Category: Emotional Wellbeing

Article Title: Maintaining a Social-Emotional Intervention and Its Benefits for Institutionalized Children

Authors: Robert B. McCall, Christina J. Groark, Larry Fish, Rifkat J. Muhamedrahimov, Oleg I. Palmov and Natalia V. Nikiforova

Abstract: This article reports the maintenance of one of the largest interventions conducted in St. Petersburg (Russian Federation) orphanages for children birth to 4 years using regular caregiving staff. One orphanage received training plus structural changes, another training only, and a third business as usual. The intervention produced substantial differences between these institutions on the Home Observation for Measurement of the Environment (HOME) Inventory and on the Battelle Developmental Inventory scores for children. These institutional differences in HOME scores (= 298) and Battelle scores for children (= 357) departing the institutions for families in St. Petersburg and the United States were maintained for at least 6 years after the intervention project. This result may be associated with certain features of the intervention and activities conducted during the follow-up interval.

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Study Title: Placement in foster care enhances quality of attachment among young institutionalized children

Authors: Smyke, A.T., Zeanah, C.H., Fox, N.A., Nelson, C.A., & Guthrie, D.

Abstract: This study examined classifications of attachment in 42-month-old Romanian children (N = 169). Institutionalized since birth, children were assessed comprehensively, randomly assigned to care as usual (CAU) or to foster care, and compared to family-reared children. Attachment classifications for children in foster care were markedly different from those in the CAU. Importantly, children placed in foster care before 24 months were more likely to have secure attachments and if placed earlier were less likely to have disorganized or insecure-other attachments. Cognitive status predicted greater likelihood of organized attachment in the CAU and greater likelihood of secure attachment in the foster care and never-institutionalized groups. Foster care is an important intervention to reduce the adverse effects following early deprivation.

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Study Title: Attachment in institutionalized and community children in Romania

Authors: Zeanah, C.H., Smyke, A.T., Koga, S.F.M., Carlson, E., & the BEIP Core Group

Abstract: This study examined attachment in institutionalized and community children 12–31 months of age in Bucharest, Romania. Attachment was assessed using ratings of attachment behaviors and ratings of caregiver descriptions in a structured interview. As predicted, children raised in institutions exhibited serious disturbances of attachment as assessed by all methods. Observed quality of caregiving was related to formation and organization of attachment in children living in institutions. These results held even when other variables, such as cognitive level, perceived competence, and quantitative interaction ratings, were controlled for. Ratings of attachment behavior in the Strange Situation and caregiver reports of signs of Reactive Attachment Disorder converged moderately. The implications of these findings for different perspectives on attachment are discussed.

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Study Title: Beyond the livelihood framework: aspirations and well-being in encounters with AIDS orphans in Mozambique

Author: Müller, T.R

Abstract: This chapter uses the resource profile approach as a framework to explore well-being and future aspirations among orphans and vulnerable children in Central Mozambique who took part in an AIDS mitigation project aimed at shoring up rural livelihoods. It is shown that participation in the project has altered the resource profile of participants, not least in terms of bolstering cultural resources and enhancing the capacity to aspire. This has wider implications for individuals’ resource profile dynamics more generally and strengthens the case for interventions into HIV/AIDS based on a holistic understanding of people’s well-being. It also shows that capital-asset-based livelihood approaches fall short in term of providing a useful framework to understand people’s lived realities.

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Authors: Caroline Kuo, Don Operario & Lucie Cluver

Abstract: South Africa faces the challenge of supporting the well-being of adults caring for growing numbers of AIDS-orphaned children. These adults play a critical role in responses to the epidemic, but little information exists in regard to their mental health needs. This paper reports on findings from n=1599 adults, recruited through representative household sampling, who serve as primary carers for children in Umlazi Township, an HIV-endemic community. Overall, 22% of participants were carers of AIDS-orphaned children, 11% were carers of other-orphaned children and 67% were carers of non-orphaned children. Prevalence of depression was 30.3%. Orphan carers, regardless of whether they cared for AIDS-orphaned or other-orphaned children, were significantly more likely than carers of non-orphaned children to meet the clinical threshold for depression (35.2% vs. 27.9%, p < 0.01). In multivariate logistic regressions, food insecurity and being a female carer were identified as additional risk factors for greater depression. In contrast, households with access to running water and households dependent on salaries as the main source of income were identified as protective factors for disparities in depression. Mental health interventions are urgently needed to address an increased risk for depression among all orphan carers, not just those caring for AIDS-orphaned children.

