Implementation of Evidence- Based Mental Health Interventions for Youth in Out-of-Home Care:

Transcription

1 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

2 My Background Education, Research, Career Goals

3 Current Postdoctoral Fellowship The Kempe Center The University of Denver

4 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

5 Current Research Interest Helping youth in foster care receive effective treatment Increasing engagement in evidence-based interventions in realworld settings by matching youth to most appropriate treatments Use implementation science to obtain outcomes superior to those obtained in clinical trials Youth Trauma Exposure ᐁ Maltreatment ᐁ Foster Care ᐁ Interventions ᐁ Implementation - - Progression of research interests within trauma framework -

6 Problem Scope Why engagement in interventions for youth in foster care?

7 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 ,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

8 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

9 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

10 The Engagement Problem Why engagement in interventions for youth in foster care?

11 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 realworld settings

12 We don t have kids to treat. Or kids who remain in treatment.

13 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 1 st session) Behavioral Time/resources Transportation Perceptual/attitudinal Perceived stigma Lack fit between youth and family concerns and treatment targets Previous mental health experiences

14 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

15 Engagement Interventions Creation of engagement interventions Address concrete barriers Address perceptions of treatment Address lack of fit between concerns and treatment

16 Barriers to Engagement: Foster Youth Screening & diagnostic challenges Etiology differences Placement instability Placement diversity Lack of biological caregiver involvement Difficulty receiving referrals from caseworkers

17 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

18 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

19 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 evidenceinformed 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?

20 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

21 What is Trauma-Focused Cognitive Behavioral Therapy? 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

22 Preliminary Research What studies will make the grant feasible?

23 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

24 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?

25 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?)

26 Study 3: Examine Stakeholder, Provider, and Caregiver Perceptions Elicit stakeholder and provider perceptions of both interventions via semistructured interviews What do you think about both interventions? Who would you refer to either intervention? What youth tend to be engaged in each intervention?

27 Grant Proposal Specific Aims

28 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

29 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

30 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

31 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?

32 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?

33 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

34 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

35 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? Advice for the Journey

36 Thank you! Contact Information: Mentor: Heather Taussig, PhD Graduate School of Social Work University of Denver