Doctorate in Educational and Child Psychology. Case Study 1: An Evidence-Based Practice Review Report

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1 Case Study 1: An Evidence-Based Practice Report Theme: Interventions for children with Special Educational Needs Is Multidimensional Treatment Foster Care (MTFC) an effective intervention for reducing externalising behaviours in children with Social, Emotional and Behavioural Difficulties, whose challenging behaviours are resulting in their current placement being at risk? Summary The Multidimensional Treatment Foster Care (MTFC) program involves placing young people, whose challenging behaviours are resulting in current placements potentially becoming unsustainable, in well-trained and supervised foster homes. The six to nine month intervention aims to enable young people to live successfully in their community through the use of intensive supervision, support, and skill development and to simultaneously prepare their original placement to provide effective parenting to enable a positive reintroduction to the family. The purpose of this systematic review was to establish whether MTFC is an effective intervention for reducing externalising behaviours in children with social, emotional and behavioural difficulties, whose challenging behaviours are resulting in their current placement being at risk. A systematic literature search identified five studies which met the inclusion criteria outlined in Table.1. These articles were coded using an adapted version of Kratochwill s Literature Coding Protocol (Kratochwill, 2003), and evaluated using the Weight of Evidence Framework (Gough, 2007). MTFC was reported to be an effective intervention for reducing children s externalising behaviours in three of the five studies. The critical analysis identified limitations in all of the studies meaning the findings must be interpreted with caution. Therefore this review does not enable confident 1

2 recommendation of MTFC to families of children with social, emotional and behavioural difficulties displaying externalising behaviours. Introduction The Department for Children, Schools and Families (DCSF) describes social, emotional and behavioural difficulties as behaviours being demonstrated by children such as being withdrawn or isolated, disruptive and disturbing; being hyperactive and lacking concentration; having immature social skills; or presenting challenging behaviours arising from other complex special needs (DCSF, 2007). Whether a child is perceived to have emotional and behavioural difficulties will depend on the nature, frequency, persistence, severity and/or cumulative effect of the behaviour, compared to normal expectations for the age of the child (Department for Education, 1994). Such behaviours are often categorised as externalising or internalising behaviours. Childhood behaviours marked by defiance, impulsivity, disruptiveness, aggression, antisocial features and over-activity are classified as externalising behaviours, where behaviours characterised by withdrawal, anxiety and dysphoria are known as internalising behaviours. Externalising behaviours are more stable, more resistant to intervention and are associated with negative outcomes in later life (Hinshaw, 1992). However, estimates of prevalence vary. This is partly due to many research investigations focussing on specific topographies, (such as aggression or self-injurious behaviour) where others have focused on more general categorisation. This use of differing definitions has contributed to wide variation in the assessment of prevalence (Lowe, Allen, Jones, Brophy, Moore, & James, 2007). Externalising behaviours, academic underachievement, and poor development of positive social skills among students are a key concern for educators and parents of children and young people(luiselli, Putnam, Handler & Feinberg, 2005). Aggression and violence in young people has been found to have implications on the progression of psychiatric impairment, school difficulties, 2

3 and legal involvement (Rappaport & Thomas, 2004) where children who engage in challenging behaviours at a young age are more likely than their nonaggressive peers to respond similarly when older and as adults (Luiselli et al., 2005). The needs of looked after children are of increasing importance to both academic researchers and policy-makers (Goddard, 2000). Looked after children are disproportionately represented in statistics relating to low levels of school attainment, exclusion from school, high levels of truancy and social exclusion (Dent & Cameron, 2003). Recognition of the emotional and behavioural difficulties experienced by looked after children (and the impact of these) has also been increasing (Sargent & O Brien, 2004) alongside evidence that placement disruption and externalising behaviour problems are associated. For example findings by Newton, Litrownik and Landsverk (2000) have suggested that multiple placements in out-of-home care are associated with both immediate and long-term negative outcomes for the child. Children who are disruptive, aggressive and/or dangerous to others are at higher risk of experiencing placement change (Newton et al., 2000). Educational psychologists can play a central role in the process of helping teachers, parents/foster carers and peers to support individual children and are well placed to give a view on the impact of different types intervention on the child s care or behaviour (Dent & Cameron, 2003). Educational Psychologists are able to provide informed perspectives that are drawn from psychological research and theory, and can help other professionals to develop a deeper understanding of pupils personal and social development, their behaviour and their learning (Dent & Cameron, 2003). Despite increasing official and academic interest, there remains significant gaps in the available literature in relation to looked after children (Dent & Cameron, 2003). The recruitment of children for research projects through schools involves co-operation from local authorities, school staff and parents. In the process of recruiting looked after children, the number of gatekeepers is increased to 3

