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著的，而且往往未满足的心理健康需求（Leslie, Hurlburt, Landsverk, & Barth, 2004）。对于学龄青少年，最常见的问题是破坏性行为障碍和创伤暴露的后遗症（例如，创伤后应激障碍[PTSD]，抑郁症）（Landsverk, Burns, & Stambaugh, in press）。这些心理健康问题反过来又与一系列负面结果（例如，功能、安置稳定性/永久性）有关（James, Landsverk, & Slymen, 2004; Landsverk, Davis, Granger, Newton, & Johnson, 1996）。在这一领域，人们对增加针对寄养青年的特定心理健康问题和需求的循证治疗的使用有着极大的兴趣。以创伤为中心的认知行为疗法（TF-CBT）可能是一个很好的选择。随机试验的证据支持TF-CBT治疗创伤后应激障碍、行为问题和其他创伤后遗症的有效性（Cohen, Deblinger, Mannarino, & Steer, 2004）。虽然TF-CBT对寄养家庭的青少年很有帮助，但将其提供给这样的青少年可能很复杂。拆解研究的结果表明，照顾者参与对TF-CBT的治疗效果最大化至关重要（Deblinger, Lippman, & Steer, 1996）。然而，现有的证据和我们的临床经验表明，养父母很少主动和持续地参与他们的寄养儿童的心理健康治疗。因此，拟议R34的主要目的是对寄养儿童和青少年进行TF-CBT的试点研究，并有针对性地关注养父母参与治疗。拟议的项目将两种互补的干预措施结合在一起——基于证据的参与策略（McKay, Stoewe, McCadam, & Gonzales, 1998）和TF-CBT （Cohen, Deblinger & Mannarino, 2006; Deblinger & Heflin, 1996）——试图改善寄养青少年的治疗和结果。该项目包括两个阶段：第一阶段：(a)基于证据的参与策略和TF-CBT的初步可行性研究（N = 10）；(b)改进和发展基于寄养父母和其他关键信息提供者反馈的人工参与干预。第2阶段：试点研究（N=80），将精细化参与策略和TF-CBT （ECBT）与“常规”TF-CBT（即无专门参与）进行比较，以评估联合干预的实施情况，并提供关键结果（如PTS症状、行为问题、安置稳定性）的初步数据。研究结果将用于一项大规模随机试验（即R- 01），研究ECBT对改善寄养家庭中有心理健康问题的青少年的结果的有效性。被寄养的青少年有很高的心理健康问题（Leslie, Hurlburt, Landsverk, & Barth, 2004）。这些包括外化（例如，品行障碍，多动症，对立违抗性障碍）和内化（例如，焦虑，抑郁，创伤后应激障碍）问题。最近对流行病学和治疗的研究表明，这种症状的组合通常与寄养家庭的青少年有广泛的创伤暴露史有关（Simms, Dubowitz, & Szilagyi, 2000）。因此，有效治疗症状需要明确的循证治疗，既要解决创伤的潜在后遗症，又要解决直接的行为表现。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，对这一高危青年群体进行了特定的修改，似乎很有希望（Deblinger, Lippman, & Steer, 1996）。拟议的研究建立并结合了现有的基于证据的策略（Cohen, Deblinger, Mannarino, & Steer, 2004; McKay, Stoewe, McDadam, & Gonzales, 1998），以更有效地治疗美国一些最危险和最脆弱的青少年。这项研究的结果将用于发展和推广寄养系统中有精神健康问题的青少年更有效的治疗方法。这些发现应有助于改善为有精神健康问题的青少年服务的整个护理系统内的治疗、服务和结果（例如，专业精神卫生提供者、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).