report, in which behavioral disorders were the main focus of
treatment. Those studies suggest that these interventions are promising
candidates for substance abusing adolescents, given the high rates at which
51
substance abuse occurs alongside behavioral disorders. One study of FFT did
focus specifically on adolescent substance abuse. Friedman (1989) compared
FFT to a parent group on frequency of substance use and severity of symptoms.
The study found decreases in substance use and improved family functioning for
both treatment groups.
MST (described later in a subsection on intensive community-based
interventions) has been adapted for adolescents who have substance abuse
problems in addition to delinquency. This adapted version includes frequent
random urine screens to detect drug use, identification of triggers for drug use,
developing a plan with the adolescent to address identified triggers when they
occur, and training in drug avoidance skills (Randall, Henggeler, Cunningham,
Rowland, & Swenson, 2001). This version of MST has shown efficacy in
controlled trials with substance abusing adolescents. In a trial comparing MST to
treatment as usual for substance-abusing juvenile offenders, those receiving
MST demonstrated greater school attendance following treatment and at the 6-
month follow-up (Brown, Henggeler, Schoenwald, Brondino, & Pickrel, 1999). A
recent follow-up of this study examined the two groups four years after treatment
(Henggeler, Clingempeel, Brondino, & Pickrel, 2002). Those who had
participated in the earlier MST program showed fewer aggressive criminal
activities and lower use of marijuana. An earlier study (Henggeler et al., 1991)
compared MST to individual counseling and found that adolescents in MST had
fewer substance-related arrests following treatment.
MDFT is the only family-based model that was developed to treat
substance abuse as the primary disorder. The intervention is focused on three
domains: the adolescent, the adolescent’s interaction with his or her family, and
the family’s interaction with the social environment. One study compared MDFT
to CBT for 224 substance abusing adolescents (Liddle, 2002). Both treatment
groups experienced significant reductions in substance use and disruptive
behaviors. However, at one year past treatment termination, the MDFT group
was more successful at maintaining these positive outcomes. In another
randomized trial, MDFT was compared to a peer group therapy intervention for
52
early-age substance users (11 to 15 years) with comorbid behavior problems.
MDFT was superior to the comparison condition in decreasing substance use
and also in reducing risk factors and increasing protective factors in family and
community domains (Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004).
Based on their research evidence and their superior outcomes to CBT in
some studies, family-based interventions are the front-runners in treatment for
adolescent substance abuse. Because children in foster care often come from
families with high levels of dysfunction, this set of interventions may be the most
appropriate for this population. Below, some of the more traditional models of
substance abuse treatment are reviewed for the purpose of providing readers
with the latest information on their research evidence. Their presence here is not
meant to promote their use. These treatments are in dire need of more research
on their effectiveness with adolescents.
Residential Treatment Centers
Residential treatment is based on the belief that a 24-hour commitment to
treatment via removal from the community and placement in a clinical setting is
necessary to produce the psychological changes that are required to function in
society (Jainchill, Hawke, De Leon, & Yagelka, 2000). Planned or recommended
length of stay ranges from 3 to 12 months.
Residential treatment models for adolescents typically target social skills
such as anger management, assertiveness, and problem-solving skills that are
thought to be especially powerful in a residential setting, because the entire
context can teach and reinforce these skills. The 12-step model is also a
common component of residential treatment models. Finally, the therapeutic
influence of peers is considered a potentially powerful component of residential
treatment, whereby adolescents can capitalize on opportunities to increase self-
efficacy and cooperative responsibility. Many long-term residential substance
abuse programs identify themselves as therapeutic communities (see De Leon,
2000, for description). The Drug Abuse Treatment Outcomes Study (DATOS), a
national survey of substance abuse treatment for adults and adolescents, found
53
that about half of residential treatment centers place great emphasis on family
therapy (Hser et al., 2001).
Research shows that long-term residential treatment is one of the most
commonly utilized treatment models for adolescent substance abuse (Rounds-
Bryant & Kristiansen, 1999; Williams & Chang, 2000; Hser et al., 2001). Despite
the proliferation of residential treatment for children and adolescents with various
mental health problems, the evidence base has been described as extremely
weak (Burns et al., 1999).
Studies, such as DATOS, involving large, nationally representative
samples have suggested two major findings for residential treatment over the last
three decades: (a) treatment retention (i.e., length of stay) robustly predicts
outcome, and (b) adolescents require a longer treatment tenure than adults
(reviewed by Jainchill et al., 2000). One recent study examined outcomes for
1,057 adolescents across 10 treatment sites representing various levels of care
(Dasinger, Shane, & Martinovich, 2004). At three months after treatment entry,
the most pronounced decreases in substance use were reported for residential
treatment. This was probably related to the highly controlled nature of the
residential setting; i.e., these adolescents were subject to the most rigorous
surveillance. Over the longer term, the highest rates of relapse were reported for
long-term residential treatment. The study highlighted the important role of
continuing care when residential models are used.
Another recent study compared substance using adolescents in a
therapeutic community (see De Leon et al, 2000, for description) to those
assigned to an alternative probation disposition (Morral, McCaffrey, & Ridgeway,
2004). At 12 months following treatment entry, adolescents in the therapeutic
community group demonstrated lower substance use and better psychological
functioning than those in the comparison group.
Findings on residential treatment for adolescent substance abuse suggest
that it may be a better option than that typically offered by the juvenile justice
system. Length of stay and follow-up care appear to be critical to obtaining and
maintaining positive effects. However, given the high cost of residential care,
54
evidence-based individual and family-based outpatient models appear to be a
better treatment option when available.
Inpatient Treatment
Short-term inpatient programs take place in medically controlled (i.e.,
hospital) environments. Services include several group and individual therapy
sessions per week. Most of these programs also emphasize family therapy.
Planned duration of stay ranges from 5 to 35 days. Upon completion of short-
term inpatient treatment, patients are typically referred to outpatient follow-up
treatment (Hser et al., 2001). Outcomes of inpatient treatment have not been
assessed. These services should only be used in crisis situations with the intent
to make a transition to longer-term treatment based in the community.
The 12-step Model
Almost three-fourths of inpatient and outpatient programs for adolescent
substance abuse incorporate some version of the 12-step model (Lawson, 1992).