4 include social services and foster parents among others. Looked after children are often felt to be particularly vulnerable, and therefore there is a tendancy to protect them from the perceived potential negative effects of research participation (Heptinstall, 2000). This may mean children are prevented from taking part in research despite the recognised need to increase the evidence base in this area and the young people having expressed a wish to do so. It is recognised in the emerging literature that many looked after children require comprehensive behavioural supports that involve family, school, and community participation (Sugai,Homer, Dulap, Hieneman, Lewis, Nelson, Scott, Liaupsin, Sailor, Turnbull, Rutherford-Turnbull, Wickham, Wilcox & Ruef, 2000). The Multidimensional Treatment Foster Care (MTFC) program began as a communitybased alternative to placement in group or residential care for children and adolescents with severe emotional and behavioural problems (Chamberlain, 2003). MTFC is based on social learning theory (Bandura, 1977) and aims to benefit from the positive socialising influence of the family. In the social learning system new patterns of behaviour can be acquired through direct experience or by observing the behaviour of others. By observing a model of the desired behaviour an individual forms an idea of how response components must be combined and sequenced in order to produce favourable outcomes. This representation serves as a guide for subsequent behavioural reproduction. During the course of learning, people not only perform a particular behaviour, but also observe the differential consequences that accompany the behaviour. Some of the responses will prove negative or unsuccessful while others produce more favourable effects. Through this process of differential reinforcement successful modes of behaviour are selected, while ineffectual ones are discarded (Bandura, 1977). MTFC involves placing young people, whose challenging behaviours are resulting in current 4

5 placements potentially becoming unsustainable, in well-trained and supervised foster homes (Rhoades, Chamberlain, Roberts, & Leve, 2013). The period of intervention typically lasts six to nine months and is focused on implementing an intensive programme across multiple settings (e.g., home, school, peer group, and community). The ultimate goals of MTFC are for young people to live successfully in their community through the use of intensive supervision, support, and skill development and to simultaneously prepare their original placement to provide effective parenting to enable a positive reunion with the family (Smith, Chamberlain, & Eddy, 2010). Four key elements are targeted during and after treatment. The MTFC model provides a consistent reinforcing environment where the youths are mentored and encouraged to perform specific tasks or behaviours designed to increase their skill base. Clear expectations and limits and well-specified consequences are delivered in a teaching-oriented manner. The young people are closely supervised and they are supported in avoiding social situations where peers engage in similar behaviours, and given assistance in establishing positive peer networks (Smith et al., 2010). The components of MTFC include: 1. Daily telephone contact with MTFC parents using the Parent Daily Report checklist (Chamberlain & Reid, 1987), 2. Weekly foster parent group meetings led by the program supervisor that are focused on supervision, training in parenting practices, and support, 3. An individualized behaviour management program implemented daily in the home by the foster parent, 4. Individual therapy for the youth, 5. Individual skills training/coaching for the youth, 6. Family therapy (for biological/original family unit of the youth) focused on parent management strategies. As part of family therapy, home visits are used throughout the 5

6 program for parents and youth to practice their skills in the context of their family environment, 7. Close monitoring of school attendance, performance, and homework completion, 8. Case management to coordinate the MTFC, family, peer, and school settings, hour on-call staff availability to MTFC and biological parents, 10. Psychiatric consultation as needed. (Rhoades et al., 2013). Parents receive 20 hours of training conducted by program supervisors and current MTFC foster parents prior to providing a MTFC placement for a young person. Training is focused on the use of behaviour management methods to establish and maintain a structured, supervised, and consistent daily living environment. Parents are supported by a team of professionals including the program supervisor, who acts as the clinical lead and has a small caseload of a maximum of 10 families. The rest of team includes family and individual therapists, a skills trainer and a foster parent recruiter/trainer. Program supervisors maintain daily contact with MTFC parents to collect data on youth adjustment and to provide ongoing consultation, support, and crisis intervention (Rhoades, et al.,, 2013; Eddy & Chamberlain, 2000; Van Ryzin & Leve, 2012). This review offers a critical appraisal of the evidence base and explores whether MTFC is an effective intervention for reducing externalising behaviours in children with social, emotional and behavioural difficulties, whose challenging behaviours are resulting in their current placement being at risk. This analysis is focused on children who are of school-age (4 19) due to alternate forms of the MTFC intervention being used with children who are of preschool age (Multidimensional Treatment Foster Care - Preschool). Differences in many areas of implementation including training for foster carers and the use of playgroup weekly sessions for development of pro-social skills resulted in an inability to review the two simultaneously. 6

7 Critical of the Evidence Base Literature Search Studies of Multidimensional Treatment Foster Care were identified through a search of PubMed,, ERIC and Science Direct using the key words Multidimensional Treatment Foster Care OR MTFC AND behavi* within the title and abstract of publications. No restriction regarding the year of publication was placed on the searches. All retrieved studies were reviewed to determine if they met criteria for inclusion in the present evaluation. Once the duplicates were removed, the titles and abstracts of seventy-two studies were screened for eligibility, using the inclusion criteria, outlined in table 1, resulting in nine potential studies for consideration. A full article review was subsequently undertaken of these remaining nine studies in order to confidently make a decision regarding the admissibility, which left five remaining studies that were deemed suitable for answering the review question. In the process of reviewing the retrieved studies, an alternative term, used in the United Kingdom for Multidimensional Treatment Foster Care, was highlighted. Therefore the search was repeated using this term Intensive Fostering within all four bibliographical databases. This search did not return any additional studies to the original systematic search. Figure 1 depicts the process followed, identifying studies from the initial searches to screening and selecting studies for the review. The excluded studies plus rationale for exclusion are listed in Appendix B. 7

