Estimating the Impact of Out-of-Home Placement on Health Risk Behavior in Adolescents Exposed to Maltreatment: An Advanced Causal Inference Approach

摘要 虐待儿童与危害健康的行为有关，这些行为带来了高昂的个人和社会成本， 例如药物使用和性危险行为。1-4将儿童安置到家庭外照料旨在 缓解这些负面影响。5关于在家照看的青少年的健康危险行为比率的调查结果 混合，6-16岁，尽管研究表明，以前在护理中的年轻人健康风险水平更高 17-20这些喜忧参半的发现可能是因为大多数研究都测试了放置方式的影响 儿童期对后来的健康危险行为的影响。然而，青春期的安置可能是一个转折点， 重定向健康危险行为的轨迹。青春期是一个快速变化的时期，也是一个典型的 这些行为的开始，21岁和青少年比年轻人更难适应安置 要测试青春期安置是否起到转折点的作用，重要的是要知道 放置会引发轨迹的长期变化、短期(特定时间)变化，或两者兼而有之。去设计 除了干预措施外，还有必要了解安置效应背后的机制。然而， 由于放置可能发生在不同的时间点，因此确定其直接和中介影响需要 将外出安置、中介者、混杂因素和结果建模为时变变量。 重要的是，外出安置是一个非随机事件，许多安置前的变量可能 预测放置位置和随后的健康风险行为。为了应对这种对因果推理的威胁，最近 研究利用了倾向评分法。23-27然而，这些方法不能适应时间- 不同的变量，排除了将安置作为转折点的测试或对其特定时间调解人的测试。 因此，建议的研究使用两种现代方法进行因果推断，即 治疗加权(IPTW)和g-估计，以测试安置对健康风险的直接和中介影响 不同时间的行为。这些方法可以解释来自观察到的混杂因素的偏差，并适应 时变变量。28，29目标1测试自上一波以来有外出安置的青少年 与那些人相比，在物质使用和开始无保护措施的性行为方面显示出短期的、特定时间的增加 留在家里的人。目标2测试青春期安置是否预示着成年人健康水平的长期上升 危险行为。目的3检验放置对成人健康危险行为影响的时变中介变量。 这些目标将在全国范围内研究的738名虐待青少年(基线年龄为11-14岁)样本中进行测试 四波就到成年了。培训计划汇集了一支杰出的指导团队，以提供 儿童福利系统研究的多学科培训，因果推断的现代量化方法， 健康危险行为的发展精神病理学，对干预和政策的影响，以及 职业发展。这将为申请者提供开始研究生涯的基础。 研究安置和儿童福利参与对青少年发展结果的影响。

ABSTRACT Child maltreatment is associated with health risk behaviors carrying high personal and societal costs, such as substance use and sexual risk behavior.1–4 Placement of children into out-of-home care aims to mitigate these negative effects.5 Findings about rates of health risk behavior among youth in out-of-home care are mixed,6–16 although studies show that young adults formerly in care have heightened levels of health risk behavior.17–20 These mixed findings may be due to the fact that most studies test effects of placement across childhood on later health risk behaviors. However, placement during adolescence may be a turning point that redirects trajectories of health risk behavior. Adolescence is a period of rapid change and a typical period for initiation of these behaviors,21 and adolescents have more difficulties adjusting to placement than do younger children.22 To test whether adolescent placement acts as a turning point, it is important to know whether placement initiates long-term changes in trajectories, short-term (time-specific) changes, or both. To design interventions, it is also necessary to understand the mechanisms underlying placement effects. However, because placement may occur at various points across time, identifying its direct and mediated effects requires modeling out-of-home placement, mediators, confounders, and outcomes as time-varying variables. Importantly, out-of-home placement is a nonrandom event, and many pre-placement variables likely predict both placement and subsequent health risk behavior. To deal with this threat to causal inference, recent research has utilized propensity score methods.23–27 However, these methods cannot accommodate time- varying variables, precluding tests of placement as a turning point or tests of its time-specific mediators. Accordingly, the proposed study uses two modern methods for causal inference, inverse probability of treatment weighting (IPTW) and g-estimation, to test direct and mediated effects of placement on health risk behaviors across time. These methods can account for biases from observed confounders and accommodate time-varying variables.28,29 Aim 1 tests whether adolescents with out-of-home placement since the prior wave show short-term, time-specific increases in substance use and initiation of unprotected sex, compared to those who remain in-home. Aim 2 tests whether adolescent placement predicts longer-term elevations in adult health risk behavior. Aim 3 tests time-varying mediators of the effect of placement on adult health risk behavior. These aims will be tested in a national sample of 738 maltreated youth (age 11-14 at baseline) studied across four waves to adulthood. The training plan brings together a distinguished mentoring team to provide multidisciplinary training in child welfare system research, modern quantitative methods for causal inference, developmental psychopathology of health risk behaviors, implications for intervention and policy, and professional development. This will provide the applicant with the foundation to launch a research career studying the effects of placement and child welfare involvement on adolescents' developmental outcomes.