The model views drug use as a disease and the primary source of problems in a
person’s life. The person must confront the disease before dealing with other
related problems. Treatment occurs in group meetings in which participants work
through the 12 individual steps (e.g., admitting the problem, asking for help,
dealing with guilt and anger, turning the problem over to a higher power). Few
studies on the program’s efficacy with adolescents exist. One study found
decreased substance use when adolescents were motivated and engaged in
treatment (Kelly, Myers, & Brown, 2002). Wells and colleagues (1994) found that
older adolescents (age 18 to 20 years) completing a 12-step program used
alcohol less frequently than those who participated in a cognitive behavioral
relapse prevention program. Both groups completed 12 weeks of treatment. At
six-month follow-up, there were no differences in treatment groups, but both had
decreased levels of substance use since before treatment. More studies are
needed on this widely used intervention.
55
Medication for Substance Abuse
Pharmacological intervention is used in substance abuse cases for two
purposes: as substitution therapy for addiction or dependence, and to treat
comorbid mental health conditions such as depression, ADHD, anxiety, and
disruptive behavior disorders. In the former case, drugs such as methadone for
opiate addiction (e.g., heroine) and naltrexone for alcohol addition are used for
patients who are severely dependent and have not responded to behavioral
intervention (Whittington et al., 2004). This approach has been studied primarily
in adult samples where methadone, in particular, has demonstrated moderate
effectiveness at managing withdrawal in patients with long-standing addictions
(Farrell & Taylor, 1994). There is little or no such evidence for adolescent
populations. Because adolescents typically do not suffer from long-term
addictions, pharmacological intervention for addiction has not generally been
recommended.
Psychopharmacological interventions for substance abusing adolescents
with comorbid psychiatric diagnoses have a similarly scant evidence base. One
controlled trial found positive effects for lithium in treating adolescents with mood
disorders and secondary substance abuse (Geller et al., 1998). No follow-up data
has been published from this trial. One randomized study involving 10
adolescents with comorbid depression and alcohol abuse compared CBT plus
sertraline to CBT plus placebo (Deas-Nesmith et al., 1998). After 12 weeks of
treatment, the two groups demonstrated similar reductions in depression and
alcohol use. Based on these findings, the use of medication for adolescents with
substance use problems should involve serious caution and consideration,
especially given the potential abuse liability in this population and high rates of
psychiatric comorbidity.
Summary
This section examined the treatment for four high prevalence psychiatric
conditions and also addressed the situation wherein children in foster care
frequently experience several specific conditions that require targeted treatment.
56
The most prevalent conditions include PTSD and abuse-related trauma,
disruptive behavior disorders (including ADHD), depression, and substance
abuse. There is a strong evidence base for treating the first three conditions with
interventions that are largely behavioral or cognitive-behavioral and that address
symptoms, behavior, and functioning. Examples of such interventions include
Trauma-Focused Cognitive Behavior Therapy, the Incredible Years, Parent-Child
Interaction Therapy, and cognitive behavior therapy for depression. Such
interventions tend to be relatively brief, and most are more effective when a
caregiver is actively involved. A number are directed at the caregiver only,
particularly when the focus is on managing the child’s disruptive behavior. For
adolescent substance abuse, family-based treatments such as MST and MDFT
are the frontrunners. Dropping a child off at a clinic for individual therapy for most
of these conditions is of very limited value. One caution about rapid endorsement
of evidence-based treatment: At the present, these interventions are not
uniformly available across the country. In addition, caution should be taken with
regard to the use of psychotropic medications for these disorders until further
research is conducted on the safety of their use with children and adolescents.
Intensive Home- and Community-Based Interventions Community-based services are frequently provided for children in foster
care in order to address their complex and multi-faceted needs and to prevent
placement in more restrictive environments outside of the community. These
interventions were both developed and tested in the community (versus a lab
setting, with moderately to severely disturbed youth), possibly increasing the
benefit for youth in foster care in contrast to clinic-based, diagnostic-specific
therapies. These interventions are often delivered in the context of a system of
care in which a team assesses, plans, and coordinates care for children and
families. Most states pay for these services under Medicaid, and there are more
powerful models that involve funding from other service sectors. There are a few
impressive examples of efforts to achieve this in the literature. A model that was
highlighted in the President’s New Freedom Commission (2003), namely,
57
Wraparound Milwaukee, is jointly funded by juvenile justice and child welfare; the
findings relative to preventing out-of-community placements and costs are
dramatic.
Inclusion of foster parents in these interventions occurs in some parts of
the country and the potential to increase their involvement needs attention. The
evidence base for most of these interventions was last reviewed in 2004 by
Farmer, Dorsey, and Mustillo. Several of these treatments are presented below
along with a brief, updated description of the research evidence and are
summarized in Table 3.
58
Table 3. Evidence for intensive home- and community-based interventions
Intervention Researcha Outcomes
Treatment foster care 4 RCTsb • More rapid improvement
• Decreased aggression
• Better post-discharge outcomes
Multisystemic Therapy 9 RCTs
1 quasi-
experimental
• Fewer arrests
• Fewer placements
• Decreased aggressive behavior
Intensive case management
(including wraparound)
4 RCTs
3 quasi-
experimental
• Less restrictive placements
• Some increased functioning
Mentoring 2 RCTs • Less substance use and aggression
• Better school, peer, and family functioning
Respite 2 wait-list controls • Fewer placements
• Reduced family stress
Crisis 1 quasi-
experimental • Most maintained home placement
• Positive family outcomes
• Increased social support
Day treatment/Partial
hospitalization
1 wait-list control
Many uncontrolled • Reduced behavior problems
• Decreased symptoms
59
• Better family functioning
Transition to Independence 3 quasi-
experimental • Positive employment outcomes
• Reduced school dropout, arrest, and homelessness
• Reduced psychiatric hospitalization
Functional Family Therapy 2 RCTs • Reduced recidivism
• Reduced rate and severity of crime
Brief Strategic Family
Therapy
6 RCTs
2 quasi-
experimental
• Increased family functioning
• Improved behavioral and emotional problems
• Increased engagement in treatment
Family-based support
services
5 RCTs
Many quasi-
experimental
• Increased knowledge and self-efficacy about mental health
service use
• Improved family interactions
• Increased service retention
Therapeutic group homes 1 RCT
2 quasi-
experimental
• Positive functional and psychological outcomes compared to
no treatment
• Outcomes inferior to TFC a See report text for specific references for each study. b RCT = Randomized Clinical Trial
60
Treatment Foster Care (TFC)
TFC, while not an intervention for youth in stable foster care, is a
frequently utilized placement for youth who cannot be effectively managed in
foster care and, thus, it is reviewed here. TFC originated from the Oregon Social
Learning Center and is based on social learning theory. Treatment foster parents
are trained in the TFC model and receive ongoing supervision. Typically, only
one foster child is placed in a home. Four RCTs have included TFC as a
treatment group. Two studies found favorable results for TFC as compared to
group home or hospital placement (Chamberlain & Reid, 1991, 1998), including
improvements in behavior problems, less recidivism, and less movement to more
restrictive treatment environments. These studies were reviewed by Farmer,
Dorsey, and Mustillo (2004). Another study compared TFC (with an added case
management component) to regular foster care (Clark et al., 1994). In general,
the TFC children demonstrated greater behavioral improvements and were less
likely to run away from home or be incarcerated. Evans, Armstrong, and
Kuppinger (1996) compared TFC to wraparound. In this study, TFC did not
demonstrate superior outcomes to wraparound although TFC did cost
substantially more than wraparound. Further, a recent randomized trial to train
regular foster parents caring for preschool-age children has demonstrated
positive findings, i.e., a greater increase in positive attachment and a decrease in
avoidant attachment (personal communication, P. Fisher, January 15, 2006). We
would also note that this trial demonstrated improvement in permanent
placement outcomes (Fisher, Berraston, & Pears, 2005), a system outcome
important for children in foster care.
