Placement Stability Research Articles

Identifying the essential competencies for resource parents to promote permanency and well-being of adolescents in care

The number of teens entering foster care and those subsequently aging out, has been steadily increasing in recent years. The majority of these teens experience placement instability while in care and do not secure permanency before entering young adulthood. These adolescents often have complex needs due to trauma histories, and as a result, many of these youth struggle with unemployment, homelessness, and incarceration, and they experience chronic physical and mental health challenges as young adults. There has been limited training available to prepare resource parents to care for adolescents who have experienced chronic trauma. The current study is the first phase of a national training and development initiative to maximize placement stability and permanency of traumatized teens placed in out-of-home care. The purpose of the current study is to identify the core competencies that are deemed essential for resource parents to be successful, and then prioritize the competencies that should be included in the training.Utilizing the Delphi method, the current study generated a comprehensive list of competencies through multiple types of data collection procedures (e.g., interviews, surveys) and sources (e.g., parents, older youth, professionals, and literature and curricula reviews). Subsequently, the competencies were prioritized for inclusion in a national training by administering two rounds of a survey to an expert panel who ranked their importance. The inclusion of the competencies in the training was based on two criteria: competencies with a minimum mean score of at least 4, and those which 75% of the panelists rated at 4 or higher. Of the 215 non-duplicative competencies generated in Round One, the panelists reached consensus for inclusion of 61 in training development. Many of them focused on trauma-informed parenting, building a trusting relationship with youth, helping youth maintain a connection with their biological family and other past supportive relationships, emotional regulation skills for the parent and youth, and how to adapt to meet the youths' unique needs.

The benefits of early care and education for child welfare-involved children: Perspectives from the field

Increasing access to early care and education (ECE) for children in the child welfare system (CWS) remains a critical issue in the United States, as the numbers of young children entering this system steadily increases. Mounting evidence suggests that participation in at least some types of ECE can mitigate the need for child welfare supervision. Moreover, ECE participation has been linked to positive developmental and school readiness outcomes, lower rates of foster placement, and greater placement stability for children in the CWS. Despite this research, ECE is not widely used by this population. This study informs recent local and federal efforts to increase ECE utilization among children in the CWS by exploring the perspectives of three stakeholder groups (child welfare caseworkers, ECE providers, and parents/caregivers) regarding the benefits of CWS-supervised children’s participation in ECE for 1) the children themselves, 2) their parents/caregivers, and 3) their caseworkers. A total of ten focus groups were conducted with these stakeholders in a large urban area in the western U.S. (n = 79). Meeting transcripts were analyzed with Atlas TI software to identify themes. Results highlight multiple ways in which participants perceived ECE as being beneficial for CWS-supervised children, as well as for their parents/caregivers, and caseworkers. These findings offer suggestions for ways to motivate caseworkers and parents/caregivers to enroll CWS-supervised children in ECE by educating them about benefits, not only for the children, but also for themselves.

The maltreatment-violence link: Exploring the role of maltreatment experiences and other individual and social risk factors among young people who offend

ObjectiveThis study investigated the extent to which violent offending in a population of young people detained in secure care facilities is related to variations in child maltreatment after controlling for other known individual and social correlates of crime. MethodOfficial child protection and youth justice records and survey information for 1819 young people were analyzed. Measures included: maltreatment factors (including type, timing and recurrence); out-of-home care placement factors (including type, age at first placement, stability and duration of placements); social factors (including family and peer risk indicators); and individual factors (including factors relating to intelligence and education, substance use, mental health problems, and behavior). Gender and cultural background were also investigated as potential moderating factors. Logistic regression was used to determine the independent effect of maltreatment factors on violent convictions in the presence of other risk factors. ResultsPersistent maltreatment was a consistent predictor of violent convictions. Other independent predictors included: aggression, anger, Indigenous status, and male gender, with household conflict also approaching significance. ConclusionCollaborative and integrated responses from both child protection and juvenile justice may be needed if comprehensive violence prevention strategies are to be developed for young offenders.