8 Table. 1. Inclusion and Exclusion Criteria. Criteria Inclusion Exclusion Intervention Intervention studied was Multidimensional Treatment Foster Care (MTFC). Studies that investigated alternative interventions. Dependent variable Standardised measures of externalising or challenging behaviours. Measures were not of participant externalising behaviour Dependent variable Behaviours recorded are not limited to those of an illegal nature. Measures were limited to behaviours of an illegal nature only. (e.g. Elliot measure of delinquency). Sample Participants are of school age Studies where participants were described to be attending preschool/nursery settings. Participants aged 3years old or younger Type of study Contains primary empirical data. Type of Study Published in a peer-reviewed journal. Language Written in the English Language Participants aged 19 years or above. Does not contain primary empirical data (e.g., review paper, theoretical paper). Not published in a peer-reviewed journal. (e.g. book, dissertation paper, thesis). Written in a language other than English Table. 2. Studies identified to be suitable in answering the research question; 1 Chamberlain, P., Price, J., Leve, L. D., Laurent, H., Landsverk, J. a, & Reid, J. B. (2008). Prevention of behavior problems for children in foster care: outcomes and mediation effects. Prevention Science : The Official Journal of the Society for Prevention Research, 9(1), Green, J. M., Biehal, N., Roberts, C., Dixon, J., Kay, C., Parry, E., Sinclair, I. (2013). Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation. The British Journal of Psychiatry : The Journal of Mental Science. 3 Hansson, K., & Olsson, M. (2012). Effects of multidimensional treatment foster care (MTFC): Results from a RCT study in Sweden. Children and Youth Services, 34(9), Leve, L. D., Chamberlain, P., & Reid, J. B. (2005). Intervention outcomes for girls referred from juvenile justice: effects on delinquency. Journal of Consulting and Clinical Psychology, 73(6), Westermark, P. K., Hansson, K., & Olsson, M. (2011). Multidimensional treatment foster care (MTFC): results from an independent replication. Journal of Family Therapy, 33(1), A full summary of the included studies including participants and outcome measures are detailed in Appendix A. 8

9 FIGURE.1. Diagram of Study Screening Process. 9

10 Quality and relevance of studies The Gough (2007) framework and an adapted version of the Kratochwill (2003) Task Force on Evidence Based Interventions in School Psychology coding protocol was used to analyse the research studies selected. The weightings of the studies were formed based on judgements of 3 aspects of the studies: A) Methodological quality (the quality of execution of the study in relation to quality standards for studies of that type) B) Methodological relevance (the appropriateness of the evidence/research design for answering the review question) C) Topic relevance (the appropriateness of the focus of the evidence for the review question) The Overall Weight of Evidence was calculated by determining the mean score across each criteria, with each one holding equal importance. The weightings for each study are given in Table 3 and Appendix C. The full coding protocol is outlined in Appendix D, with details of how judgements were made regarding the weightings being detailed below. Measures and Design The systematic literature review highlighted seven studies that investigated the effect of MTFC on behavioural outcomes using measures that solely targeted illegal measures (e.g. Elliot Scale of Delinquency). These studies were excluded from this review (see table 1) as it was felt that limiting behavioural outcomes to those that are illegal in nature, and often with a focus on related alcohol and drug use, will narrow the implications this review may have on Educational Psychology practise. Therefore it was felt that these studies were too specific in focus to answer the research question when aiming to reduce externalising behaviours of all description with children with social, emotional and behavioural difficulties. 10

11 The designs of the included studies were similar with each study collecting baseline data of externalising behaviours such as aggression and disruptive behaviour. However, the time that postintervention measures were taken by the researchers varied from five to twenty-four months and this will have an effect on the outcomes. This was highlighted in a meta-analysis of parent training programmes where researchers found that follow-up measures taken one year following the completion of an intervention, the effects remained meaningful, but were small in magnitude (Lundahl, Risser, & Lovejoy, 2006). Three studies used more than one source of data collection, and studies conducted by Leve et al., (2005) and (Chamberlain et al., 2008) only used data collected from the perspective of the foster parent. This affected the overall quality of methodology in the study and was reflected in the weight of evidence (table 3, Appendix C). The majority of the studies used similar measures of challenging behaviours. Four studies (Green et al., 2013; Hansson & Olsson, 2012; Leve et al., 2005; Westermark, Hansson, & Olsson, 2011) used the Child Behaviour Checklist (Achenbach, 1991). Although many of the studies did not report reliability or validity for the Child Behaviour Checklist (CBCL), Westermark et al. (2011) reported a Cronbach α of and test re- test reliability score of However it is important to note that all but one study did not used the full CBCL, with Hansson & Olsson, (2012) and Westermark et al. (2011) using the problem scale and Leve et al. (2005) only using the delinquency subscale. This reduction in content will have implications for the reliability of the measure. A second measure that was used alongside the CBCL in two studies (Hansson & Olsson, 2012; Westermark et al., 2011) was the Youth Self Report (Achenbach & Rescorla, 2001) with a reported Cronbach α of and test re- test reliability score of 0.87 (Westermark et al., 2011). Similar to the CBCL the problem scale of the Youth Self Report was used without the competence scale, which will have implications for the measure s reliability. The final study (Chamberlain et al., 2008) 11

12 used the Parent Daily Report Checklist (Chamberlain & Reid, 1987). The reliability and validity for this measure was not reported however, this questionnaire is well referenced in the literature. Participants The total number of participants ranged from ten years to eighteen years of age. Three studies reported the mean ages of the participants (Hansson & Olsson, 2012; Leve et al., 2005; Westermark et al., 2011) with similar mean ages in years of 14.8, 15.3 and 15.4 respectively. Only one of the five studies met the Kratochwill (2003) criteria for sufficient sample size and this is reflected in weightings of evidence awarded for the Analysis in table 3 (see Appendix C). All studies used random allocation of participants to intervention and control trials, resulting in the intervention group consisting of 50.83% of all participants. All studies were awarded a promising weighting of evidence for the comparison group within Quality of Methodology because, although participants were randomly assigned, the control of change agents was not used in any study. Due to the limited research on MTFC, there is no current meta-analysis to identify an expected effect size for this intervention. Therefore analysis of the current literature was extended to the effects of parent training programs, with the aim of reducing challenging behaviours in children. This search resulted in a meta-analysis written by Lundahl, Risser and Lovejoy (2006) who concluded that the mean effect size for child behaviour was This indicates a minimal (0.08) deficit from what Cohen (1988) describes as a medium effect size. Subsequently a medium effect size was expected for the five studies selected for this analysis, with a sufficiently large N of 64 or above. Only one study (Chamberlain et al., 2008) met this criteria. 12

