Occupational Therapy's Emerging Role With Transitioning Adolescents in Foster Care

The American Occupational Therapy Association's Centennial Vision advocates for an emphasis on intervention and prevention services for children, young people, the aging, and those with severe and persistent mental illness. This article discusses mental health issues among adolescents in foster care, a population that would greatly benefit from occupational therapy services emphasizing skill development in the areas of independent living, vocation, and health. Additionally, current intervention modalities used by other disciplines with adolescents in foster care are explored. Finally, a pilot study demonstrating the opportunities for occupational therapists to influence the long-term outcomes of adolescents in foster care is described.     

The Kawa River Model: Applying Theory to Develop Interventions for Combat and Operational Stress Control

This article proposes the implementation of the occupational therapy Kawa (Japanese for river) model to promote “culturally relevant” client-centered care for combat and operational stress control services provided in the military context. Currently, the occupational therapy literature lacks a culturally sensitive approach to address the military service members’ experiences with combat and operational stress. A review of the Kawa model features are provided within a case study for a military service member affected by combat and operational stress. This theoretical article offers a pragmatic method for infusing occupational therapy theory to address the cultural aspects of military service members in recovery.     

Mental Health Problems of Children in Foster Care

We compared the rates of mental health problems in children in foster care across three counties in California. A total of 267 children, ages 0 to 17, were assessed two to four months after entry into foster care using a behavioral screening checklist, a measure of self-concept and, in one county, an adaptive behavior survey. Results confirmed previous research and indicated consistently high rates of mental health problems across the three counties. Behavior problems in the clinical or borderline range of the CBCL were observed at two and a half times the rate expected in a community population. Fewer children fell within the clinical range on the self-concept measure. No significant differences in rates between the three county foster care cohorts were observed, despite the different demographic characteristics of the counties. On the adaptive behavior scale, the mean scores for children in foster care were more than one standard deviation below the norm. Our findings suggest that the most important mental health screening issue with children in foster care is to identify what specific mental health problems need to be addressed so that the most effective treatment services can be provided.     

Emotional Intelligence: An Opportunity for Occupational Therapy

Emotional intelligence theory developed within the psychology and business fields and is described as an ability to monitor emotions and to use the information to guide thinking and problem solving. Emotional intelligence skills are needed by occupational therapy practitioners to support therapeutic use of self, promote client-centered care, and foster communication skills within the workplace. A scenario illustrates how emotional intelligence supports the therapeutic use of self during a clinical interaction. The Mayer Salovey Caruso Emotional Intelligence Test is introduced as a resource for occupational therapy practitioners to measure and develop therapeutic relationship skills based upon emotional intelligence research.     

Predictors of Placement Outcomes in Treatment Foster Care: Implications for Foster Parent Selection and Service Delivery

Treatment foster care (TFC) is a normalizing environment in which to treat those children whose particular needs are not addressed in traditional foster care and for whom an institutional setting is a restrictive and unnecessary alternative. However, when the foster care placements of these emotionally and behaviorally disturbed children fail, as they often do, the children are shifted from one home to another without the opportunity to experience permanence or emotional attachment, resulting in poor adjustment to foster care. Placement stability, which depends in part upon effective matching of foster children with potential foster families, is critical for achieving positive outcomes in TFC. Yet, there is a dearth of information to guide placement agencies in making decisions about matching foster children with families. Moreover, once a successful match has been made, it is equally vital that service delivery be of high quality so that permanence is maintained. We review research on the predictors of positive outcomes in foster care, focusing on studies involving emotionally or behaviorally disturbed children, and provide recommendations for selecting foster parents and for ensuring high quality foster care services and placement stability.     

Client-Centered and Family-Centered Care: Refinement of the Concepts

Occupational therapy has emphasized the relationship between the therapist and the client. The occupational therapy guidelines for client-centered practice produced in the 1980s by the Canadian Department of National Health and Welfare and the Canadian Association of Occupational Therapists (Task Force on Guidelines for the Practice of Occupational Therapy, 1983) has had variable use over the years. While occupational therapists believe in the principles of client-centered care, the philosophical concepts have been difficult to fully implement and also seem narrow in light of all the external forces and challenges posed by today's clients and their rights, and the ethics of medicine. Other concepts need to be in place to facilitate the true constructs of client-centered care. A historical overview of the medical perspective and the occupational therapy perspectives on client-centered and family-centered care are reviewed. Lessons learned from the various iterations of client-centered and family-centered care are posed for consideration of a newer more inclusive relationship-centered concept for occupational therapy.     

