What type of programs improve the mental health outcomes of children in out-of-home care?

Introduction

Children in out-of-home care (OOHC) experience elevated risks for mental health challenges and other adverse social outcomes. It is therefore critical to identify what can contribute to supporting good mental health in children in care. This resource provides a summary of the most common program types aiming to improve outcomes for children in OOHC. It also summarises the evidence for the effectiveness of these programs.

This resource serves as an introduction to mental health supports for children in care and is best suited to practitioners who are not overly familiar with the OOHC research or evidence. Our practice papers offer more information about OOHC in Australia and a detailed discussion of mental health outcomes for children in care, as well as practical guidance on supporting the mental health and wellbeing of children in OOHC.

Mental health outcomes in out-of-home care

Children with experience of OOHC have a higher risk of developing mental health challenges than children who have not experienced OOHC. Mental health challenges for children in care can include trauma-related difficulties, attachment challenges, internalising difficulties, depression and suicidality (Engler et al., 2022; Gabrielli et al., 2015; Washington et al., 2018). Children who have been in OOHC are also at increased risk for mental health challenges into adulthood, as well as for poor educational and employment outcomes and contact with the justice system (Jäggi et al., 2022; Walsh et al., 2018). Aboriginal and Torres Strait Islander children are significantly over-represented in OOHC, owing to the systemic impacts of colonisation and ongoing policies of child removal (AIHW, 2023; O’Donnell et al., 2019; Liddle et al., 2022). Moreover, Aboriginal and Torres Strait Islander children often experience poorer mental health outcomes in care, compared to non-Indigenous children (Raman et al., 2011; Walsh et al., 2018). It is therefore important to identify what interventions or programs can best address the unique needs and support the mental health of children in OOHC, to help improve their short and long-term outcomes.

Programming to support child mental health in out-of-home care

There are many programs, models and approaches that aim to improve outcomes for children in OOHC. The countless individual programs are difficult to compare due to differences in program aims, descriptive information available on the programs, and evidence of effectiveness.

Drawing from previous reviews of programs for children in OOHC (Evans et al., 2023; Shlonsky, 2017; Watt & Jakob, 2020), we identified high-level categories of program types and approaches used to support children’s mental health in OOHC. These program types and approaches are outlined in Table 1, along with examples of specific programs, and a summation of the general strength of evidence for each program category. It is important to note that there is some degree of overlap between some program approaches: specific programs may have features of more than one program type, and some approaches may be adopted in conjunction with others.

In this resource, we focus on summarising program ‘types’ and ‘approaches’ – that is, broad categories of programs or approaches to practice that share common features or mechanisms. Although this resource does not explore specific named programs or models, we do provide some examples of named programs that fit into broad types. This resource also has a specific focus on programs for addressing mental health and/or wellbeing for children while they are in OOHC or transitioning from OOHC. It does not include services, policies or programs aimed at preventing contact with child protection services or placement in OOHC.

Consistent with previous reviews, we found limited published literature on programs with a primary aim to provide cultural support for Aboriginal and Torres Strait Islander children in OOHC (AIHW, 2021; Shlonsky, 2017; Watt & Jakob, 2020). Some of these programs overlap with other program category types (e.g. cultural support delivered through mentoring and/or youth behavioural change programs, cultural safety and support guidelines embedded within organisational or residential programs). For this reason, cultural support programs are not outlined as a discrete program category type.

1. Therapeutic foster care is also referred to as enhanced foster care, treatment foster care, specialist or specialised foster care, intensive foster care, or professional foster care. There is not a consistent definition or use of these terms; however, often therapeutic foster care involves specialised training and/or support for foster carers, limits on the number of children in a foster home, involvement of therapeutic specialists, and collective planning and collaborative decision making (often in the form of care teams).

As outlined in Table 1, the most common program types or approaches described in OOHC literature are:

• carer training and support
• therapeutic foster care
• attachment-based programs
• child therapies
• educational support
• restoration or family contact support
• leaving and after care
• youth behavioural change; and
• organisational or system-level models (Evans et al., 2023; Watt & Jakob, 2020).

Of these program types, the most documented appear to be carer training and support (for foster carers) and/or carer-child attachment-based programs.

Table 1. Program approaches used to improve mental health and/or wellbeing outcomes in OOHC

Note: Due to limited published studies and/or a focus on mental health programs for children in OOHC that can be delivered by generalist practitioners, the following are not outlined in this table: child protection services or policies; programs aimed at preventing OOHC contact; cultural support programs; or informal programs or programs delivered for children in informal care arrangements.

Overall, carer training and support programs, therapeutic foster care, and attachment-based programs appear to have the most promising (or strong) evidence (Dalgaard et al., 2022; Downes et al., 2016; Kerr & Cossar, 2014; Uretsky & Hoffman, 2017). However, due to variations in program designs and limited high-quality evidence, it is difficult to determine the effectiveness of the other program types, and more high-quality research is needed.

While there are hundreds of program models to improve mental health and wellbeing outcomes for children in OOHC, few have been sufficiently described or evaluated to determine their effectiveness (Hambrick et al., 2016; Shlonsky, 2017; Tarren-Sweeney, 2021).² There is also significant variation in program and study design and outcomes across programs (Dalgaard et al., 2022; Uretsky & Hoffman, 2017; Watt & Jakob, 2020). Moreover, there are significant methodological limitations in the studies and program evaluations that have been undertaken, including a reliance on cross-sectional and observational study designs, and a lack of reporting on child outcomes (Dalgaard et al., 2022; Uretsky & Hoffman, 2017; Washington et al., 2018; Watt & Jakob, 2020).