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Authors: Monica H. Swahn, Jane B. Palmier, Rogers Kasirye, & Huang Yao 

Abstract: While suicidal behavior is recognized as a growing public health problem world-wide, little is known about the prevalence and risk factors for suicidal behaviors among street and slum youth in Africa, and in Uganda, specifically. The number of youth who live on the streets and in the slums of Kampala appears to be growing rapidly, but their mental health needs have not been documented, which has hampered resource allocation and service implementation. This study of youth, ages 14-24, was conducted in May and June of 2011, to assess the prevalence and correlates of suicidal behavior. Participants (N = 457) were recruited for a 30-minute interviewer-administered survey through eight drop-in centers operated by the Uganda Youth Development Link for youth in need of services. Bivariate and multivariate logistic regression analyses were computed to determine associations between psychosocial correlates and suicide ideation and suicide attempt. Reporting both parents deceased Adj.OR = 2.36; 95% CI: 1.23-4.52), parental neglect due to alcohol use (Adj.OR = 2.09; 95% CI: 1.16-3.77), trading sex for food, shelter or money (Adj.OR = 1.95; 95% CI: 1.09-3.51), sadnesss (Adj.OR = 2.42; 95% CI: 1.20-4.89), loneliness (Adj.OR = 2.67; 95% CI: 1.12-6.40) and expectations of dying prior to age 30 (Adj.OR = 2.54; 95% CI: 1.53-4.23) were significantly associated with suicide ideation in multivariate analyses. Parental neglect due to alcohol use (Adj.OR = 2.04; 95% CI: 1.11-3.76), sadness (Adj.OR = 2.42; 95% CI: 1.30-7.87), and expectations of dying prior to age 30 (Adj.OR = 2.18; 95% CI: 1.25-3.79) were significantly associated with suicide attempt in multivariate analyses. Given the dire circumstances of this vulnerable population, increased services and primary prevention efforts to address the risk factors for suicidal behavior are urgently needed.

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Authors: Monica H Swahn, Lindsay Gressard, Jane B Palmier, Rogers Kasirye, Catherine Lynch, & Huang Yao.

Introduction: Violence among youth is a major public health issue globally. Despite these concerns, youth violence surveillance and prevention research are either scarce or non-existent, particularly in developing regions, such as sub-Saharan Africa. The purpose of this study is to quantitatively determine the prevalence of violence involving weapons in a convenience sample of service-seeking youth in Kampala. Moreover, the study will seek to determine the overlap between violence victimization and perpetration among these youth and the potentially shared risk factors for these experiences.

Methods: We conducted this study of youth in May and June of 2011 to quantify and describe high-risk behaviors and exposures in a convenience sample (N=457) of urban youth, 14-24 years of age, living on the streets or in the slums and who were participating in a Uganda Youth Development Link drop-in center for disadvantaged street youth. We computed bivariate and multivariate logistic regression analyses to determine associations between psychosocial factors and violence victimization and perpetration.

Results: The overall prevalence of reporting violence victimization involving a weapon was 36%, and violence perpetration with a weapon was 19%. In terms of the overlap between victimization and perpetration, 16.6% of youth (11.6% of boys and 24.1% of girls) reported both. In multivariate analyses, parental neglect due to alcohol use (Adj.OR=2.28;95%CI: 1.12-4.62) and sadness (Adj.OR=4.36 ;95%CI: 1.81-10.53) were the statistically significant correlates of victimization only. Reporting hunger (Adj.OR=2.87 ;95%CI:1.30-6.33), any drunkenness (Adj.OR=2.35 ;95%CI:1.12-4.92) and any drug use (Adj.OR=3.02 ;95%CI:1.16-7.82) were significantly associated with both perpetration and victimization.

Conclusion: The findings underscore the differential experiences associated with victimization and perpetration of violence involving weapons among these vulnerable youth. In particular, reporting hunger, drunkenness and drug use were specifically associated with victimization and perpetration. These are all modifiable risk factors that can be prevented. It is clear that these vulnerable youth are in need of additional services and guidance to ameliorate their adverse childhood experiences, current health risk behaviors and disadvantaged living context.