13 Intervention The integrity by which the intervention itself was carried out was explicitly discussed in the studies, where the Parent Daily Report Checklist was used in each research project to ensure fidelity to the intervention design, and reference to the MTFC manual mentioned in the majority of studies. However the training and monitoring received by the foster carers was variable within the studies. The Manual for the MTFC explicitly states the initial training that should be received by foster parents (which varies depending on the age of the young people being placed in their care) and the ongoing supervision and support that should be received in order to maintain fidelity of implementation. The fidelity of the MTFC implementation will affect the ability of the publication to answer the research question due to the impact it has on the overall quality of the study. Therefore the fidelity of the MTFC implementation, as reported in the research, was reflected in the weight of evidence (table 3, Appendix C). Table 3. Overall Weight of Evidence. Is Multidimensional Treatment Foster Care an effective intervention for reducing externalising behaviours in children with social, emotional and behavioural difficulties, whose challenging behaviours are resulting in their current placement being at risk? (A) (B) (C) (D) Quality of Methodology Relevance of Methodology Relevance of evidence to the review question Overall Weight of Evidence Westermark, Hansson, & Olsson. (2011) Medium High High High Hansson & Olsson. (2012) Medium High High High Green et al. (2013) Medium High High High Chamberlain et al. (2008) Leve, Chamberlain & Reid. (2005) Medium High Medium Medium Low High Medium Medium

14 Overall Weight of Evidence Mean Score High At least 2.5 Medium Between 1.5 and 2.4 Low Less than 1.4 Effectiveness of MTFC in reducing externalising behaviour All studies reported that MTFC had a positive impact on externalising behaviours demonstrated by the young people. Table 4 summarises the results of each of the five individual studies, and a brief discussion of the results is detailed below; Three of the studies identified a significant reduction in externalising behaviours. Westermark et al. (2011) concluded that only the young people included within the MTFC intervention showed a consistent statistical significance in externalising behaviour reduction. She stated that the clinically significant changes illustrated that MTFC, in comparison with Treatment As Usual (TAU), had more young people reducing their externalising behaviours at a minimum of one standard deviation of a normal population. This was supported by the results of Leve et al. (2005) who found that, only young people who were allocated into the MTFC intervention showed statistical significance in externalising behaviour reduction, as rated by their Foster Caregivers. Similarly Chamberlain et al. (2008) found that foster parents in the MTFC condition reported significantly lower externalising behaviour rates in post-intervention measures than those in the TAU group. Chamberlain et al. (2008) concluded that the results showed that participation in MTFC increased parental effectiveness, which related to decreased child behaviour problems. This was particularly evident in families who reported higher levels of externalising behaviours at the baseline assessment. However, Hansson and Olsson, (2012) found that both groups of young people showed a significant but similar reduction in externalising behaviours over time. Comparably Green et al. (2013) found that the young people in the MTFC group had a marginally better outcome for the measure of CGAS, 14

15 which was a composite score developed from the CBCL and YSR measures, than the usual care group but this was not statistically significant. Therefore Green et al. (2013) and Hansson and Olsson (2012) both suggest that there is no evidence that MTFC results in in a greater reduction in externalising behaviours when compared with usual treatment. Table 4. Outcomes and effect sizes of included studies. Study Outcome Effect Size* Effect Size Interpretation Westermark, Reduction in behaviours (cohen s d) Hansson, & Olsson. considered as challenging as Small (2011) rated by participants YSR 0.33 themselves (YSR) and by Foster CBCL 0.19 Parents (CBCL) Overall Weight of Evidence High 2.6 Hansson & Olsson, (2012) Reduction in behaviours considered as challenging as rated by participants themselves (YSR) and by Foster Parents (CBCL) (cohen s d) YSR 0.20 CBCL 0.25 Small High 2.6 Green et al., (2013) Reduction in behaviours considered as challenging as rated by participants by Foster Parents (CGAS) (cohen s d) CGAS: 0.50 Medium High 2.8 Chamberlain et al., (2008) Reduction in behaviours considered as challenging as rated by participants by Foster Parents (PDR) (cohen s d) PDR 0.26 Small Medium 2.2 Leve, Chamberlain & Reid (2005). Reduction in behaviours considered as challenging as rated by participants by Foster Parents (CBCL) (Partial Eta Square) CBCL 0.07 Medium Medium 2 *All effect sizes were calculated and reported within the original studies. Indicators of a small, medium or large effect size are dependent on the method used for calculation (see Table 5). Table 5. Indicators of a small, medium or large effect size depending on the method used for calculation Type of effect size Small Medium Large Partial Eta Square (Cohen, 1988) Cohen's d (Cohen, (Green & Salkind, 2008) 15