Transitioning from congregate care: Preparation and outcomes

Of particular concern to child welfare professionals working with youth in foster care is the quality of services rendered to youth in foster care who are imminently making the transition to adulthood and independence, i.e., those at risk for aging out of foster care, many of whom live in congregate care facilities. This qualitative study focuses on the experiences of youth in congregate care in New York City's foster care system, the effectiveness of efforts to prepare youth for life after foster care, and post-discharge outcomes for youth, particularly when discharged to independent living. The study included interviews with professionals as well as young adults who had exited foster care after placements in congregate care settings. Results indicated that professionals and young adults were concerned about the quality of independent living preparation, viewed housing as a serious issue for youth exiting foster care, attributed youth's lack of employment to poor pre-discharge educational and work preparation services, and emphasized the importance of personal connections after youth leave care.     

THE CHALLENGE TO MENTAL HEALTH SERVICES IN THE 1980s

Robert W. Gibson MD, is interviewed concerning the potential impact of restricted funding for mental health services in the 1980s, particularly as this applies to the practice of occupational therapy. Topics covered include the decreasing length of inpatient hospitalization; the possibility of a shifting emphasis lo the treatmcnt of the severely and chronically ill; increasing utilization of rehabilitative services; and suggestions to facilitate greater interprofessional collaboration. Thc establishment of measurable outcomes for continued or improved reimbursement of occupational therapy services is stressed, and the potential for multiprofession group practices as a cost-effective approach to reduced business and industry health care costs is suggested.     

Interpersonal Skills Training to Reduce Aggressive and Delinquent Behavior: Limited Evidence and the Need for an Evidence-Based System of Care

The prevention of aggressive and delinquent behavior during childhood and adolescence is one of the highest priorities for public health and crime prevention. The most common approach to preventing or treating these conduct problems has been to provide interpersonal skills training to the affected youth. This paper reviews all randomized controlled trials evaluating interpersonal skills training programs as an intervention to reduce conduct problems. Research shows that such programs have weak empirical support as isolated interventions. An alternative evidence-based system of care is described. Such a system would include behavioral parent training and behavioral classroom-based interventions for young children at risk of developing problems, as well as multisystemic family therapy or multidimensional treatment foster care for chronic delinquents. Within such a network of services, interpersonal skills training could play an important supportive role. Such a system holds the greatest promise for reducing the prevalence of aggressive and delinquent behavior in communities.     

Effective Treatment for Mental Disorders in Children and Adolescents

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.     

In-Home Family Therapy as a Prevention of Foster Care Placement: Clients' Opinions About Therapeutic Services

The purpose of this qualitative study was to explore clients' perceptions of the in-home family therapy services they received. The sample consisted of 20 low-income families who were at risk for having their children placed in foster care, but who had ultimately retained custody of their children. Results indicate that families view in-home family therapy as a useful intervention. They expressed appreciation for the therapists, their availability, and the support offered. Participants also stated that they wished services could have been more frequent and longer-term. Implications for researchers and practitioners are discussed.     

The heart of the matter 2: integration of ecosystemic family therapy practices with systems of care mental health services for children and families

Many children in this country do not receive the mental health care they need. At the same time, a nationwide movement known as systems of care is providing innovative services for families and children. This article links the ideas inherent in systems of care with ecosystemic family therapy principles and practices. Based on a study of nine innovative systems of care pilot projects in Massachusetts, it describes how these innovative programs, and others like them, have been most successful in increasing access to services and providing for coordinated services. They have been less successful in accomplishing positive clinical and functional outcomes. Change in these systems is often described in terms of how services are provided. Not enough attention is given to the conversations that take place between families and case coordinators and how these conversations lead to long-term change. This article contends that the ways in which services are delivered in these systems of care fit well with ecosystemic family therapy principles and practices. We, as family therapists, have an opportunity to link these two sets of ideas, which share common assumptions and values and increase the likelihood of positive clinical outcomes for children and families.     

Demographic,Clinical, and Geographic Predictors of Placement Disruption among Foster Care Youth Receiving Wraparound Services

The effective delivery of wraparound depends upon the availability of a wide range of community-based services. This study seeks to determine the impact of proximity to resources on the effectiveness of a wraparound program for stabilizing foster care placements among a sample of youth. We present a methodology for deriving proximity scores for individual clients using Geographic Information Systems technology, and incorporate this score into a model for predicting placement disruption among youth in foster care receiving services within a wraparound model aimed at preventing placement disruptions. Cox Regression is used to predict length of time until placement disruption using clinical, demographic, and service proximity measures. Risk of placement disruption is predicted by trauma experiences, risk behaviors, and age, and is reduced by the presence of child strengths and proximity to resources. The impact of proximity to resources on placement disruption varies by land use type, suggesting that proximity exerts a greater impact on youth in rural and suburban areas than in urban areas where wraparound service delivery models may be able to overcome distance and other barriers. Implications for the implementation of wraparound programs as well as service system planning are discussed.     

