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Implementation of Evidence-Based Mental Health Interventions for Youth in Out-of-Home Care: Promoting Engagement by Matching Youth to Interventions
Erin P. Hambrick, PhD NIMH T32 Postdoctoral Fellow Developmental Psychobiology Research Group
My Background Education, Research, Career Goals
Current Postdoctoral Fellowship
The Kempe Center The University of Denver
Research Background Mental health related risk and resilience factors post natural disaster exposure
Risk and resilience factors for youth in foster care with maltreatment histories
Disseminating evidence-based interventions for youth within outpatient mental health centers
Youth Trauma Exposure
ᐁ Maltreatment
ᐁ Foster Care
ᐁ Interventions
ᐁ Implementation
Current Research Interest
Helping youth in foster care receive effective treatment
Increasing engagement in evidence-based interventions in real-world settings by matching youth to most appropriate treatments
Use implementation science to obtain outcomes superior to those obtained in clinical trials
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- Progression of research interests within trauma framework -
Problem Scope Why engagement in interventions for youth in foster care?
Foster Care In 2002, $22 billion were spent on foster care and adoption in the US
Rates declining in US
523,000 children in care in 2002
407,000 in 2011
Focus has been on safety & permanency
Focus is now on wellbeing
Recent increase in knowledge that safety and permanency did not equal wellbeing
Mental Health Problems in Foster Youth Youth in foster care have high rates of:
Maltreatment (50%) & violence exposure (85%)
Clinically significant mental health problems (50 - 60%)
Up to 25% is Posttraumatic Stress Disorder
The US Department of Health and Human Services is now funding “trauma screening and functional assessment for all children who enter foster care” in many US states
Emphasis on identifying those in need of treatment
Ultimate goal is to improve wellbeing so that permanency (e.g., adoption) can also continue to improve
Researchers involved in these efforts state that through these assessments, “gaps in services are just beginning to be identified”
Foster Youth and Mental Health Services 50 – 65% of the youth who need mental health intervention do not receive it
Some are not identified as in need of treatment
Some do not have access to any services, much less evidence-based interventions
Youth referred to treatment do not evidence better outcomes than youth not referred
Problems with efficacy of interventions in foster populations
Problems with identifying which youth would benefit from which services
Problems with engagement
The “Engagement” Problem Why engagement in interventions for youth in foster care?
We have… National emphases on screening foster youth for mental health problems
Evidence-based interventions for foster youth
Knowledge about how to implement evidence-based interventions in real-world settings
We don’t have kids to treat. Or kids who remain in treatment.
Engagement Problems Engagement is related to better treatment outcomes
Both Behavioral and Perceptual barriers to engagement; perceptual stronger predictor of actual engagement
Problems with Enrollment (50% do not attend 1st session)
Behavioral Time/resources
Transportation
Perceptual/attitudinal
Perceived stigma
Lack fit between youth and family concerns and treatment targets
Previous mental health experiences
Engagement Problems Problems with Retention (2/3 drop out within 7 sessions)
Behavioral
Attendance
Homework completion
Perceptual/attitudinal
Perceived stigma
Lack fit between youth and family concerns and treatment targets
Previous mental health experiences
Engagement Interventions Creation of “engagement interventions”
Address concrete barriers
Address perceptions of treatment
Address lack of fit between concerns and treatment
Barriers to Engagement: Foster Youth Screening & diagnostic challenges
Etiology differences
Placement instability
Placement diversity
Lack of biological caregiver involvement
Difficulty receiving referrals from caseworkers
Evidence-Based Interventions Established via RCTs with replication
Increasing landscape of interventions for youth in foster care
US federal funding has incentivized states to provide certain interventions for youth in foster care
Not enough availability
Not enough evidence for efficacy with foster youth
No consistent or validated way to match youth to interventions
What can we do to improve engagement?
Study existing evidence-based interventions that have been shown to work for foster youth
Determine ways to match identified youth to the treatment in which they are most likely to be engaged, building on engagement interventions
Two-Year Postdoctoral Research Plan
Learn about engagement of foster youth in evidence-based treatment
How do we define engagement?
What are rates of engagement in evidence-based interventions in the real world?
What are differences in evidence-informed treatments that would facilitate or impair engagement in certain youth?
What do stakeholders think of existing evidence-based treatments? Who would they refer?
Write a grant to match youth to appropriate interventions
How can we use what we know about each treatment to facilitate engagement & match kids to appropriate treatment?
How can we learn more about which treatment is best at engaging which youth?