16 Conclusions The systematic review analysed five studies to explore whether Multidimensional Treatment Foster Care (MTFC) an effective intervention for reducing externalising behaviours in children with social, emotional and behavioural Difficulties, whose placements are at risk due to challenging behaviour. The Three studies awarded high for Overall Weight of Evidence resulted in contradictory findings. Westermark et al. (2011) provided evidence that MTFC may be an effective intervention for reducing externalising behaviour. Small effect sizes were found for the difference between the two groups with results of statistical significance in externalising behaviour reduction in two measures of externalising behaviours from multiple sources (d= 0.19 and d=0.33). Conversely However, Green et al. (2013) did find a medium effect size (d=0.50) and Hansson and Olsson, (2012) reported small effect sizes (d=0.20 and d=0.25). These effect sizes need to be interpreted with caution. Despite achieving a high weight of evidence, none of these studies used a large enough participant number to state an effect size at 80% power which may contribute to the contradictory evidence. Two studies awarded medium for Overall Weight of Evidence (Chamberlain et al., 2008; Leve et al., 2005) provided support for MTFC being an effective intervention for reducing externalising behaviour. A medium effect size was found for the difference between the two groups in the CBCL delinquency subscale (Leve et al., 2005) and a small effect size was found for the difference in the PDR checklist measure (Chamberlain et al., 2008). Change between baseline and end of intervention scores was also significant for children in the MTFC groups in both studies. However, these results must be considered in light of the methodological limitations of the studies resulting in them being weighted as medium rather than high. Neither study used multiple sources of data to enable triangulation of information. Therefore both studies are limited by a lack of inter-rater reliability and the possibility of bias from the MTFC Foster Carers who, following a substantial training and intervention timeframe, may have been invested in a positive outcome for the MTFC condition. 16

17 Secondly, neither measure was norm referenced to a population of children in out-of-home placement and thirdly both studies only used a single measure of externalising behaviour. This has an impact on the reliability. In particular the CBCL delinquency subscale is comprised of thirteen items and this use of a single subscale will reduce the applicability of the Cronbach α of and test re-test reliability score of 0.94 reported in the manual for the entire CBCL. Due to the limitations of the reviewed studies, and the contradictory results reported within them, the review suggests that it is not appropriate for Educational Psychologists to recommend Multidimensional Treatment Foster Care to the families of children with social, emotional and behavioural difficulties who are displaying externalising behaviours on the evidence that has been produced so far. This has been concluded in light of the significant resources required to ensure a high level of fidelity and the potential implications of removing a child from their family home and placing them in a treatment placement that has not been conclusively established as effective. As stated in the introduction, Newton et al. (2000) have suggested that multiple placements in out-ofhome care are associated with both immediate and long-term negative outcomes for the child. If a reduction in externalising behaviours is not noted in response to MTFC, there is a potential for the young person being unable to return to their previous placement (often family home) resulting in a second out-of-home placement and the associated negative outcomes. MTFC needs to be further evaluated using designs that incorporate measures which have good evidence for reliability and validity, using multiple sources of data that can be triangulated in order to reduce bias. Importantly this needs to be done with a larger number of participants in order to gain 80% power. In addition the design of studies could incorporate a wider range of measure to increase the relevance of research to educational Psychology Practice. 17

18 Despite being a recommended parent training intervention on the Department of Education website, few educational outcomes have been researched as secondary outcomes alongside the primary outcome of a reduction in challenging behaviours. One such study has been completed by (Rhoades et al., 2013) who found a medium effect size (d=0.48) of MTFC on School Activities which included attendance and time spent engaged with homework. Similarly (Leve & Chamberlain, 2007) found medium effect sizes in attendance ( ଶ = 0.07) and homework completion ( ଶ = 0.09). Both of these factors have positive implications on outcomes for academic success and social development in young people (Coutts, 2004; Sheldon, 2007). However, both of these studies focussed on adolescent girls and further research would be required to see if these results generalise to other populations. 18

19 References Achenbach. (1991). Manual for the Child Behavior Checklist and 1991 profile. Burlington, VT: University of Vermont Department of Psychiatry. Achenbach & Rescorla. (2001) Manual for the ASEBA School-age Form and Profiles. Burlington, VT: Research Centre for Children, Youth and Families, University of Vermont. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological, 84(2), Chamberlain, P., Price, J., Leve, L. D., Laurent, H., Landsverk, J. a, & Reid, J. B. (2008). Prevention of behavior problems for children in foster care: outcomes and mediation effects. Prevention Science : The Official Journal of the Society for Prevention Research, 9(1), Coutts, P. M. (2004). Meanings of Homework and Implications for Practice. Theory Into Practice, 43(3), Dent, R. J., & Cameron, R. J. S. (2003). Developing Resilience in Children Who are in Public Care: The educational psychology perspective. Educational Psychology in Practice, 19(1), Eddy, J. M., & Chamberlain, P. (2000). Family managment and deviant peer association as mediators of the impact of treatment condition on youth antisocial behavior. Journal of Consulting and Clinical Psychology, 68(5), Goddard, J. (2000). The education of looked after children. Child and Family Social Work, 5(1), Gough. (2007). Weight of Evidence: a framework for the appraisal of the quality and relevance of evidence. Applied and Practice Based Research, 22(2), Green, J. M., Biehal, N., Roberts, C., Dixon, J., Kay, C., Parry, E., Sinclair, I. (2013). Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation. The British Journal of Psychiatry : The Journal of Mental Science. Hansson, K., & Olsson, M. (2012). Effects of multidimensional treatment foster care (MTFC): Results from a RCT study in Sweden. Children and Youth Services, 34(9), Heptinstall, E. (2000). Research note. Gaining access to looked after children for research purposes: lessons learned. British Journal of Social Work, 30(6), Kratochwill, T. R., & Steele Shernoff, E. (2004). Evidence-Based Practice: Promoting Evidence-Based Interventions in School Psychology. School Psychology, 33, Leve, L. D., & Chamberlain, P. (2007). A Randomized Evaluation of Multidimensional Treatment Foster Care: Effects on School Attendance and Homework Completion in Juvenile Justice Girls. Research on Social Work Practice, 17(6), Leve, L. D., Chamberlain, P., & Reid, J. B. (2005). Intervention outcomes for girls referred from juvenile justice: effects on delinquency. Journal of Consulting and Clinical Psychology, 73(6),