Therefore, there is often limited evidence for the effectiveness of even some of the most widely-used programs (Dalgaard et al., 2022; Kinsey & Schlösser, 2013; Watt & Jakob, 2020). This makes it difficult to compare outcomes across programs and to determine the strength of evidence at the overall program approach level (Shlonsky 2013, 2017; PRC, 2014). These limitations have led some researchers to call for more evidence to identify the common elements of programs or implementation factors that contribute to effective and successful approaches (Albers et al., 2017; Shlonsky, 2017; Washington et al., 2018).

There are also important gaps in the scope of the existing research. Much of the research is from the United States and there is limited published evidence on Australian programs (Evans et al., 2023; Shlonsky, 2017). Most of the research has also focused on building the skills of foster carers in managing children’s mental health and behaviour, with significant research gaps for effective programs in other placement arrangements or contexts (Dickes et al., 2018; Lin, 2014; Wu et al., 2020). Of particular concern in the Australian context is a lack of evidence on effective supports in kinship care, and what works to support the mental health of Aboriginal and Torres Strait Islander children in OOHC (Shlonsky, 2017; Watt & Jakob, 2020).

Similarly, there is limited research or evidence on the most effective, or best ways to design and implement, other forms of support for carers – for example, holistic support approaches such as respite care, financial assistance, or training and support mechanisms for professional carers (Lin, 2014; McLaughlin et al., 2017). There is insufficient evidence on which organisational and systems approaches are effective (Bailey et al., 2019; Galvin et al., 2022; Mensah et al., 2020). Finally, little is known about children’s perspectives of quality care and support services (Knight & Kingston, 2021; Smales et al., 2020; Steenbakkers et al., 2018).

2. This is also the case for trauma programs for children who have experienced neglect or abuse more broadly, not just those who are in OOHC (PRC, 2014).

The research and practice literature indicate that some of the most documented program approaches to improve children’s mental health in OOHC are carer training and support, attachment-based programs, and therapeutic foster care. These three overall program types also have the strongest evidence for effectiveness in improving child mental health and wellbeing. However, the evidence for what works in improving child mental health outcomes in OOHC is constrained by a lack of research or strong evidence on key program types.

There are critical gaps in the evidence base that need to be addressed. As outlined earlier, there was limited literature on effective programs to support the cultural needs of Aboriginal and Torres Strait Islander children. There is a critical need for Aboriginal and Torres Strait Islander-led programs and services to ensure children in care have their cultural and mental health and wellbeing needs met (Krakouer et al., 2018; Raman et al., 2017). There is also a need for more literature that documents these approaches (Shlonsky, 2017; Watt & Jakob, 2020). In addition, there are evidence gaps around what works in kinship care, what organisational and systems approaches are effective, and children’s perspectives of quality care and support (Hambrick et al., 2016; Kemmis-Riggs et al., 2018; Shlonsky, 2017).

These findings highlight the need for further research on the specific qualities and components of effective programs and to identify best practice when supporting children in OOHC (Smales et al., 2020; Steenbakkers et al., 2018). More research is therefore needed to identify what works, for whom and under what circumstances (Smales et al., 2020; Steenbakkers et al., 2018). However, promising programs appear to be those that are trauma-informed, culturally safe, multi-component/holistic, and co-designed with children and carers (Green et al., 2022; Higgins & Butler, 2007; Luu et al., 2019; Savaglio et al., 2021). It is also important to acknowledge that OOHC experiences are not homogenous and the mental health outcomes of children in care are influenced by various child, family and environmental factors (Baldwin et al., 2019; Maclean et al., 2016; Walsh et al., 2018).

When delivering programs for children, it is important for practitioners to consider what support is most appropriate for each individual child (including their age, placement type and cultural background) and that best meets the needs of the child and/or their carers (Albers et al., 2017; Shlonsky, 2017; Washington et al., 2018). In particular, it is critical to consider how applicable, effective and safe programs are for Aboriginal and Torres Strait Islander children and families.

More from Emerging Minds and AIFS

• For comprehensive discussion of child mental health outcomes in OOHC refer to our practice paper, Understanding the mental health and wellbeing of children in out-of-home care. Learn more about effective practice elements in Practice principles for supporting the mental health and wellbeing of children in out-of-home care.
• Emerging Minds has a range of short articles that may be helpful, including ones on the importance of supporting carers to promote children’s mental health, and how to support children who have experienced cumulative harm.
• Child Family Community Australia (CFCA) has a number of relevant resources including ones on co-design in OOHC research, supporting children’s attachment needs in OOHC, how to better support foster and kinship carers, residential care models, and recent developments in therapeutic residential care in Australia.

More information on programs, their evidence and guidance on selecting appropriate programs

• The Centre for Excellence in Therapeutic Care (CETC) has comprehensive research reviews and practice guides for professionals working with children in OOHC. For example, research reviews on therapeutic foster care, supporting kinship carers and trauma-informed care; and practice guides for intensive care workers and residential care workers, on reflective practice, implementing care teams, and trauma-informed and relationship-based care.
• The NSW Department of Communities and Justice (DCJ) and Family and Communities Services Insights, Analysis and Research (FACSIAR) has produced an OOHC Evidence and Gap Maps report and datasets.
• The California Evidence-Based Clearinghouse For Child Welfare (CEBC) provides access to a program registry and guides on selecting and implementing evidence-based programs and practices.
• The Victorian Department of Families, Fairness and Housing (DFFH) developed the Menu of Evidence for children and family services, which outlines the evidence for programs that support children and families. While not specific to OOHC, many of the programs outline the evidence for OOHC placement as an outcome.
• The SNAICC website offers examples of Aboriginal and Torres Strait Islander-led early-intervention programs.
• The Outcomes, Practice and Evidence Network (OPEN) provides resources and relevant case studies, with a particular focus on monitoring and evaluation.

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