Multisystemic Therapy (MST)
MST is an ecologically oriented, family-based treatment model for children
and adolescents with behavior and substance abuse problems. The model has
more recently been applied to maltreated children with positive results (Swenson
& Henggeler, 2003). MST is brief (3-6 months) and takes advantage of
61
community resources. An overarching aim of MST is family preservation. MST
has been the subject of nine RCTs and at least one quasi-experimental study.
Comparison treatments have included individual counseling (Borduin, Henggeler,
Blaske, & Stein, 1990), usual juvenile justice services (Leshied & Cunningham,
2002), usual mental health services (Rowland et al., 2005), psychiatric
hospitalization (Henggeler et al., 2003), and usual child welfare services (Ogden
& Halliday-Boykins, 2004). MST has been linked to many positive outcomes such
as decreased aggressive behavior, fewer arrests, fewer placements, and
improvements in family functioning. Long-term follow-up findings have also been
positive (Schaeffer & Borduin, 2005). Several reviews provide more detail on the
findings for MST with one recent review critical of the evidence presented for its
effectiveness in child welfare (Brestan & Eyberg, 1998; Kazdin, 2000; Burns,
Schoenwald, Burchard, Faw, & Santos, 2000; Hoagwood, Burns, Kiser,
Ringeisen, & Schoenwald, 2001; Aos, Phipps, Barnoski, & Leib, 2001; Chorpita
et al., 2002; Curtis, Ronan, & Borduin, 2004; Littell, 2005).
Intensive Case Management
Case management models vary considerably and are generally not
viewed as treatment but rather as an approach to plan, monitor, coordinate, and
advocate for the set of services a child needs. Some provide individual case
managers while others rely on case management teams. The amount of training
required of case managers and the extent to which case managers also provide
therapy vary as well. The research on case management includes several RCTs
in which different models of case management are compared to each other as
well as to other types of treatment. Other quasi-experimental studies have also
examined change over time for children in case management. In general, these
studies have suggested that case management is superior to usual services in
gaining access to services (Paulson, Gratton, Stuntzer-Gibson, & Summers,
1995) and in improving functional outcomes for children with emotional and
behavioral problems (Evans, Huz, McNulty, & Banks, 1996).
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Intensive case management, in which the case manager receives special
training and carries a low caseload, has produced results similar to or better than
regular case management in two studies (Evans, Banks, Huz, & McNulty, 1994;
Cauce et al., 1994), superior to TFC in another study (Evans et al., 1994; Evans,
Armstrong, Kuppinger, Huz, & McNulty, 1998), and superior to case
management provided by the child’s regular therapist in a third study (Burns,
Farmer, Angold, Costello, & Behar, 1996).
Mentoring
Mentors are usually volunteers (some trained and some untrained) who
serve as role models and supportive adult figures to children in both community
and school settings. They may focus on the development of social skills and
provide opportunities for prosocial activities (e.g., recreation, work). In 2002,
Dubois and colleagues published a meta-analysis of 55 mentoring programs,
including Big Brother/Big Sister (DuBois, Holloway, Valentine, & Cooper, 2002).
Their results suggest some positive outcomes. Mentoring was related to better
school performance, peer relations, and family functioning. In addition, children
with mentors exhibited less substance abuse and aggression. The meta-analysis
also revealed some common features of effective mentoring programs such as
providing ongoing training to mentors, having mentors with backgrounds in
helping professions, including parent involvement or support, arranging
organized activities, and setting expectations for frequency of mentor-mentee
contact. Farmer, Dorsey, and Mustillo (2004) reviewed the research on
mentoring, including the Dubois meta-analysis, and described the support as
mixed, as some studies have reported no results or even negative results
(Keating, Tomishima, Foster, & Alessandri, 2002) probably tied to failure to
address the factors identified above.
Respite
Respite services are used to give caregivers of children with emotional
and behavioral disorders time away from their parenting duties. Care is
63
temporarily provided by an alternate caregiver either in or out of the child’s home.
Controlled research on respite for this population is limited to two wait-list control
experiments (Boothroyd, Kuppinger, Evans, Armstrong, & Radigan, 1998; Bruns
& Burchard, 2000). These studies suggest that respite care can reduce the
number of outside-of-home placements and can also decrease family stress.
However, the Boothroyd et al. study also found that fewer families used respite
services than expected. They speculated that this may have been due to lack of
knowledge that these services were available.
Crisis
Crisis services are used in emergency situations to provide immediate
care. The time and place at which crisis services are accessed is often the point
of entry into longer-term mental health services. Crisis services include three
main components: evaluation and assessment, crisis intervention and
stabilization, and follow-up planning. Some examples of service settings are
crisis hotlines, hospital emergency rooms, runaway shelters, walk-in crisis
intervention services, and crisis group homes. Staff are available 24 hours a day
every day and offer short-term services (e.g., four to six weeks).
The main goals are to link children and their families to services in the
community, to involve families in treatment, and to avoid hospitalization.