20 Lowe, K., Allen, D., Jones, E., Brophy, S., Moore, K., & James, W. (2007). Challenging behaviours: prevalence and topographies. Journal of Intellectual Disability Research : JIDR, 51(Pt 8), Luiselli, J. K., Putnam, R. F., Handler, M. W., & Feinberg, A. B. (2005). Whole- school positive behaviour support: effects on student discipline problems and academic performance. Educational Psychology, 25(2-3), Lundahl, B., Risser, H. J., & Lovejoy, M. C. (2006). A meta-analysis of parent training: moderators and follow-up effects. Clinical Psychology, 26(1), Newton, R. R., Litrownik, a J., & Landsverk, J. a. (2000). Children and youth in foster care: distangling the relationship between problem behaviors and number of placements. Child Abuse & Neglect, 24(10), Retrieved from Rappaport, N., & Thomas, C. (2004). Recent research findings on aggressive and violent behavior in youth: implications for clinical assessment and intervention. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine, 35(4), Rhoades, K. a, Chamberlain, P., Roberts, R., & Leve, L. D. (2013). MTFC for High Risk Adolescent Girls: A Comparison of Outcomes in England and the United States. Journal of Child & Adolescent Substance Abuse, 22(5), Sargent, K., & O Brien, K. (2004). The Emotional and Behavioural Difficulties of Looked after Children: Foster Carers Perspectives and an Indirect Model of Placement Support. Adoption & Fostering, 28(2), Sheldon, S. B. (2007). Improving Student Attendance With School, Family, and Community Partnerships. The Journal of Educational Research, 100(5), Smith, D. K., Chamberlain, P., & Eddy, J. M. (2010). Preliminary Support for Multidimensional Treatment Foster Care in Reducing Substance Use in Delinquent Boys. Journal of Child & Adolescent Substance Abuse, 19(4), Sugai, G., Horner, R. H., Dunlap, G., Hieneman, M., Lewis, T. J., Nelson, C. M., Ruef, M. (2000). Applying Positive Behavior Support and Functional Behavioral Assessment in Schools. Journal of Positive Behavior Interventions, 2(3), Van Ryzin, M. J., & Leve, L. D. (2012). Affiliation with delinquent peers as a mediator of the effects of multidimensional treatment foster care for delinquent girls. Journal of Consulting and Clinical Psychology, 80(4), Westermark, P. K., Hansson, K., & Olsson, M. (2011). Multidimensional treatment foster care (MTFC): results from an independent replication. Journal of Family Therapy, 33(1),

21 Westermark, Hansson, & Olsson. (2011) Appendices Appendix.A. Summary of Studies Study Participant Sample Intervention Design Measures Outcomes 35 young people Multidimensional Randomised Childhood aged between 9 and Treatment Foster Controlled Behaviour 18 who met the Care Trial Checklist clinical diagnosis of (CBCL) conduct disorder (according to DSM- IV-TR) and were at risk of losing permanent placement. home Youth Self Report (YSR) MTFC : CBCL mean total score (pre) 60.2 CBCL mean total score (post) 30.7 YSR mean total score (pre) 74.7 YSR mean total score (post) 38.6 TAU: CBCL mean total score (pre) 74.3 CBCL mean total score (post) 55.1 Intervention group (N=20) Control (TAU) group (N= 15) YSR mean total score (pre) 62.6 YSR mean total score (post) 46.3 Hansson & Olsson. (2012) 46 young people aged between 12 and 17 who met the clinical diagnosis of conduct disorder (according to DSM- IV-TR) and were at risk of losing permanent home placement. Multidimensional Treatment Foster Care Randomised Controlled Trial Childhood Behaviour Checklist (CBCL) Youth Self Report (YSR) MTFC : CBCL mean total score (pre) 62.6 CBCL mean total score (post) 39.6 YSR mean total score (pre) 56.6 YSR mean total score (post) 40.4 TAU: CBCL mean total score (pre) 65.2 CBCL mean total score (post) 46.6 Intervention group (N=19) Control (TAU) group (N= 27) YSR mean total score (pre) 52.9 YSR mean total score (post) 43.9 Green et al. (2013) 33 young people aged between 10 and 17 who were displaying severe challenging behaviour and were at risk of losing permanent home placement. Intervention group (N=20) Control (TAU) group (N= 13) Multidimensional Treatment Foster Care Randomised Controlled Trial Childhood Behaviour Checklist (CBCL) Youth Self Report (YSR) This information was integrated, transcribed, and then converted into a CGAS score. MTFC : CGAS mean total score (pre) 47.7 CGAS mean total score (post) 56.0 TAU: CGAS mean total score (pre) 48.3 CGAS mean total score (post)