Vocational Transition in Acute Care Psychiatry

The history of vocational rehabilitation in mental health occupational therapy is a sporadic one. Today, vocational integration is an essential part of holistic practice. The Vocational Transition group protocol identifies vocational services in acute care settings for psychiatric inpatients who are planning to return to work after discharge.     

Foster mother state of mind and treatment use: Different challenges for different people

On the basis of our research findings from the last 10 years, we have developed a training program for foster parents that targets three critical needs for infants in foster care. This treatment program has now been manualized to allow dissemination to other sites. With our intervention as well as any other, we see it as critical to tailor services to the needs of individual clients rather than adhering in doctrinaire fashion to the manual. In particular, we suggest that attending to foster parents' state of mind with regard to attachment is vital to providing an effective treatment. In this article, we present examples of foster parents with different states of mind and describe how treatment is tailored to meet their individual needs.     

Family-centered intensive case management: A step toward understanding individualized care

New York State's initial attempt at individualizing services occurred within the context of an experiment. We randomly assigned children 5–12 years old who were referred for out-of-home placement in treatment foster care to either treatment foster care, Family-Based Treatment (n=15), or to Family-Centered Intensive Case Management (FCICM) (n=27). FCICM used teams of case managers and parent advocates to provide in-home services. Flexible service dollars, respite care, and behavior management skills training were available to assist teams in individualizing care. Preliminary outcomes indicate that children in FCICM are doing as well or better than children assigned to FBT in their functioning and symptom reduction. Parents of children in FCICM have made gains, although not at a statistically significant level, in behavior management skills and family strengths that allow them to provide care for their children at home.     

Outpatient Psychotropic Medication Use in the US: A Comparison Based on Foster Care Status

Using data from the Client/Patient Sample Survey, a nationally representative study of outpatient mental health service utilization, the prevalence and correlates of psychotropic medication receipt for youth who live with families and in foster care are compared. The medication rate is similar for both groups, with slightly more than one-third of youth treated with medication. Additionally, when medication is prescribed, it is the sole intervention provided for close to one half of each group, and the distribution of other services received (such as clinical case management and collateral services) is similar, regardless of living situation. However, the predictors of medication use differ for the two groups. Among foster care youth, only presenting problems of depressed mood, being withdrawn, and suicidality significantly increase the odds of medication; among youth with families, sociodemographic characteristics (male gender), and a range of clinical factors (disruptive behavior disorder, presenting problems of hyperactivity and sleep disturbance, prior mental health service receipt, and inpatient or residential care referral sources) increase the likelihood of medication. The conclusion that distinct sets of factors predict medication for the two groups was reinforced by results of multivariate analyses; foster care status moderates the association between medication receipt and only one of the correlates examined (gender). Implications, limitations, and areas for future research are presented.     

Manufacturing Mistrust: Issues in the Controversy Regarding Foster Children in the Pediatric HIV/AIDS Clinical Trials

The use of foster children as subjects in the pediatric HIV/AIDS clinical trials has been the subject of media controversy, raising a range of ethical and social dimensions. Several unsettled issues and debates in research ethics underlie the controversy and the lack of consensus among professional researchers on these issues was neither adequately appreciated nor presented in media reports. These issues include (1) the tension between protecting subjects from research risk while allowing them access to the possible benefits of research; (2) the blurring of the potentially conflicting roles of investigator and physician and the boundaries between research and therapy; (3) the adequacy of Institutional Review Board oversight; and (4) trust and the relationships among physicians, investigators and industry. The media controversy about the pediatric HIV/AIDS clinical trials can be seen as a means of “manufacturing mistrust” in health care, research and social services that have not always met the needs and expectations of the public. In an era of emerging infections, it is critical to the public’s health that people understand the role of rigorous and ethical research in the development of safe and effective care. Investigators, journalists and the public need to become knowledgeable about major ethical issues in the conduct of research in order to engage in dialogue about balancing research risks and benefits and to be able to distinguish fact from distortion in an era of multiple and rapid transmission of information.     

Service Needs of Foster Families with Children who have Disabilities

We examined the service needs of foster families with children who have disabilities. Foster parents in a large Canadian city were asked “What services or supports would be helpful to you?” The responses to this question were edited for clarity and to eliminate redundancies, and sorted into piles of like statements by a group of 15 foster care professionals. Two types of statistical analysis were applied to the sorting of the statements to describe the relationship between statements and their groupings. The major concepts were identified according to the contents of the cluster and a map was constructed to provide a graphic representation of the conceptualization process. The major services and supports identified in this study were: support in the community, financial support, accommodating school system, good relationships with social workers, responsive professionals, information, comprehensive medical care, services for aboriginal children and families, transitional services, and respite.