With the exception of one quasi-experimental study (Evans et al., 2003), the
research base for crisis services consists of only uncontrolled studies. These
uncontrolled studies have shown that crisis services are successful at diverting
youth from institutional placement (see Kutash and Rivera, 1996, for review). The
Evans et al. study randomly assigned children and families presenting with a
mental health crisis to home-based crisis intervention or intensive case
management that had been adapted for crisis situations. Families assigned to the
home-based crisis intervention showed increased family cohesion immediately
following treatment, but these positive outcomes were not maintained at six-
month follow-up. Families assigned to both groups showed increased social
support through the follow-up period. There was some evidence that these latter
64
increases occurred earlier during treatment for the families who received crisis
intervention. Child welfare agencies should perhaps look more closely at these
types of interventions given the promising results they have shown in
successfully diverting children from placement (cf. Burt & Bleat, 1974).
Day Treatment
Day treatment, also known as partial hospitalization, is an intensive form
of treatment that is less restrictive than inpatient care. Typically, these programs
combine individual and family counseling, education, skills training, and
recreation therapy. Day treatment can take place in a hospital, clinic, or school
setting. The research base was most recently reviewed by Burns et al. (1999). All
studies have been uncontrolled with the exception of one study that compared
intensive day treatment to wait-list control for children (age 5 to 12 years) with
disruptive behavior disorders (Greek, Parizeau, & Saying, 1993). At six months,
children in day treatment had experienced more improvements in symptoms and
family functioning.
Findings from uncontrolled studies have shown improvements in behavior
and family functioning that have been sustained at long-term follow-up (see
Greek, 1997, and Kutash and Rivera, 1996, for review). In terms of educational
outcomes, about three-quarters of children in day treatment are reintegrated into
mainstream schools with the help of special education and community resources.
These studies also suggest that day treatment is effective at preventing more
restrictive (e.g., residential) placement, and they point to family participation as
an essential factor for achieving these positive outcomes.
Transition to Independence
Clark and Davis (2000) have described the Transition to Independence
Process (TIP), an individualized program that helps prepare adolescents for the
transition to adulthood. TIP encourages secondary education and teaches
community living skills through exposure. The program emphasizes respect for
individual values and goals through a strengths-based approach. Evidence on
65
the effectiveness of TIP is just now beginning to emerge. Results from
uncontrolled evaluations suggest positive employment outcomes and reduced
school dropout, arrest, homelessness, and psychiatric hospitalization (Bridge,
Davis, & Florida, 2000; Clark et al., 2002).
Family Therapy
The main goal of family therapy models is family preservation, and this
implies keeping children in the community as a priority. For this reason, these
models fall under the category of community-based intervention. The two leading
family therapy models are Functional Family Therapy (FFT) and Brief Strategic
Therapy (BSFT).
FFT is a family-based therapy focused on decreasing maladaptive
behaviors in children age 11 to 18 years at risk for or presenting with disruptive
behavioral disorders and/or substance abuse. The specific components of the
intervention are aimed at both enhancing protective factors and reducing risk.
FFT can be delivered in the home, clinic, or juvenile facility. Treatment is brief,
typically requiring no more than 26 hours of direct service time. Sexton and
Alexander (2003) provided a more detailed description of FFT. In controlled trials,
FFT has compared favorably to residential treatment in reducing re-offending
(Sexton & Alexander, 2000) and in reducing onset of behavioral problems in
siblings (Alexander, Pugh, Parsons, & Sexton, 2000).
BSFT is designed for children and adolescents age 6 to 17 years who
exhibit emotional and behavioral problems, and also for families with problematic
relations such as anger, blaming, and other negative interactions. BSFT can be
provided in the home, clinic, and other community-based settings such as a
social work agency. Szapocznik and Williams (2000) published a review of the
research on BSFT over the prior 25 years. RCTs with Caucasian and Hispanic
youth have demonstrated the positive effects of BSFT such as decreased
behavior problems, decreased association with antisocial peers, increased family
involvement in therapy, and increased family communication and warmth
66
(Szapocznik et al., 1988; Diamond & Liddle, 1996; e.g., Coatsworth, Santisteban,
McBride, & Szapocznik, 2001; Santisteban et al., 2003).
Family-based Education and Support
Supportive family-based interventions provide parenting education,
psychological support, and practical support to parents/caregivers of children
with disruptive behavior disorders. Many programs also promote family
engagement in the mental health service system. These programs are usually
implemented in a group format. The goal is to give caregivers the skills and
supports they need to cope with their child’s mental health difficulties. As such,
families have dual roles: (1) direct recipients of the intervention and (2) partners,
or co-therapists, in providing treatment to their children. Five RCTs and several
quasi-experimental studies have been conducted (for review, see Comer and
Fraser, 1998; McKay and Bannon, 2004; Farmer et al., 2004; Hoagwood, 2005).
Studies have demonstrated improved family interactions, increased service
retention, and increased knowledge about the mental health service system.
Therapeutic Group Homes
Group homes are used for children and adolescents with behavioral
disturbance to learn and practice their social and psychological skills. Homes can
be based inside or outside the community and usually serve 5-10 clients at one
time. The prominent group home model is the teaching family (TF) model,
originally developed at the University of Kansas (Phillips, Phillips, Fixsen, & Wolf,
1974). In this model, two adults in the home act as parents. While research on
group homes is sparse (as reviewed most recently by Farmer et al., 2004), the
strongest available evidence is for the TF model.
In addition to many replication studies that have demonstrated successful
implementation with strong fidelity to the TF model (reviewed by Fixsen, Blase,
Timbers, and Wolf, 2001), three studies exist. An early study compared 13
teaching family group homes to 9 non-teaching family group homes (Kirigin,
Braukmann, Atwater, & Wolf, 1982). During treatment, youths in the teaching
67
family homes had fewer criminal offenses and higher ratings of treatment
satisfaction than youths in the comparison homes. However, these differences
were not maintained at one-year post-treatment assessment.
Two further studies of treatment foster care (TFC) have included group
homes as the comparison condition. The first study used a matched group
design and found that group homes produced similar outcomes to TFC but were
much more expensive to implement (Rubenstein, Armentrout, Levin, & Herald,
1978). A more recent study used a randomized design and found more positive
outcomes in the TFC condition in a shorter period of time. TFC was also
associated with longer maintenance in the community and decreased criminal
involvement over one year following discharge (Chamberlain & Reid, 1998).