Key factors and characteristics of successful resource parents who care for older youth: A systematic review of research

There is growing recognition that competent, committed resource parents are a critical component to the effective delivery of foster and adoptive services for teens placed in out-of-home-care. This study implemented a systematic review process to identify the personal characteristics, skills and abilities of successful resource families that maximize foster and adoptive parent retention and maximize placement permanency of teens placed in out of home care. Starting with an extensive search of the literature across the last two decades and outreach to locate studies, the authors systematically analyzed research that used permanency and placement stability as the primary dependent variables and personal characteristics/attributes, knowledge, skills and abilities as independent variables. Of the 838 total documents identified, 48 were original research studies that focused on one or more of these variables. Although rigorous and systematic, this research was hampered by differing definitions, samples, measures, and the type of analysis utilized among these studies. Personal characteristics that promoted permanency and placement stability included having a tolerance for rejection, flexible expectations, having a sense of humor, having a belief in a higher power, belief in self-efficacy, having higher education, having sufficient economic resources, having healthy family and marital functioning, having access to support systems, and being motivated to foster/adopt. Knowledge, skills, and abilities resources families acquired that promoted permanency and placement stability included the ability to communicate effectively, maintain attentiveness to the parent/child relationship (i.e. using routines and structure while also offering children a variety of experiences), understand the effects of trauma and teach socio-emotional health, provide culturally competent care, recognize, express and process grief, take care of oneself, valuing and participating in life -long learning, training and education, and valuing a connection to the child's birth family.

Completed FDA feasibility trial of surgically placed temporary diaphragm pacing electrodes: A promising option to prevent and treat respiratory failure

BackgroundEtiologies contributing to failure to wean from mechanical ventilation (MV) are multiple, resulting in morbid and costly outcomes. Diaphragm pacing (DP) is used in spinal cord injury to replace MV. Temporary DP could be utilized in acute respiratory failure to reduce MV. MethodsA prospective FDA feasibility trial evaluated temporary DP electrodes implanted in each hemi-diaphragm during a subject's primary procedure. Objectives included: ability to provide ventilation, stability analysis with diaphragm electromyography, and adverse event monitoring. ResultsTwelve patients underwent successful implantation via median sternotomy, laparoscopy or laparotomy. Electrode stimulation exceeded ideal tidal volumes by an average of 37% (0%–95%) confirming ability to prevent atrophy. Daily electromyography confirmed stability of placement and was useful in evaluating hypoventilation. There were no complications and all 48 study electrodes remained intact until complete removal. ConclusionThis trial demonstrates ease of placement, removal, functionality and safety of temporary DP electrodes which therapeutically decreases diaphragm atrophy.

Educational stability policy and the interplay between child welfare placements and school moves

Despite recent improvements in child welfare placement stability, youth in foster care still experience high rates of school moves. Although these findings are well documented in the literature, few studies have considered the interplay between child welfare placements and school moves. The purpose of this study was to determine the proportion of school moves that can be reduced through implementation of the educational stability provisions of the Fostering Connections to Success and Increasing Adoptions Act (FCA, 2008) and the Every Student Succeeds Act (ESSA, 2015), and to identify opportunities to minimize the number of transitions that children and youth in foster care experience. Findings indicate that implementation of the FCA and the ESSA is a critical, but partial, solution for ensuring the educational stability of students in foster care. This article provides an empirical rationale for states and local jurisdictions to incorporate non-regulatory recommendations in order to fill the gaps in federal regulations.

Medical complexity and placement outcomes for children in foster care

ObjectiveMedical complexity threatens placement stability and permanency outcomes for children in foster care (FC). This study aimed to characterize for US children in FC: 1) medical complexity, using number of diagnosed types of disability as a proxy; 2) demographic and removal characteristics based on level of complexity; and 3) whether increasing levels of complexity were associated with foster care placement outcomes. MethodsThe analysis included children in FC, ages 0–21 whose disability status was clinically assessed and documented (n=538,695). Using data from the FY 2014 Adoption and Foster Care Analysis and Reporting System, medical complexity was categorized (0–4+) based on 5 disability types: emotional, hearing/vision, intellectual, physical, and other. Bivariate analyses (χ2 tests, Kruskall-Wallis) compared the distribution of demographic and removal characteristics among complexity groups. Multiple logistic regression evaluated relationships between medical complexity and placement outcomes, including length of stay in FC, placement stability, and permanency. ResultsTwenty-three percent of the sample had 1 disability type, 7% had 2, 3% had 3, 1% had 4+, and 67% had no disability. Children with increasing complexity were more likely to be older, older on FC entry, male, Black, non-Hispanic, placed in a group home or institution, have abuse, neglect, and/or child disability/behavior as reason for removal, and have poor placement outcomes. ConclusionChildren in FC with greater medical complexity are at risk for undesirable placement outcomes. By recognizing and addressing the unique needs of this vulnerable population, pediatric providers and child welfare staff may identify strategies to improve placement outcomes.