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Study Title: Improving Outcomes for Youth in Foster Care: Trauma-Focused CBT

Context: Children and adolescents in foster care have significant, and often unmet, mental health needs (Leslie, Hurlburt, Landsverk, & Barth, 2004). For school-aged youth, the most common problems are disruptive behavior disorders and sequelae of trauma exposure (e.g., Posttraumatic Stress Disorder [PTSD], Depression) (Landsverk, Burns, & Stambaugh, in press). Such mental health problems, in turn, are linked to a range of negative outcomes (e.g., functioning, placement stability/permanency) (James, Landsverk, & Slymen, 2004; Landsverk, Davis, Granger, Newton, & Johnson, 1996). There is tremendous interest in the field to increase use of evidence-based treatments that target specific mental health problems and needs of youth in foster care. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) potentially provides an excellent fit. Evidence from randomized trials supports the efficacy of TF-CBT in treating PTSD, behavior problems, and other trauma sequelae (Cohen, Deblinger, Mannarino, & Steer, 2004). Although TF-CBT holds promise for youth in foster care, there are likely complexities in providing it to such youth. Findings from dismantling research indicate that caregiver involvement is crucial for maximizing treatment effects of TF-CBT (Deblinger, Lippman, & Steer, 1996). However, available evidence and our clinical experience suggest that foster parents are infrequently engaged in a proactive and ongoing manner in their foster children’s mental health treatment.

Study Aims: Therefore the primary aim of the proposed R34 is to conduct a pilot study of TF-CBT with children and adolescents in foster care, with a targeted focus on engaging foster parents in treatment. The proposed project brings together two complementary interventions-evidence-based engagement strategies (McKay, Stoewe, McCadam, & Gonzales, 1998) and TF-CBT (Cohen, Deblinger & Mannarino, 2006; Deblinger & Heflin, 1996)-in an attempt to improve treatment and outcomes for youth in foster care.

Methods: The project includes two phases: Phase 1: (a) preliminary feasibility study (N = 10) of the evidence-based engagement strategies and TF-CBT; and (b) refinement and development of a manualized engagement intervention based on feedback from foster parents and other key informants. Phase 2: pilot study (N=80) of the refined engagement strategies and TF-CBT (ECBT) compared to ‘usual practice’ TF-CBT (i.e., no specialized engagement) to assess implementation of the combined intervention and provide preliminary data on critical outcomes (e.g., PTS symptoms, behavioral problems, placement stability). Findings will be used to inform a large-scale randomized trial (i.e., R- 01) on effectiveness of ECBT to improve outcomes for youth in foster care with mental health problems. Youth in foster care have very high rates of mental health problems (Leslie, Hurlburt, Landsverk, & Barth, 2004). These include externalizing (e.g., conduct disorder, ADHD, oppositional defiant disorder) as well as internalizing (e.g., anxiety, depression, PTSD) problems. Recent research on epidemiology and treatment has suggested that this combination of symptoms is often related to youth in foster care’s extensive histories of exposure to trauma (Simms, Dubowitz, & Szilagyi, 2000) Therefore, effective treatment of the symptoms requires explicit evidence-based treatment that addresses both the underlying sequelae of trauma and the immediate behavioral manifestations. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) is an evidence- based treatment that appears promising, with specific modifications, for this group of high-risk youth (Deblinger, Lippman, & Steer, 1996).

Implications: The proposed research builds from and combines existing evidence- based strategies (Cohen, Deblinger, Mannarino, & Steer, 2004; McKay, Stoewe, McDadam, & Gonzales, 1998) to more effectively treat some of the nation’s most at-risk and vulnerable youth. Findings from this research will be used to develop and disseminate more effective treatments for youth with mental health problems in the foster care system. Such findings should help improve treatment, services, and outcomes within the entire system of care that serves youth with mental health problems (e.g., specialty mental health providers, child welfare and child protective services, juvenile justice).

Principal Investigator: Shannon Dorsey (University of Washington)

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Study Title: Trauma-Focused CBT: Potential Mechanisms that inhibit and facilitate change

Context: Child maltreatment and interpersonal adversity put children at increased risk for posttraumatic stress disorder (PTSD), depression and suicide, substance abuse, and a host of negative mental health outcomes. Recent evidence documents that childhood adversity can have pernicious neurobiological and psychosocial effects that extend risk into adulthood. Trauma- Focused Cognitive-Behavioral Therapy (TF-CBT) has been demonstrated in numerous randomized clinical trials to be an efficacious treatment for maltreated and traumatized children. Early intervention with TF-CBT has the potential to alter the trajectory of risk associated with childhood adversity.

Study Aims: The overall goals of the proposed research are to identify potential mechanisms of change, inhibitors of change, and predictors of early dropout in this treatment. The proposed research integrates a sophisticated analysis of the process of change into an ongoing effectiveness trial of TF-CBT that has been transported to community mental health facilities throughout the state of Delaware.