These findings suggest that although therapeutic group homes can have
positive effects, TFC may be a better option for youth in foster care when a more
highly structured placement is needed. Some very recent and current work is
focused on the primary processes of group home treatment (Breland-Noble et al.,
2004; Breland-Noble, Farmer, Dubs, Potter, & Burns, 2005). There is hope that
this work will provide more information about which specific elements of these
treatment models lead to lasting, positive outcomes.
How Are Evidence-based Interventions Spreading? Consistent with national policy since the issue of the Surgeon General’s
Report on Mental Health (1999), a range of initiatives to spread evidence-based
practice across the country has been undertaken. They vary in auspice (usually
state) and the range of interventions. This part of the report provides two sets of
examples that are relevant to mental health treatment of youth in foster care.
First, we review initiatives that are being undertaken in children’s mental health
systems. These are likely to have an impact on treatment for children in foster
care because most of the treatment is provided in mental health clinic settings.
Second, we review initiatives that are being undertaken directly within child
welfare/foster care service settings and which provide a direct application to a
foster care population.
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This report does not contain an exhaustive review but does identify
exemplary initiatives to disseminate mental health treatment by states, the
federal government, and foundations. With an emerging literature on such
initiatives (see Burns, 2003; Chambers, Ringeisen, and Hickman, 2005), there
are lessons about the challenges involved in moving evidence-based practice
into the field. Future dissemination and implementation efforts will have the
advantage of increased understanding of the stages of adoption, implementation,
and sustainability including the specific processes at each stage. In the interim,
several resources (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004;
e.g., Fixsen, Naoom, Blase, Friedman, & Wallace, 2005) can provide conceptual
(and empirical) guidance about factors that require attention prior to and during
such initiatives. Appendix C provides information about the availability of formal
training and other educational resources for many of the evidence-based
interventions described previously.
Briefly described are statewide efforts to move evidence-based practice
into local mental health service systems for youth and families. Several states,
particularly Ohio and California, have created training institutes that focus on
designated interventions such as treatment foster care or functional family
therapy. Agency participation is voluntary. In contrast, Michigan decided to train
child mental health center staff statewide in two interventions that address the
most common clinical conditions (i.e., cognitive behavior therapy for depression
and parent management training for disruptive behavior disorders). Alternatively,
Oregon selected an approach tied to reimbursement and established a list of
evidence-based interventions that could be selected from with a four-year period
to achieve 75% evidence-based practice.
An Annie E. Casey Foundation–supported initiative called BlueSkies has
proposed a community-based continuum of care for seriously emotionally
disturbed youth. Its three components include multisystemic therapy for intensive
treatment; TFC for respite; and functional family therapy for maintenance. The
communities being considered for a demonstration of this continuum of care
have to demonstrate that resources will be available to continue services once
69
the demonstration is over; thus, the challenges of sustaining the provision of new
services without ongoing support will be addressed.
The Substance Abuse and Mental Health Services Administration
(SAMHSA)-supported Child Initiative is also engaged in tests of adding evidence-
based interventions to System of Care sites. Randomized trials are currently
being conducted in West Virginia, Oregon, Oklahoma, and Ohio of Parent-Child
Interaction Therapy and of Brief Strategic Family Therapy.
The National Child Traumatic Stress Network, also supported by
SAMHSA, is significantly engaged in efforts to disseminate Trauma-Focused
Cognitive Behavior Therapy. This is occurring through trainings around the
country, subsequent consultation/supervision, manual development, and an
excellent website with online training. As the intervention developers train local
clinicians who will in turn become trainers, a cascading effect should be seen in
the greater availability of expert treatment. Use of the Internet for training in
areas of the country where face-to-face training is not available (or in concert
where trainers are available) is innovative and will further increase access to TF-
CBT (go to www.musc.edu/tfcbt ).
Finally, the Center for the Advancement of Mental Health at Columbia
University is training and coaching mental health practitioners in California, Utah,
Texas, and New York in evidence-based approaches.
The findings from these state-level, foundation-supported, and federal
initiatives and others will inform directions for child welfare in collaboration with
human service partners to specify and implement evidence-based clinical
interventions for youth in foster care.
Foster Care Initiatives A number of evidence-based initiatives are directly involving the child
welfare/foster care system. The State of Oklahoma has partnered with Mark
Chaffin and his colleagues at the University of Oklahoma School of Medicine to
test and disseminate evidence-based interventions in child welfare populations
and foster care settings. Their work to date has included initiatives with a strong
70
CDC- and NIMH-funded research component that seeks to implement PCIT and
Project Safe Care across the state.
The State of California recently has funded the development of a
Clearinghouse for Evidence-Based Practice in Child Welfare that is being
implemented under contract from the Chadwick Center for Children and Families.
This initiative will post reviews of the evidence for interventions in numerous
areas, including mental health treatment for children and adolescents involved
with child welfare. The Oregon Social Learning Center has recently partnered
with the County of San Diego child welfare system and the Child and Adolescent
Services Research Center at Children’s Hospital in San Diego to test a parent
management training intervention for foster parents that is modeled on the
principles of Multidimensional Treatment Foster Care (MTFC). With funding from
NIMH, the partnership has recently completed a two-phase study of the model’s
effectiveness with promising results in decreased behavior problems among
children 6 to 11 years in foster care and better placement outcomes (decreased
changes of placement and increased reunification).
Implications for Treating Common Conditions and Accessing Evidence-
base Care
• Inform and educate child welfare workers (CWWs) about a select set of
evidence-based interventions that work for the above conditions to
facilitate appropriate referrals.
• Identify mental health providers in the community who have training in
these interventions.
• At the agency level, clarify expectations about the importance of active
foster parent participation in clinical interventions when this is appropriate
or required.
• Train CWWs in approaches for engaging foster parents (and biological
parents where appropriate) in treatment for the foster child.
71
Treatment for Complex and Co-occurring Conditions Youth with complex combinations of mental health conditions and
functional impairment associated with long-term risks such as multiple episodes
and types of maltreatment, other trauma (e.g., domestic violence and loss), and
instability of placements would benefit from intensive home- and community-
based services. Children in foster care often move on to “deep end” services in
institutional settings because of failure to manage their behavior in the
community. The benefit of care in institutional settings is not well substantiated
and may even be deleterious due to close association with deviant peers, the risk
of contagion, loss of contact with family and peers, and other factors.
Fortunately, there are alternatives to the care and treatment of these youth
today. Increasing the availability of intensive home- and community-based
services while in foster care could benefit children and prevent further movement
away from family and community. These are intensive interventions that tend to
be long –term, which could more effectively address the needs of such youth.