Local authority foster care

The number of local authority foster placements rose last year, with Ofsted analysis showing most councils delivering high-quality services with improvements in placement stability and post-18 support

Placement Stability, Cumulative Time in Care, and Permanency: Using Administrative Data from CPS to Track Placement Trajectories.

Objectives: The Quebec Youth Protection Act was amended in 2007. The main goal of this reform was to improve placement stability for children who are removed from their home for their protection. Among several legal provisions introduced was the establishment of maximum age-specific durations of out-of-home care, after which a plan must be established to provide stability for children placed in substitute care by finding permanent homes for them. The purpose of this study is (1) to examine trends in placement use and placement stability since the reform and (2) to document the current frequency of each type of placement setting, the cumulative time in care before the exit to permanency, and the sustainability of the permanency outcome. Methods: The study relies on 3 entry cohorts of all children investigated who received protection measures in the province of Quebec during 3 specific time frames before and after the reform (n = 9620, 8676, 8425). Cohorts were observed for a period varying from 3 to 4 years. Administrative data from all 16 child protection agencies were used to track placement trajectory indicators and to compare cohorts. Results: There has been a decrease in the proportion of children receiving protection measures who were placed in care since the reform, and placement in kinship care has become more frequent among children placed. Placement stability improved slightly after the reform. Overall, for infants, the most frequent type of permanency attained is adoption, while reunification is the option most often indicated for older children. Some children are at a greater risk of experiencing unstable placement trajectories: young children have a high rate of reunification breakdown, some wait a long time to be adopted, and adolescents are frequently removed from the substitute care setting where they were supposed to stay until the age of 18. Conclusions: The results suggest interesting avenues for policy makers and service providers to improve the stability of placement trajectories. Advantages and disadvantages of administrative data are discussed.

Chronic Illness, Placement Stability, and Hospitalizations within Child Welfare: The Role of Initial Living Arrangement

Despite the high prevalence of chronic medical conditions among youth in child welfare, there is a paucity of research examining placement stability and frequency of medically-related hospitalizations for this vulnerable subpopulation. These questions are explored, with an emphasis on understanding the impact of initial living arrangement on each outcome. This study assessed 945 youth (ages 5–17) in out-of-home care within the Illinois child welfare system, using a matched sample of youth with (n = 318) and without (n = 627) a chronic medical illness. Placement stability and number of medically-related hospitalizations were compared between the two groups. Additionally, negative binomial regressions were used to assess the relationship between participant characteristics, type of living arrangement, and both placement stability and medically-related hospitalizations. Placement stability was not associated with having a chronic medical illness. However, stability was associated with initial living arrangement, with youth in kinship care having a lower likelihood of subsequent placement changes than youth in foster care or residential placements. Number of medically-related hospitalizations was significantly associated with having a chronic medical illness. Number of medically-related hospitalizations was also associated with type of initial living arrangement: kinship care showed a lower likelihood of hospitalizations than foster care or residential placements. Results provide preliminary evidence that kinship care should be prioritized for youth with a chronic medical illness over placement in foster care or residential settings, as kinship care showed higher placement stability and lower rates of medically-related hospitalizations for youth with chronic medical illness.

Sexual behavior and pregnancy among adolescents in foster family homes.