22 Chamberlain et al. (2008) 700 young people aged between 5 and 12 who were displaying severe challenging behaviour resulting in current placement not being sustainable under current conditions. Multidimensional Treatment Foster Care Randomised Controlled Trial Parent Daily Report Checklist (PDR) MTFC : PDR mean total score (pre) 47.7 PDR mean total score (post) 56.0 TAU: PDR mean total score (pre) 48.3 PDR mean total score (post) 55.3 Intervention group (N=359) Control (TAU) group (N= 341) Leve, Chamberlain & Reid. (2005) 81 females aged between 13 and 17 who were displaying severe challenging behaviour resulting in current placement not being sustainable under current conditions. Multidimensional Treatment Foster Care Randomised Controlled Trial Childhood Behaviour Checklist (CBCL) MTFC : CBCL mean total score (pre) 79.7 CBCL mean total score (post) 64.8 TAU: CBCL mean total score (pre) 78.7 CBCL mean total score (post) 70.0 Intervention group (N=37) Control (TAU) group (N=44) 22

23 Appendix. B: Excluded Studies Reference Source: Rationale for exclusion Excluded following: Harold, Kerr, Van, DeGarmo, Rhoades & Leve (2013). Depressive symptom trajectories among girls in the juvenile justice system: 24-month outcomes of an RCT of multidimensional treatment foster care. Prevention Science. 14, PubMed Measures were not of participant externalising behaviour Jonkman, Bolle, Lindeboom, Schuengel, Oosterman, Mirjam; Boer & Lindauer (2012). Multidimensional treatment foster care for preschoolers: Early findings of an implementation in the Netherlands. Child and Adolescent Psychiatry and Mental Health, 6,38 - PubMed participants described to be attending preschool/nursery settings Title review Chamberlain, Roberts, Jones, Sosna & Price. (2012). Three collaborative models for scaling up evidence-based practices. Administration and Policy in Mental Health, 39, PubMed Does not contain primary empirical data Leve, Fisher & Chamberlain. (2009). Multidimensional Treatment Foster Care as a preventative intervention to promote resiliency among youth in the child welfare system. Journal of Personality, 77, PubMed Does not contain primary empirical data Feil, Edward G; Sprengelmeyer, Peter G; Davis, Betsy; Chamberlain, Patricia. (2012). Development and testing of a multimedia Internet-based system for fidelity and monitoring of multidimensional treatment foster care. Journal of Medical Internet Research. 14, PubMed Measures were not of participant externalising behaviour Saldana & Chamberlain. (2012). Supporting Implementation: the role of community development teams to build infrastructure. American Journal of Community Psychology, 50, PubMed Measures were not of participant externalising behaviour Graham, Yockelson, Kim, Bruce, Pears & Fisher, (2012). Effects of maltreatment and early intervention on diurnal cortisol slope across the start of school: A pilot study. Child Abuse & Neglect Measures were not of participant externalising behaviour Title review Holmes, Ward & McDermid. (2012). Calculating and comparing the costs of multidimensional treatment foster care in English local authorities. Children and Youth Services Science Direct Measures were not of participant externalising behaviour Chamberlain, Saldana, Brown, Hendricks & Leve. (2011). Implementation of multidimensional treatment foster care in California: A randomized control trial of an evidencebased practice. In Roberts-DeGennaro & Fogel (Eds.), Using evidence to inform practice for community and organizational change. (pp ). Chicago: Lyceum Books Not published in a peer-reviewed journal Title review 23

24 Van Ryzin, & Leslie. (2012). Affiliation with delinquent peers as a mediator of the effects of multidimensional treatment foster care for delinquent girls. Journal of Consulting and Clinical Psychology. 80, PubMed ERIC Measures limited to behaviours of an illegal nature only Farmer, Burns, Wagner, Murray & Southerland, (2010). Enhancing "usual practice" treatment foster care: Findings from a randomized trial on improving youths' outcomes. Psychiatric Services PubMed Alternative Intervention Heywood, (2010). Predictors of favourable outcomes among children in foster care: An analysis of early childhood variables and their relationship to the development of assets. Dissertation s International: Section B: The Sciences and Engineering. Vol.70, Not published in a peer-reviewed journal Tininenko. (2009). Actigraphic evaluation of sleep disturbance in young children. Dissertation s International: Section B: The Sciences and Engineering Not published in a peer-reviewed journal Buchanan. (2009). An investigation of predictors of educational engagement for severely antisocial girls. Dissertation s International Section A: Humanities and Social Sciences Not published in a peer-reviewed journal Kerr, Leve, Chamberlain, (20099). Pregnancy rates among juvenile justice girls in two randomized controlled trials of multidimensional treatment foster care. Journal of Consulting and Clinical Psychology PubMed ERIC Measures were not of participant externalising behaviour Bruce, McDermott, Fisher & Fox (2009). Using behavioral and electrophysiological measures to assess the effects of a preventive intervention: A preliminary study with preschoolaged foster children. Prevention Science PubMed participants described to be attending preschool/nursery settings Price, Chamberlain, Landsverk & Reid, (2009). KEEP fosterparent training intervention: Model description and effectiveness. Child & Family Social Work. 14, Does not contain primary empirical data Miller, Keith Andrew. (2008). Exploring placement instability among young children in the multidimensional treatment foster care preschool study. Dissertation s International: Section B: The Sciences and Engineering participants described to be attending preschool/nursery settings Fisher, Philip A; Kim, Hyoun K (2009). Intervention effects on foster preschoolers attachment-related behaviors from a randomized trial. Prevention Science. 8, PubMed participants described to be attending preschool/nursery settings 24

