Introduction
1Many countries promote foster care and similar programs as the best option for vulnerable young people who have been abandoned, orphaned, neglected or are otherwise unsafe at home. Worldwide, more than eight million young people with these backgrounds grow up in large institutions or orphanages, under detrimental conditions including strict routines, lack of personal relationships and isolation from wider society [1]. However, foster care programs need to be well designed and support stable placements so as to provide a better alternative. Unstable placements are likely to be as harmful as institutionalisation to a child's future mental health and function [1]. International research confirms that foster care children who experience placement disruption and instability are at heightened risk of a range of poor outcomes [2].
2These young people typically have disrupted families and a history of exposure to emotional, physical or sexual trauma, poverty and other adversities [3-8]. They also commonly experience problems with alcohol and other drugs, suicidal ideation and self-harm, school dropout and contact with the criminal justice system. They are less likely than others of the same ages to have timely access to mental health care [7, 9-11]. Proactive, regular and voluntary help-seeking is infrequent among vulnerable young people [11, 12].
3 Each week in the Australian state of Victoria (population of 5.9 million) nearly 60 children and young people are removed from home by the State due to significant risk of harm and placed into the care of another person or an organisation: this is known locally as ‘out-of-home care’ (OoHC) ([13], p. 28). The main types of OoHC are home-based – foster care, in the private home of a substitute family receiving payment for the child's living expenses, or kinship care, with a family member or approved custodian; and residential care, in a house with up to four young people supported by paid staff (see Glossary) [13]. The young people have varied cultural backgrounds and typically have experienced serious disadvantage and trauma early in life. Many have multiple and complex needs, with poor mental health and poor social function before they enter care, while living in care and after they leave care [13, 14].
4 Young people are legally required to leave the state protection of OoHC at the age of 18 in Australia. They then encounter limited opportunities for work or further education and are at significant risk of homelessness [14]. A longitudinal study of young people leaving care in Australia reported that nearly 50% had attempted suicide within four years [15]. One in three young women had become pregnant or given birth within 12 months of leaving care [3]. Thirty-five percent of young people in state care in another study had become homeless within 12 months of leaving care [16].
5 The Ripple project is a five-year action research study (2013-2017) funded by the Australian National Health and Medical Research Council and conducted in Melbourne (Victoria, Australia). It aims to work in collaboration between government child protection services, community service organisations (CSOs) that manage the care programs on behalf of the government, and mental health services, with the participation of youth peer leaders.
Aims
6The overall aim is to assess whether a mental health intervention that enhances the therapeutic care roles and capacities of carers and case managers in OoHC will improve the consistency and quality of OoHC for all young people (12-17 years) in the sector, and access to early intervention when indicated for prevention and treatment of mental illness. Both outcomes will contribute to improving the mental health of young people living in OoHC. Outcomes are being assessed at baseline and three years later for the young people, the carers and care coordinators, and the services. The primary outcomes assessed for the young people are rates of emotional distress, harmful use of substances and disturbed conduct, and changes in function and well-being.
7The Ripple project has three components:
- needs assessment and implementation of a systemic mental health intervention;
- a controlled trial of the mental health, social and economic outcomes of the intervention over three years;
- nested process evaluation of the intervention.
8This article provides an overview of the results of the needs assessment conducted with young people, mental health professionals, carers and care workers. The results have contributed to the development of the intervention, which is described briefly. The intervention is underway and will be completed in 2017.
Methods
9A complex care system surrounds the young people removed from their families because of neglect or abuse in Victoria. Child Protection officers in the Victorian Department of Health and Human Services (DHHS) are responsible for investigating reports of a young person's neglect or abuse and referral to the Victorian Children's Court if concerned about safety in the family. Sometimes this leads to the young person's placement in OoHC. Most care of young people in OoHC is provided by CSOs. The CSOs recruit and support foster and kinship carers, and manage small residential houses with care staff [17]. Primary care and mental health services in the community provide health and mental health care, and education, welfare and justice systems are involved as required. There are difficulties in developing and maintaining links between these sectors in part because of the complex needs and placement instability of many of the young people.
10 The Ripple intervention includes regular contact between skilled mental health clinicians with special training and supervision and staff of the CSOs, to offer evidence-based mental health support, knowledge and skills tailored to the local needs. The intervention has been shaped and refined by the needs assessment described below and during the process of implementation. Specialist practitioners with youth mental health and substance abuse expertise are trained and supported to work with the organisations, care coordinators, carers and trained youth leaders in OoHC. Participation of young people with experience of OoHC is a central feature of the intervention. This participation is likely to improve the chances of a successful intervention by creating a positive climate and generating useful ideas and links to decision makers [18–21].