Objective To examine the prevalence of and factors associated with sexual behavior and pregnancy involvement among adolescents in foster family homes. Methods A cross-sectional study was conducted among a random sample of children living in foster family homes. Logistic regression with Firth's correction was used to determine factors associated with sexual risk behavior and pregnancy involvement (i.e. having been pregnant or gotten someone pregnant). Results About half of adolescents (aged 13-18 years) in foster family homes ever had sex, of whom, one third had first sex before the age of 14 and one sixth had two or more sexual partners in the past 3 months. Of adolescents in the study, 9% had ever been pregnant or gotten someone pregnant. Although adolescents in foster family homes had higher rates of sex initiation and pregnancy involvement than those in the general population, the two groups had comparable rates of current sexual risk behavior. Being placed in kin/fictive kin foster homes [odds ratio (OR): 3.04; 95% confidence interval (CI): 1.18-7.80] and number of placement settings (OR: 1.20; 95% CI: 1.02-1.42) were associated with multiple sexual partners, while a history of running away from a foster home (OR: 7.64; 95% CI: 1.87-31.18) was associated with pregnancy involvement. Conclusions Efforts targeting placement stability including prevention of running away may reduce sexual risk behavior and pregnancy involvement among adolescents in foster family homes.

A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities.

The child welfare system is an access point for children’s mental health services. Psychiatric residential treatment facilities (PRTFs) are the most restrictive, and most expensive setting for children to receive long-term care. Given the high rates of behavioral health concerns among maltreated children in out-of-home care, research is needed to examine the factors that predict entry in PRTFs among children investigated for maltreatment. This exploratory study used cross-sector administrative records linked across multiple systems, including child welfare records and Medicaid claims, from a single state over a five-year period (n = 105,982). Cox proportional hazards modeling was used to predict entry into a PRTF. After controlling for many factors, PRTF entry was predicted by diagnosis code indicating a trauma-related condition, antipsychotic medication prescriptions, and entry into lower levels of out-of-home care, supporting the view that youth are admitted to PRTFs largely due to clinical need. However, PRTF admission is also associated with characteristics of their experiences with the social service system, primarily foster care placement stability and permanency. Implications for practice and research are discussed.

Trauma-Informed Resource Parent Training and the Impact on Knowledge Acquisition, Parenting Self-Efficacy, and Child Behavior Outcomes: A Pilot of the Resource Parent Curriculum Parent Management Training (RPC+)

ABSTRACTThis pilot study illustrates one state’s development, implementation, and outcomes of a trauma-informed curriculum called the Resource Parent Curriculum + CARE (RPC+). The RPC+ is an intensive co-trained curriculum intended to be trauma-informed and skills-based focused on ameliorating child behavior problems that are frequently the source of parenting stress and placement instability. This article will provide a literature review of child and caregiver needs, describe the training curriculum, and present the results from the pilot implementation of the curriculum. Preliminary findings from this study show participants of the RPC+ show positive changes pre- to post-training on a number of dimensions that have been correlated with placement stability for children including knowledge of trauma, parenting self-efficacy, and child behavior outcomes.

Child strengths and placement stability among racial/ethnic minority youth in the child welfare system

While all children deserve a stable living environment, national data illustrate that many states struggle to achieve placement stability for youth in the child welfare system as a significant number of children in foster care continue to experience multiple placements while in state custody. Prior research has not considered the impact of youth protective factors or strengths on the frequency of placement changes that youth experience while in the child welfare system. This study examined the association between strengths measured at multiple levels (i.e., individual, family, and community) and placement stability among 4022 minority youth (aged 10–18) using administrative and clinical data from the Illinois child welfare system. Negative binomial regressions at the family level revealed that youth with at least one loving and supportive family member experienced 16% fewer placement changes than youth without family strengths. At the community level, youth attending schools that work to create an environment that meets its students’ needs experienced 13% fewer placement changes than youth without educational supports. These findings can inform the quality of treatment and services provided to minority youth in the child welfare system.

Placement Instability Among Young People Removed from Their Original Family and the Likely Mental Health Implications.