Major examples include intensive case management, multisystemic therapy,
treatment foster care, crisis services, respite care, mentoring, and several types
of family therapy, in addition to special education services in school or
recreational and work opportunities in the community. The critical challenge to
creating such a continuum of care is to engage the relevant other providers (e.g.,
schools, juvenile justice, Medicaid) in a joint endeavor.
Implications for Developing Intensive Home- and Community-based
Services
• A true partnership among the relevant human services agencies at the
state or county level is necessary to create the policy and structure for
delivering these services in an integrated manner.
• Although theoretically supported by Medicaid through Early Periodic
Screening Detection and Treatment (EPSDT) legislation (services are
reimbursed in many states), engaging the state Medicaid office for such
72
initiatives is essential to help ensure that adequate funds will be available
in a timely way.
• Developing service capacity requires resources for training, ongoing
supervision/consultation, and monitoring outcomes.
• A review of model programs and class action suits may offer guidance for
planning and implementation.
Test Evidence-based Mental Health Practices within the Child Welfare System
Evidence-based interventions have been identified with the potential to
address the mental health needs of youth in foster care delivered largely by the
mental health system. What may be more innovative is the provision of specific
mental health interventions within the child welfare system. Several important
studies are underway to test their applicability within child welfare. Very
promising is the state-wide implementation of Parent-Child Interaction Therapy in
an experimental design across the state of Oklahoma.
A second important study will test the potential to adapt treatment foster
care principles of parent management training for a training approach to regular
foster care parents. A third significant initiative sponsored by the National Child
Traumatic Stress Training Center will train clinicians in 12 sites across the
country to provide Trauma-Focused Cognitive Behavior Therapy (for child sexual
and/or physical abuse). Further, other studies are examining strategies for the
dissemination of diagnostic-specific interventions, and the lessons learned from
them will also be applicable to increasing the availability of evidence-based
practices for maltreated youth in child welfare.
Implications for the Spread of Evidence-based Interventions in Child
Welfare
• Track the progress of dissemination studies of mental health interventions
in foster care and clinical interventions relevant to the needs of these
children to determine readiness for large-scale adoption.
73
• Learn from the challenges of intervention adoption and dissemination
efforts (e.g., stakeholder buy-in, the importance of policy and
organizational factors, and factors contributing to sustainability) prior to
making policy decisions.
• Consider additional candidate interventions for implementation within child
welfare, in contrast to those more likely to be provided in the mental health
system.
• For evidence-based interventions that require the expertise and resources
of the mental health system, develop a partnership with clearly explicated
roles for each system, preferably with joint child welfare and mental health
and/or Medicaid funding.
IV. LEGAL INTERVENTION The final section of the report addresses this question posed by the Casey Family Programs: “How many lawsuits have been filed because of the failure to
meet the mental health needs of foster youth?”
This section benefits by having access to a recently completed study Child
Welfare Consent Decrees: Analysis of Thirty-Five Court Actions from 1995 to
2005 (Kosanovich & Joseph, 2005) that was jointly sponsored by the Child
Welfare League of America and the ABA Center on Children and the Law. This
short section summarizes the findings from the study related to the mental health
care issue.
Class-action litigation has become a highly frequent action in the United
States to force reform of child welfare policy and practice. Within the past
decade, the study found that “there has been child welfare class action litigation
in 32 states, with consent decrees or settlement agreements in 30 of these.” The
study investigators found that “twenty-one states currently operate under court
consent decrees, settlement agreement or are under pending litigation brought
against public child welfare agencies (pg. 6).”
74
The decrees have addressed a wide range of child welfare issues. All of
the 35 state cases were coded for whether they addressed any one or more of
these following issues:
1. Properly license and train foster parents
2. Place children in adequate and safe foster and group homes
3. Properly report, investigate, and address abuse and neglect incidents
4. Provide needed medical, dental, and mental health services to foster
children
5. Ensure adequate parent-child or sibling visitation
6. Ensure social workers have manageable caseloads, training, and
supervision
7. Provide children and families with adequate case planning and review.
The fourth issue most directly addresses the question raised by Casey
Family Programs. In their analysis, the study investigators found that 20 of the 35
decrees have addressed service provision, including 12 decrees explicitly dealing
with mental health care. We would note that 6 decrees addressed substance
abuse problems and 7 decrees among the 35 addressed the more generic
treatment needs of children in foster care.
Limiting the number of decrees to those dealing with the narrow definition
of failure to provide treatment for the mental health needs of children in foster
care may underestimate the scope of this issue within the decrees. Many other
issues may be indirectly linked to provision of mental health care, such as
training of caseworkers and foster parents, education and independent living
services for children in foster care, parent-child visitation, minimizing disrupted
placements and reduction in number of placements, residential facility
placement, and support and supervision of foster parents. These latter issues
may be especially linked to mental health care because of the high prevalence of
externalizing problems seen in children who are involved in foster care and the
findings that externalizing problems are best addressed through parent-mediated
interventions.
75
In summary, mental health care is a significant part of the 35 court actions
that have occurred over the past decade. We would also note that we know of no
research that has systematically examined the impact of legal action on quality of
child welfare practice relative to mental health care or on improvement in
outcomes for the children receiving such care.
V. RECOMMENDATIONS
This report has reviewed a wide scope of literature related to the mental
health care of children in foster care. In this final section, we highlight selected
findings on which we base a small number of recommendations.
The majority of children residing in foster care demonstrate need for mental
health care and related services to address developmental problems.
Increase Access To Care
• Inform child welfare workers (CWWs) about the importance of early
identification and treatment.
• Institute a standard protocol for screening and assessment to identify
need for mental health care upon entry into the child welfare system.
• Educate CWWs about local resources and create a liaison with mental
health providers to facilitate rapid referrals into mental health services.
• Monitor referrals and follow-up with foster parents to ensure that youth
receive services.
There is a high rate of use of mental health services for children in foster care
with most care being delivered in standard outpatient services as well as a high
rate of use of institutional care. While there is little evidence that these well-
tested interventions are being routinely used in usual care settings, several
candidate solutions are especially relevant for children in foster care, including
76
cognitive behavior treatments for PTSD and abuse-related trauma, intensive
interventions such as treatment foster care as well as parent management
training models.