Methods: Sessions from 75 children who received TF- CBT will be coded with an observational coding system designed to capture theoretically important therapeutic processes. TF-CBT is hypothesized to be associated with a curvilinear pattern of in-session affective arousal and cognitive/emotional processing of the trauma, with peak levels occurring when the child develops a trauma narrative in the exposure phase of therapy. A transient increase in affective arousal is thought to reflect activation of the trauma memories and to facilitate processing. More processing during this narrative phase is hypothesized to be the primary predictor of improvement in PTSD symptoms and problematic child behaviors. Therapist support and caregiver involvement in treatment are expected to help prepare the child for change by decreasing avoidance, a primary inhibitor of later arousal and processing. Caregiver avoidance and processing when exposed to the child’s narrative are also expected to predict child outcomes.

Implications: The proposed research has the potential to reveal key processes that can be mobilized to increase the potency of TF-CBT, reduce rates of dropout, and enhance therapist training as dissemination efforts are undertaken.

Principal Investigator: Adele Hayes (University of Delaware)

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Study Title: Enhancing Ugandan HIV-Affected child development with caregiver training

Context: Children up to the age of 5 years affected by HIV are the most vulnerable subgroup of HIV populations globally, especially in low-resource areas. This is because of the strategic, volatile, and vulnerable nature of this highly sensitive period of child development. Mediational intervention for sensitizing caregivers (MISC) has a structured training program to enable caregivers to improve their children’s cognitive and social development during everyday casual interactions in the home.In our preliminary NIMH R34 findings, Ugandan HIV children of caregivers receiving MISC training biweekly for a year showed significantly greater gains on the Mullen Early Learning Scales Composite of g fluid intelligence, when compared to children whose caregivers received a standard health/nutrition education intervention (treatment as usual or TAU). The MISC caregivers were also significantly less depressed, and their child mortality that year was significantly lower.

Study Aims:  Study Aim 1 will evaluate if MISC significantly enhances child outcomes when compared to controls for both HIV-positive and orphan children when assessed from baseline to 6, 12, and 18 months. Study Aim 2 will evaluate if MISC significantly enhances caregiver EWB and daily functioning outcomes. To better understand the mechanisms of MISC-enhanced child development, a Secondary Aim is to evaluate the mediating effect of improved caregiver EWB outcomes on corresponding child development gains, and the modifying effects of caregiver HIV illness and functioning on child outcomes.

Methods: One hundred Ugandan HIV-positive preschool and 200 HIV orphan caregiver/child dyads will be enlisted from Kayunga and Pallisa Districts. These dyads will be randomly assigned by village clusters to either biweekly MISC or health/nutrition education TAU intervention for one year. Child Outcomes are the child development gains on the Mullen, the Early Childhood Vigilance Test (ECVT) of attention, and the Color- Object Association Test (COAT) of memory, the Behavior Rating Inventory of Executive Functioning – Preschool (BRIEF-P), and the caregiver administered version of the Achenbach CBCL. Caregiver Outcomes include an array of emotional wellbeing (EWB) and daily functioning measures validated during the initial qualitative study phase.

Implications: The Overall Impact comes from establishing the feasibility, acceptability, and effectiveness of MISC for HIV orphans and vulnerable children (OVC) and their caregivers in low resource settings; the sustainability of MISC in low resource settings since it is not dependent on published materials or outside resources; the complementary dual impact of significant psychotherapeutic benefit for the caregiver, especially mothers struggling with HIV disease. MISC will also reduce HIV child mortality because in our initial R34 findings, MISC heightened maternal bonding, sensitivity to serious illness, and the prompter seeking of medical care. It also can improve treatment adherence. Finally, our evidence-based MISC caregiver training interventions can be readily implemented globally as a sustainable way to augment OVC cognitive, psychosocial, and medical wellbeing.

Public Health Relevance: Early childhood (up to age 5 yrs) is a period of dramatic change in the cognitive, emotional, social, and behavioral domains; children continuously progress by observing and interacting with the world around them. In the face of economic instability and nutritional, medical and educational deprivation, HIV-affected very young children are the most vulnerable HIV subgroup globally because their families are often the most vulnerable, with little margin for sustaining a favorable developmental milieu for the child. Through strategic caregiver interventions during this sensitive period of child neurodevelopment, our study findings have the potential for positively re-directing the developmental trajectories of tens of millions of HIV-affected children globally.

Principal Investigator: Michael J. Boivin (Michigan State University)

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