25 Kazdin, Alan E. (2007). Psychosocial treatments for conduct disorder in children and adolescents. In Nathan, & Gorman, (eds.) A guide to treatments that work pp New York: Oxford University Press Not published in a peer-reviewed journal Powell, & Lochman, (2004). Multidimensional Treatment Foster Care: A Conceptually Based, Empirically Validated Approach to Treating Antisocial Behavior in Youth.. PsycCRITIQUES. Vol.49 Does not contain primary empirical data Smith, Dana K. (2004). Risk, Reinforcement, Retention in Treatment, and Reoffending for Boys and Girls in Multidimensional Treatment Foster Care. Journal of Emotional and Behavioral Disorders. 12, ERIC Measures limited to behaviours of an illegal nature only Chamberlain, Patricia. (2003). The Oregon Multidimensional Treatment Foster Care model: Features, outcomes, and progress in dissemination. Cognitive and Behavioral Practice Science Direct Does not contain primary empirical data Chamberlain, Patricia. (2003). Treating chronic juvenile offenders: Advances made through the Oregon multidimensional treatment foster care model. In Antisocial behaviour and delinquency in girls. Pp Washington DC: American Psychological Association; 2003 Science Direct Not published in a peer-reviewed journal Smith, Dana K. (2003) Gender differences in behaviour change during treatment with chronically delinquent youths. Dissertation s International: Section B: The Sciences and Engineering.63, Not published in a peer-reviewed journal Chamberlain, Patricia; Fisher, Philip A; Moore, Kevin. (2002) Multidimensional treatment foster care: Applications of the OSLC intervention model to high-risk youth and their families. In Reid, Patterson, & Snyder (Eds.) (2002). Antisocial behaviour in children and adolescents: A developmental analysis and model for intervention. Pp Washington, DC: American Psychological Association Not published in a peer-reviewed journal Moore, Sprengelmeyer, & Chamberlain, (2001). Communitybased treatment for adjudicated delinquents: The Oregon Social Learning Center s Monitor Multidimensional Treatment Foster Care program. Residential Treatment for Children & Youth. 18, Does not contain primary empirical data Fisher, Philip A; Chamberlain, Patricia. (2001). Multidimensional treatment foster care: A program for intensive parenting, family support, and skill building. In Walker & Epstein, (Eds). (2001). Making schools safer and violence free: Critical issues, solutions, and recommended practices. Pp Austin: PRO-ED ERIC Not published in a peer-reviewed journal Eddy, & Chamberlain, (2000). Family management and deviant peer association as mediators of the impact of treatment condition on youth antisocial behavior. Journal of Consulting and Clinical Psychology.68, PubMed Measures limited to behaviours of an illegal nature only 25

26 Chamberlain & Reid (1998). Comparison of two community alternatives to incarceration for chronic juvenile offenders. Journal of Consulting and Clinical Psychology, 66, PubMed Measures limited to behaviours of an illegal nature only Fisher & Chamberlain, (2000) Multidimensional treatment foster care: A program for intensive parenting, family support, and skill building. Journal of Emotional and Behavioral Disorders.8, ERIC Does not contain primary empirical data Taylor, Eddy & Biglan (1999). Interpersonal skills training to reduce aggressive and delinquent behavior: Limited evidence and the need for an evidence-based system of care. Clinical Child and Family Psychology PubMed Does not contain primary empirical data Smith, Chamberlain & Eddy (2010). Preliminary Support for Multidimensional Treatment Foster Care in Reducing Substance Use in Delinquent Boys. Journal of Child & Adolescent Substance Abuse ERIC Measures limited to behaviours of an illegal nature only Eddy, Bridges Whaley & Chamberlain. (2004). The prevention of Violent Behavior by Chronic and Serious Male Juvenile Offenders. A 2-Year Follow-up of a Randomized Clinical Trial. Journal of Emotional and Behavioral Disorders Chamberlain, Leve,& DeGarmo. (2007). Multidimensional Treatment Foster Care for Girls in the Juvenile Justice System: 2-Year Follow-Up of a Randomized Clinical Trial. Journal of Consulting and Clinical Psychology ERIC ERIC Does not contain primary empirical data Does not contain primary empirical data Antoine & Fisher. (2006). Preparing Foster Children for School. Education Digest: Essential Readings Condensed for Quick ERIC Does not contain primary empirical data Lee, Bright, Svoboda, Fakunmoju, & Barth. (2011) Outcomes of Group Care for Youth: A of Comparative Studies. Research on Social Work Practice ERIC Does not contain primary empirical data Leve & Chamberlain. (2005) Association with Delinquent Peers: Intervention Effects for Youth in the Juvenile Justice System. Journal of Abnormal Child Psychology Pubmed ERIC Measures were not of participant externalising behaviour Vargas & Koss-Chioino. (1992) Working with Culture: Psychotherapeutic Interventions with Ethnic Minority Children and Adolescents. Austin: PRO-ED ERIC Not published in a peer-reviewed journal Henggeler & Sheidow (2012) Empirically Supported Family- Based Treatments for Conduct Disorder and Delinquency in Adolescents. Journal of Marital and Family Therapy PubMed Eric Does not contain primary empirical data 26

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