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

描述(由申请人提供)：寄养中的儿童和青少年有重要的，而且往往得不到满足的心理健康需求(Leslie，Hurlburt，Landsverk，&Barth，2004)。对于学龄青年来说，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和Stambaugh出版社，正在出版中)。这类心理健康问题反过来又与一系列负面后果有关(例如，功能、安置稳定性/永久性)(James，Landsverk，&Symen，2004；Landsverk，Davis，Granger，Newton，&Johnson，1996)。在这一领域，人们对更多地使用循证治疗非常感兴趣，这些治疗针对寄养中的青年的具体心理健康问题和需求。以创伤为重点的认知行为疗法(TF-CBT)潜在地提供了极好的契合性。来自随机试验的证据支持TF-CBT在治疗创伤后应激障碍、行为问题和其他创伤后遗症方面的有效性(Cohen，Deblinger，Mannarino，&Steer，2004)。尽管TF-CBT为寄养中的年轻人带来了希望，但向这些年轻人提供这种服务可能会很复杂。拆解研究的结果表明，照顾者的参与对于最大化TF-CBT的治疗效果至关重要(Deblinger，Lippman，&Steer，1996)。然而，现有证据和我们的临床经验表明，寄养父母很少以积极和持续的方式参与寄养儿童的心理健康治疗。因此，拟议的R34的主要目标是对寄养中的儿童和青少年进行一项关于TF-CBT的试点研究，重点是让寄养父母参与治疗。拟议的项目结合了两项相辅相成的干预措施--循证参与战略(McKay，Stoewe，McCadam和Gonzales，1998)和工作队-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)基于证据的参与战略和专题小组-CBT的初步可行性研究(N=10)；(B)根据养父母和其他主要信息提供人的反馈，完善和制定一项手册参与干预措施。第二阶段：对改进的介入策略和TF-CBT(ECBT)进行试点研究(N=80)，并与“通常做法”的TF-CBT(即，没有专门的介入)进行比较，以评估联合干预的实施情况，并提供关于关键结果的初步数据(例如，PTS症状、行为问题、安置稳定性)。研究结果将被用来为一项大规模随机试验(即R-01)提供信息，以了解ECBT改善寄养有精神健康问题青年的结果的有效性。寄养家庭的青少年有很高的心理健康问题发生率(Leslie，Hurlburt，Landsverk，&Barth，2004)。这些问题包括外在化(如品行障碍、多动症、对立违抗性障碍)和内在化(如焦虑、抑郁、创伤后应激障碍)问题。最近的流行病学和治疗研究表明，这种症状的组合通常与寄养家庭中的年轻人有广泛的创伤暴露史有关(Simms，Dubowitz，&Szilagyi，2000)，因此，有效的症状治疗需要明确的循证治疗，既解决创伤的潜在后遗症，又解决直接的行为表现。以创伤为重点的认知行为疗法(TF-CBT)是一种循证治疗方法，对于这群高危青年似乎很有希望，但有特定的修改(Deblinger，Lippman，&Steer，1996)。这项拟议的研究建立并结合了现有的循证策略(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年。这项研究的结果将用于在寄养系统中为有精神健康问题的青少年开发和传播更有效的治疗方法。这些调查结果应有助于改善为有心理健康问题的青少年提供服务的整个护理系统内的治疗、服务和成果(例如，专门的精神卫生服务提供者、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).