Moving Beyond Usual Outpatient and Institutional Care
• Examine the evidence base for interventions to treat common clinical
conditions and more complex conditions experienced by youth in foster
care.
• Assess the availability of evidence-based interventions at the local and
national levels to assure relevance and explore adaptations needed for
youth in foster care.
• Identify candidate evidence-based interventions to meet mental health
needs at the local level.
There are a number of very effective interventions and promising practices
that have been developed for the four conditions likely to be found in children
residing in foster care, as discussed above. There are many challenges to
integrating these effective interventions into the services that are provided for
children in foster care. Strong efforts are underway to address these challenges
in selected areas.
Increase the Use of Evidence-Based Interventions in Child Welfare
• Track the progress of dissemination studies of mental health interventions
in foster care and those on clinical interventions relevant to the needs of
these children to determine readiness for large-scale adoption.
• Learn from the challenges of intervention adoption and dissemination
efforts (e.g., stakeholder buy-in, the importance of policy and
organizational factors, and factors contributing to sustainability) prior to
making policy decisions.
77
• Consider additional candidate interventions for implementation within child
welfare, in contrast to those more likely to be provided in the mental health
system.
• For evidence-based interventions that require the expertise and resources
of the mental health system, develop a partnership between mental health
and child welfare with clearly explicated roles of each system and
preferably with joint child welfare and mental health and/or Medicaid
funding.
There is substantial use of legal remedies, such as consent decrees and
settlements across the United States, to leverage improvements in services to
children in the foster care system. There is a need for systematic research on the
impact of these legal remedies on mental health service delivery.
Finally, we would suggest that foundations such as the Casey Family
Programs have a vital role to play in efforts to improve mental health care for
children in child welfare and we offer a small number of modest
recommendations.
Using Evidence to Improve Practice and Policies in Child Welfare
• Consider the unique leverage points that Casey Family Programs can use
to assist initiatives to improve mental health care for children in foster care
through increased use of very promising interventions.
• Use the unique experience of Casey Family Programs to initiate and
support partnership dialogue between child welfare and mental health
service systems around efforts to integrate evidence-based interventions
into services for children in foster care.
• Provide leadership to the child welfare community as it works to improve
service delivery through the use of evidence about interventions that show
great promise for improving well-being for children in foster care.
78
Appendix A
Resources and Registries for Identifying Evidence-Based Interventions for Children and Adolescents
Federal/National SAMHSA’s National Registry of Evidence-based Programs and Practices
(NREEP):
http://www.modelprograms.samhsa.gov/
The Office of Juvenile Justice and Delinquency Prevention’s Model Programs
Guide (MPG):
http://www.dsgonline.com/mpg2.5/mpg_index.htm
National Institute of Drug Abuse
Preventing Drug Use Among Children and Adolescents: A Research Based
Guide for Parents, Educators, and Community Leaders:
http://www.drugabuse.gov/pdf/prevention/RedBook.pdf
National Center for Injury Prevention and Control, Centers for Disease Control
and Prevention
Using Evidence-Based Parenting Programs to Advance CDC Efforts in Child
Maltreatment Prevention:
http://www.cdc.gov/ncipc/pub-res/parenting/ChildMalT-Briefing.pdf
Center for Substance Abuse Treatment (CSAT)
Center for the Application of Substance Abuse Technologies (CASAT)
Centers for the Application of Prevention Technologies (CAPT):
Western CAPT: http://captus.samhsa.gov/western/about/index.cfm
Mountain West Addiction Technology Transfer Center (MWATTC):
http://casat.unr.edu/mwattc/newsite/
79
Frontier Recovery Network (FRN): http://casat.unr.edu/frn/
Northeast CAPT: http://captus.samhsa.gov/northeast/about/about.cfm
Child Welfare League of America, Research to Practice Initiative:
http://www.cwla.org/programs/r2p/default.htm
National Association of State Mental Health Program Directors Research
Institute, Inc. (NRI): http://www.nri-inc.org/
Office of Juvenile Justice and Delinquency Prevention (OJJDP)
Blueprints for Violence Prevention Initiative
http://www.ncjrs.org/html/ojjdp/jjbul2001_7_3/contents.html
80
Selected State Initiatives
The Nevada Practice Improvement Collaborative (PIC):
http://casat.unr.edu/nevadapic/
New York State Office of Mental Health Evidence-Based Practices :
http://www.omh.state.ny.us/omhweb/EBP/WebResources.htm
Hawaii Child and Adolescent Mental Health Division (CAMHD):
http://www.hawaii.gov/health/mental-health/camhd/index.html
Oregon Commission on Children and Families (OCCF):
http://www.oregon.gov/OCCF/Mission/BestPrac/besthm/mibesthm.shtml
Research and Training Center on Family Support and Children’s Mental Health
Portland State University, Portland, Oregon
Promising Practices Initiative:
http://www.rtc.pdx.edu/pgProjPromising.php
The California Child Welfare Clearinghouse for Evidence-Based Practice:
http://www.cachildwelfareclearinghouse.org/
California Healthy Kids Resource Center (CHKRC):
http://www.californiahealthykids.org/
Washington State Institute for Public Policy: http://www.wsipp.wa.gov/
81
Organizations and University-Based Groups Engaged in Analysis of Treatment Research Literature:
The Cochrane Collaboration: http://www.cochrane.org/
The Campbell Collaboration: http://www.campbellcollaboration.org/
National Implementation Research Network (NIRN): http://nirn.fmhi.usf.edu/
RAND Corporation Promising Practices Network (PPN):
http://www.promisingpractices.net/
Major Published Reviews:
Mental Health: A Report of the Surgeon General (1999)
http://www.surgeongeneral.gov/library/mentalhealth/home.html
Youth Violence: A Report of the Surgeon General (2001)
http://www.surgeongeneral.gov/library/youthviolence/youvioreport.htm
The President’s New Freedom Commission on Mental Health (2003)
http://www.mentalhealthcommission.gov/reports/reports.htm
Closing the Quality Chasm in Child Abuse Treatment: Identifying and
Disseminating Best Practices, The Findings of the Kauffman Best Practices
Project to Help Children Heal from Child Abuse (2004):
http://musc.edu/cvc/kauffmanfinal.pdf
82
Child Physical and Sexual Abuse: Guidelines for Treatment (2002)
Office for Victims of Crime, Office of Justice Programs, U.S. Department
of Justice
http://musc.edu/cvc/guide1.htm
Synthesis of Reviews of Children’s Evidence-based Practices
Jacqueline Yannacci, M.P.P., and Jeanne C. Rivard, Ph.D.
