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

描述（由申请人提供）：寄养儿童和青少年有显着的，往往未得到满足，心理健康需求（莱斯利，赫尔伯特，Landsverk，& Barth，2004）。对于学龄青少年来说，最常见的问题是破坏性行为障碍和创伤后遗症（例如，创伤后应激障碍[PTSD]，抑郁症）（Landsverk，Burns，& Stambaugh，出版中）。这些心理健康问题反过来又与一系列负面结果有关（例如，功能、放置稳定性/持久性）（James，Landsverk，& Slymen，2004; Landsverk，Davis，格兰杰，牛顿，&约翰逊，1996）。在该领域有极大的兴趣，以增加使用循证治疗，针对特定的心理健康问题和需要的青年寄养。以创伤为中心的认知行为疗法（TF-CBT）可能提供了一个很好的适合。来自随机试验的证据支持TF-CBT在治疗PTSD，行为问题和其他创伤后遗症方面的疗效（Cohen，Deblinger，Mannarino和Steer，2004）。虽然TF-CBT为寄养青年带来了希望，但向这些青年提供这种服务可能存在复杂性。拆解研究的结果表明，照顾者的参与对于TF-CBT的治疗效果最大化至关重要（Deblinger，Lippman和Steer，1996）。然而，现有的证据和我们的临床经验表明，养父母很少参与积极主动和持续的方式在他们的寄养儿童的心理健康治疗。因此，拟议的R34的主要目的是对寄养儿童和青少年进行TF-CBT试点研究，重点是让寄养父母参与治疗。拟议的项目汇集了两个互补的干预措施-基于证据的参与战略（McKay、Stoewe、McCadam和冈萨雷斯，1998年）和TF-CBT（Cohen、Deblinger和Mannarino，2006年; Deblinger和海夫林，1996年）-试图改善寄养青年的治疗和结果。该项目包括两个阶段：第一阶段：（a）对循证参与战略和TF-CBT进行初步可行性研究（N = 10）;（B）根据养父母和其他关键信息提供者的反馈，完善和开发手动参与干预措施。第2阶段：与“常规做法”TF-CBT（即，没有专门的参与），以评估综合干预措施的实施情况，并提供关键结果的初步数据（例如，PTS症状、行为问题、放置稳定性）。研究结果将用于为大规模随机试验提供信息（即，R- 01）关于ECBT在改善有精神健康问题的寄养青年的结果方面的有效性。寄养的青少年有很高的心理健康问题率（莱斯利，Hurlburt，Landsverk，& Barth，2004）。这些包括外部化（例如，行为障碍、多动症、对立违抗性障碍）以及内化（例如，焦虑、抑郁、创伤后应激障碍）问题。流行病学和治疗的最新研究表明，这种症状的组合往往与寄养家庭中的青少年广泛的创伤暴露史有关（Simms，Dubowitz，& Szilagyi，2000）因此，症状的有效治疗需要明确的循证治疗，解决创伤的潜在后遗症和直接的行为表现。以创伤为中心的认知行为疗法（TF-CBT）是一种基于证据的治疗方法，经过特定的修改后，对这组高危青少年似乎很有希望（Deblinger，Lippman和Steer，1996）。拟议的研究建立在现有的证据为基础的战略（科恩，Deblinger，Mannarino，和Steer，2004年;麦凯，Stoewe，McDadam，和冈萨雷斯，1998年），以更有效地治疗一些国家的最危险和脆弱的青年。这项研究的结果将用于为寄养系统中有心理健康问题的青少年开发和传播更有效的治疗方法。这些发现应该有助于改善整个护理系统中的治疗、服务和结果，为有心理健康问题的青少年提供服务（例如，专业精神健康提供者、儿童福利和儿童保护服务、少年司法）。

DESCRIPTION (provided by applicant): 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. 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. 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). 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).