BackgroundYoung people in out-of-home care are more likely to experience poorer mental and physical health outcomes related to their peers. Stable care environments are essential for ameliorating impacts of disruptive early childhood experiences, including exposure to psychological trauma, abuse and neglect. At present there are very few high quality data regarding the placement stability history of young people in out-of-home care in Australia or other countries.ObjectivesTo undertake the first systematic census of background, care type and placement stability characteristics of young people living in the out-of-home care sector in Australia.MethodsData was collected from four non-government child and adolescent community service organisations located across metropolitan Melbourne in 2014. The sample comprised 322 young people (females 52.8%), aged between 12 – 17 years (mean age=14.86 [SD=1.63] years).ResultsMost young people (64.3%) were in home-based care settings (i.e., foster care, therapeutic foster care, adolescent care program, kinship care, and lead tenant care), relative to residential care (35.7%). However, the proportion in residential care is very high in this age group when compared with all children in out-of-home care (5%). Mean age of first removal was 9 years (SD=4.54). No gender differences were observed for care type characteristics. Three quarters of the sample (76.9%) had a lifetime history of more than one placement in the out-of-home care system, with more than a third (36.5%) having experienced ≥5 lifetime placements. Relative to home-based care, young people in residential care experienced significantly greater placement instability (χ2=63.018, p<0.001).ConclusionsPlacement instability is common in the out-of-home care sector. Given stable care environments are required to ameliorate psychological trauma and health impacts associated with childhood maltreatment, well-designed intervention-based research is required to enable greater placement stability, including strengthening the therapeutic capacities of out-of-home carers of young people.

Relationship between out-of-home care placement history characteristics and educational achievement: A population level linked data study

Studies generally show children who have entered out-of-home care have worse educational outcomes than the general population, although recent research suggests maltreatment and other adversities are major contributing factors. Children’s out-of-home care experiences vary and may affect their outcomes. This study examined the influence of placement stability, reunification, type of care, time in care and age at entry to care on children’s educational outcomes. We conducted a population-based record-linkage study of children born in Western Australia between 1990 and 2010 who sat State or national Year 3 reading achievement tests (N=235,045 children, including 2160 children with a history of out-of-home care). Children’s educational outcomes varied with many aspects of their care experience. Children placed in residential care were particularly likely to have low scores, with an unadjusted OR 6.81, 95% CI[4.94, 9.39] for low reading scores, which was partially attenuated after adjusting for background risk factors but remained significant (OR=1.50, 95% CIs [1.08, 2.08]). Reading scores were also lower for children who had experienced changes in care arrangements in the year of the test. A dose-response effect for multiple placements was expected but not found. Older age at entering care was also associated with worse reading scores. Different characteristics of a child’s care history were interwoven with each other as well as child, family and neighbourhood characteristics, highlighting a need for caution in attributing causality. Although the level of educational difficulties varied, the findings suggest a widespread need for additional educational support for children who have entered care, including after reunification.

School readiness of maltreated preschoolers and later school achievement: The role of emotion regulation, language, and context

Guided by bio-ecological theory, this study aimed to: (1) identify heterogeneity in the developmental patterns of emotion regulation for maltreated preschool-aged children; (2) examine the role of gender, language, placement instability, cognitive stimulation, and emotional support on patterns of stability and change of emotion regulation over time; and (3) elucidate the role of emotion regulation/dysregulation patterns on later academic achievement. This study utilized data from the first cohort of the National Survey of Child and Adolescent Well-Being. Results using LCA and LTA models indicated stability and change in emotionally regulated vs. emotionally dysregulated latent classes across 4, 5, and 6 ½ years of age. Placement instability significantly increased the likelihood of being classified as emotionally dysregulated at wave 1. Moreover, children classified as emotionally dysregulated by age 6 ½ scored significantly lower than children who were classified as emotionally regulated on measures of reading and math achievement by age 10. Based on these findings, placement stability at first contact with CPS should be promoted in order to prevent cascading negative effects on emotion regulation. Additionally, children who are more emotionally dysregulated by the time they transition to formal schooling should receive increased socioemotional and socioemotional learning supports.