Can improving engagement help reduce costs, increase provider perceptions, and improve outcomes?
What is Fostering Healthy Futures? 30 week preventive intervention
No diagnoses
Mentoring & skills group components
No active caregiver component
Domains of impact: decrease trauma symptoms (including dissociation), & internalizing symptoms; increases quality of life
93% of youth enrolled completed treatment
What is Trauma-Focused Cognitive Behavioral Therapy? 12 – 24 week intervention
Children must exhibit significant PTSD symptoms
Psychoeducation, skill building, exposure, cognitive work
Caregiver involvement throughout
Domains of impact: Reduces trauma symptoms, depression, behavior problems
Treatment completion has been linked to foster parent involvement
66% of foster youth enrolled completed treatment
Preliminary Research What studies will make the grant feasible?
Study 1: Define Engagement Evaluate engagement in Fostering Healthy Futures
Identify factors that predict both behavioral (attendance) and attitudinal (enjoyment, participation in activities) engagement
Define engagement
Examine whether engagement moderates treatment outcomes
Contextualize these data based on what is known about engagement of foster youth in TF-CBT
Study 1: Define Engagement What factors should be considered to help define engagement (caregiver characteristics? Mentor characteristics? Child characteristics?)
At what point in treatment should engagement be measured?
Pick “subset” of engaged kids and evaluate their outcomes, to help define engagement?
Whose report of engagement to use when there are multiple reporters?
Study 2: Measurement of Engagement – Clinical and Implementation Trials
Compare engagement in the Fostering Healthy Futures and Trauma-Focused CBT research trials to engagement in implementation trials
Evaluate if engagement differs from research trials to implementation efforts.
Consider factors related to implementation difficulties (problems receiving referrals? Stigma that differs in real-world settings?)
Study 3: Examine Stakeholder, Provider, and Caregiver Perceptions Elicit stakeholder and provider perceptions of both interventions via semi-structured interviews
What do you think about both interventions?
Who would you refer to either intervention?
What youth tend to be engaged in each intervention?
Grant Proposal Specific Aims
Aim 1: Create Assessment Strategy
Create Assessment Strategy to Improve Engagement
Build on existing engagement interventions
Use information regarding engagement in both treatments and provider and stakeholder perceptions to create an assessment strategy to determine a child’s “fit” for either intervention
Review Strategy
Have stakeholders, providers, and caregivers evaluate strategy and integrate feedback into the assessment strategy
Key Engagement Related Characteristics: FHF No diagnoses
30-week intervention
No active caregiver component
93% of youth enrolled completed treatment
Children are transported to treatment
Youth are followed post-placement disruption
Foster care experiences normalized through group
Case management component
Key Engagement Related Characteristics: TF-CBT Children must exhibit significant PTSD symptoms
12- to 24-week intervention
Psychoeducation, skill building, exposure, cognitive work
Caregiver components
Treatment completion has been linked to foster parent involvement
66% of foster youth enrolled completed treatment
Children are not typically maintained post placement disruption
Aim 2: Evaluate Engagement
Place youth in FHF or TF-CBT
Randomize some of youth to either intervention
Use assessment strategy to match some youth with intervention
Evaluate Engagement
What are engagement rates in both treatments in the group that was matched to treatments versus the group that was randomly assigned?
Is engagement superior in youth who were matched to interventions rather than randomized?
Aim 3: Do Improvements in Engagement lead to other Positive Outcomes?
Costs
Are there less wasted treatment costs?
Provider Perceptions
Are provider perceptions of the treatment improved?
Mental Health Outcomes
Are mental health outcomes superior?
Broad Implications If we can increase engagement in youth in foster care, we can do so with other populations
Knowledge about whether increased engagement influences implementation is likely generalizeable
Career Research Goals
Study implementation of evidence-based interventions for youth in OOHC
Understand factors related to youth’s engagement
Create implementation strategies to improve engagement (or tx optimization; tx adaptations)
Evaluate relation between engagement and provider satisfaction & fidelity
Match youth with treatments and match treatments with organizations
Advice for the Journey
1) From your perspective, how significant is the research question? 2) How helpful would the outcomes of this implementation study be to providers in real-world settings? 3) Is there a better intervention to use in the implementation trial than TF-CBT? 4) What other studies could I consider conducting that would inform the creation of the implementation strategy?
Thank you! Contact Information: [email protected] Mentor: Heather Taussig, PhD Graduate School of Social Work University of Denver [email protected]