Center for Mental Health Quality and Accountability,
NASMHPD Research Institute, Inc.
http://ebp.networkofcare.org/uploads/Synthesis_of_Reviews_of_the_Research_o
n_Evidence_Based_and_Promising_Practices_9592994.pdf
Office of Juvenile Justice and Delinquency Prevention (OJJDP)
Strengthening America’s Families: Exemplary Parenting and Family Strategies
for Delinquency Prevention: http://www.strengtheningfamilies.org/
Mihalic, S.F., and Aultman-Bettridge, T. (2004). A guide to effective school-based
programs. In: Policing and School Crime (W.L. Turk, Ed.). Englewood Cliffs, NJ:
Prentice Hall.
83
Appendix B
Office for Victims of Crime (OVC) Criteria for Evidence-Based Treatments2
1. Well-supported, Efficacious Treatment 1. The treatment has a sound theoretical basis in generally accepted
psychological principles.
2. A substantial clinical-anecdotal literature exists indicating the treatment’s value
with abused children, their parents, and/or their families.
3. The treatment is generally accepted in clinical practice as appropriate for use
with abused children, their parents, and/or their families.
4. There is no clinical or empirical evidence or theoretical basis indicating that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5. The treatment has a book, manual, or other available writings that specifies
the components of the treatment protocol and describes how to administer it.
6. At least two randomized, controlled treatment outcome studies (RCT) have
found the treatment protocol to be superior to an appropriate comparison
treatment, or no different or better than an already established treatment when
used with abused children, their parents, and/or their families.
2 Saunders, B. E., L. Berliner, & Hanson, R.F. (December 10, 2002). Child physical and sexual abuse: Guidelines for treatment. Charleston, SC: Office for Victims of Crime.
84
7. If multiple treatment outcome studies have been conducted, the overall weight
of evidence supports the efficacy of the treatment.
2. Supported and Probably Efficacious Treatment 1. The treatment has a sound theoretical basis in generally accepted
psychological principles.
2. A substantial clinical-anecdotal literature exists indicating the treatment’s value
with abused children, their parents, and/or their families.
3. The treatment is generally accepted in clinical practice as appropriate for use
with abused children, their parents, and/or their families.
4. There is no clinical or empirical evidence or theoretical basis indicating that the
treatment constitutes a substantial risk of harm to those receiving it, compared to
its likely benefits.
5. The treatment has a book, manual, or other available writings that specifies
the components of the treatment protocol and describes how to administer it.
6. At least two studies utilizing some form of control without randomization (e.g.,
matched wait list, untreated group, placebo group) have established the
treatment’s efficacy over the passage of time, efficacy over placebo, or found it to
be comparable to or better than an already established treatment.
7. If multiple treatment outcome studies have been conducted, the overall weight
of evidence supports the efficacy of the treatment.
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Appendix C National Training Resources for Evidence-Based Interventions
The interest in and push toward an increase in evidence-based practice
has spawned training organizations with expertise in an intervention. The training
model typically involves didactic teaching in combination with ongoing
consultation or supervision. Information about how to access such resources is
available below.
The Incredible Years
The Incredible Years programs were developed by Carolyn Webster-
Stratton, M.S.N., M.P.H., Ph.D., Professor and Director of the Parenting Clinic at
the University of Washington, Seattle.
http://www.incredibleyears.com/
Parent-Child Interaction Therapy (PCIT)
In the early 1980s, Sheila Eyberg at the Oregon Health Sciences
University developed an intensive treatment method for preschoolers with
disruptive behavior disorders and their parents. Because poor parent-child
interaction is an important source of disruptive behavior problems, Eyberg’s
Parent-Child Interaction Therapy (PCIT) focuses on teaching parents a set of
specific behavior management techniques within play therapy techniques with
their child.
http://www.ucdmc.ucdavis.edu/caare/mental/pcit.html
http://www.ucdmc.ucdavis.edu/caare/mental/pcit_traincenter.html
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Trainers include Judy Cohen, M.D., Tony Mannarino, M.D., and Esther
Deblinger, Ph.D. National trainers can be identified through the National Child
Traumatic Stress Network.
http://www.nctsn.org/
86
Brief Strategic Family Therapy (BSFT)
Olga Hervis, MSW, LCSW, is the co-author and developer of the
nationally-validated, award-winning family therapy model known as Brief
Strategic Family Therapy. The Family Therapy Institute of Miami (FTTIM)
provides training leading to certification in BSFT and also provides training in
Family Effectiveness Training, also an award-winning model program, which is a
psycho-educationally-based adaptation of BSFT to be utilized with younger,
prevention/early intervention target populations.
http://www.brief-strategic-family-therapy.com/bsft-training
Functional Family Therapy (FFT)
FFT is an empirically grounded, well –documented, and highly successful
family intervention for at-risk and juvenile justice-involved youth.
http://www.fftinc.com/index.php
FFT Clinical Services System
An integrated system for monitoring the practice of Functional Family
Therapy in community practice settings.
http://www.fftcss.com/
Treatment Foster Care (TFC)
Treatment foster care is a clinically effective and cost-effective alternative
to residential treatment facilities that combines the treatment technologies
typically associated with more restrictive settings with the nurturing and
individualized family environment. The website for the Multidimensional
Treatment Foster Care model at the Oregon Social Learning Center and two
more generic websites are included below.
http://www.mtfc.com
http://www.ffta.org/links/other_resources.html
http://www.fosterparentcollege.com/
87
Multisystemic Therapy (MST)
The major goal of MST is to empower parents with the skills and
resources needed to independently address the difficulties that arise in raising
teenagers and to empower youth to cope with family, peer, school, and
neighborhood problems. Within a context of support and skill-building, the
therapist places developmentally appropriate demands on the adolescent and
family for responsible behavior. Intervention strategies are integrated into a social
ecological context and include strategic family therapy, structural family therapy,
behavioral parent training, and cognitive behavior therapies.
http://www.mstservices.com/
Teaching-Family Model
The Teaching-Family Model provides behavioral treatment to client
populations in need of such residential care. There is research and information
about disseminating the Teaching-Family Model beginning with its origin, through
its replication, and into its adaptations.
http://www.teaching-family.org/
http://www.teaching-family.org/bibliography.html
http://www.familyinnovations.org/tfs.html
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