Supporting Looked After Children and Care Leavers In Decreasing Drugs, and alcohol (SOLID): protocol for a pilot feasibility randomised controlled trial of interventions to decrease risky substance use (drugs and alcohol) and improve mental health of looked after children and care leavers aged 12\u201320\xa0years

BackgroundLooked after children (LAC) and care leavers are young people who have been placed under the legal care of local authorities, in many instances due to a history of abuse and/or neglect. These young people have a significantly increased risk of substance use and mental disorder compared to their peers. The aim of the SOLID study is to assess the feasibility and acceptability of a definitive three-arm multi-centre randomised controlled trial (RCT) that compares the effectiveness of two interventions that aim to reduce risky drug and alcohol use and improve mental health among LAC aged 12 to 20 years with usual care.MethodsAll LAC aged 12 to 20 years residing in four local authorities in North East England will be screened by their social worker for risky drug and alcohol use using the CRAFFT (Car, Relax, Alone, Forget, Friends and Trouble) screening tool. Those who score ≥2 will be invited to take part in the trial after further eligibility checks. Informed consent will be taken and baseline data collected. Participants will then be randomised into either (i) Motivational Enhancement Therapy, (ii) Social Behaviour and Network Therapy, or (iii) control–usual care. Follow-up data will be collected 12 months post-baseline. The baseline and follow-up questionnaires will measure self-reported drug and alcohol use, mental health and well-being and health-related quality of life. The follow-up will also collect data on placement stability and self-reported sexual, antisocial and criminal behaviour. Participants will also be asked about the use of health and social services. A detailed process evaluation, using both qualitative and quantitative methods, will be conducted and involve LAC, their carers, social workers and drug and alcohol practitioners.DiscussionDespite having an increased likelihood of risky substance misuse, there is a lack of evidence outlining specific interventions to decrease drug and alcohol use targeting LAC. This feasibility study will provide the information needed to develop a definitive trial. LAC will benefit from the results of this study and the further development of the interventions.Trial registrationISRCTN80786829

The Herts and minds study: evaluating the effectiveness of mentalization-based treatment (MBT) as an intervention for children in foster care with emotional and/or behavioural problems: a phase II, feasibility, randomised controlled trial

BackgroundA significant proportion of children in the social care system in England present with mental health problems, with the majority experiencing some form of emotional and behavioural difficulties. The most effective treatments for these children are currently unknown, partly due to a lack of robust, controlled studies. Researchers have identified a number of obstacles to conducting well-designed research with this population, making the need to test the feasibility of a randomised controlled trial especially important.Methods/designThis protocol outlines a two-arm, randomised control feasibility trial to explore the acceptability and credibility of mentalization-based treatment (MBT) as a treatment for reducing emotional and behavioural difficulties in looked after children and to test the possibility of addressing a number of methodological challenges to conducting high-quality research with this population. MBT is a relatively new intervention which, in the adaptation of the model tested here, includes many of the features of therapy identified in NICE guidelines as necessary to support children in care. The two arms are MBT and usual clinical care (UCC). The study will take place in Hertfordshire Partnership University NHS Foundation Trust with follow-up at 12 and 24 weeks.DiscussionThis study will aim to ascertain whether it is worthwhile and feasible to progress to testing the intervention in a full-scale definitive randomised controlled trial (RCT). This study therefore has the potential to improve our understanding of the obstacles to conducting high-quality research with this very vulnerable population, and in the medium term, could help to improve the stability of foster placements and the emotional well-being of children in care.Trial registrationISRCTN90349442

A novel entry point for pedicle screw placement in the thoracic spine.

This study was aimed to introduce a novel entry point for pedicle screw fixation in the thoracic spine and compare it with the traditional entry point. A novel entry point was found with the aim of improving accuracy, safety and stability of pedicle screw technique based on anatomical structures of the spine. A total of 76 pieces of normal thoracic CT images at the transverse plane and the thoracic pedicle anatomy of 6 cadaveric specimens were recruited. Transverse pedicle angle (TPA), screw length, screw placement accuracy rate and axial pullout strength of the two different entry point groups were compared. There were significant differences in the TPA, screw length, and the screw placement accuracy rate between the two groups (P<0.05). The maximum axial pullout strength of the novel entry point group was slightly larger than that of the traditional group. However, the difference was not significant (P>0.05). The novel entry point significantly improved the accuracy, stability and safety of pedicle screw placement. With reference to the advantages above, the new entry point can be used for spinal internal fixations in the thoracic spine.