Needs assessment
11A needs assessment was conducted with young people, home based carers, practitioners and clinicians working across the OoHC and mental health sectors. Practitioners included practice leaders from CSOs, Child Protection workers, and staff of the Australian Childhood Foundation. Mental health clinicians were working in three agencies participating in the project: the Royal Children's Hospital, Orygen Youth Health Clinical Program and the Youth Support and Advocacy Service.
Needs assessment: wave 1 census
12The Ripple study uses a cross-sectional design to define the study population on two occasions, at the beginning of the Ripple intervention (wave 1) and after three years (wave 2). A census of young people in care was required because accurate information about the sector is not available to the community or the sector. Information was collected in a predefined two-week period (from 18 August 2014) about the young people aged 12 to 17 years living in OoHC settings managed by the four partner CSOs across two of the four regions of metropolitan Melbourne. The four CSOs – Anglicare, MacKillop Family Services, Salvation Army (Westcare and SalvoCare Eastern) and the Victorian Aboriginal Child Care Agency – are the main providers of care in these regions. The census collected data on demographic characteristics including cultural and linguistic backgrounds and identity as Aboriginal and Torres Strait Islanders, and care placements. Research assistants attended each of the CSO settings and worked with staff to identify clients for the census.
13Approval for the project was obtained from research ethics committees of the University of Melbourne (No. 1340674), Deakin University (No. 2014-046) and Anglicare Victoria (No. 2014-02) and ratified by research review committees of the other CSOs. The Victorian Department of Human Services Research Coordinating Committee approved the study.
Needs assessment: focus groups and interviews
14Four focus groups were held, each with between nine and 11 participants, with a total of 37 practitioners from CSOs and child trauma support services (CSO practitioners), and mental health clinical services and drug and alcohol support services (mental health clinicians).
15 A focus group with seven participants and three separate interviews were held with carers with experience providing foster or kinship care. Questions aimed to elicit information from each group about previous experiences of mental health support, including barriers to receiving support and good experiences. Careful attention was paid to the language used and terms preferred by each group. Recommendations for good practice were requested. Thematic analysis was conducted of the transcripts from recordings of the focus groups and interviews. Needs were interpreted using a social determinants of mental health framework (VicHealth, 2009).
16 Interviews and focus groups were held with fourteen young people aged 18-25 years with lived experience of OoHC (residential, foster and kinship care) and identifying with Aboriginal and Torres Strait Islander and other cultural backgrounds, as well as heterosexual and same-sex identifying.
Results
Wave 1 census
17Details were recorded for a total of 323 young people in OoHC ( table 1).
Table 1
Table 1
Wave 1 Census and Interview Participants, Ripple Controlled Trial (see glossary for definition of terms).Wave 1 census: demographic characteristics
18 Their average age was 15 years (SD = 1.6), with 39% of the cohort aged between 12-14 years. Most (92%, n = 288) were Australian born. The remaining 35 young people were born in 15 countries in Africa, Asia and the Middle East. The age of arrival is available for 18 of these young people, with the mean value 8 years (SD = 4.0, min = 3, max = 16). The most frequently spoken languages other than English were Arabic (n = 7) and Vietnamese (n = 6). There were five young people using Auslan. Nineteen percent (n = 62) of the cohort identified as Aboriginal or Torres Strait Islanders. The proportion of young people with a registered disability was 10% (n = 33).
Wave 1 census: care characteristics
19 Most (59%) young people were in home-based care types, including foster care (31%), Adolescent Care Program (8%) and kinship care (20%). Thirty-six percent of young people lived in residential care and a further six percent lived in lead tenant accommodation (see Glossary for description of care types).
20 The average age that young people had been removed from their families was nine years old (SD = 4.5, min = 0, max = 17). The number of months in the current placement varied from less than one to 148, with a mean of 24 months (SD = 29.3).
21 Recent placement instability was apparent in the lives of 30% of the young people. In the previous year, 70% (n = 225) of young people had had one placement, 18% (n = 57) two placements, 8% (n = 26) three to four placements, and 4% (n = 14) between five and 10 placements.
22 Lifetime placement instability was higher: only 23% (n = 75) of the young people had had one placement; 14% (n = 44) had had two placements, 24% (n = 79) three to four placements, 29% (n = 93) between five and 10 placements, and 10% (n = 31) more than 10 placements.
Wave 1 data collection
23 As many as possible of the young people identified in the census and eligible for interview, and their carers and case managers, were subsequently interviewed in wave 1 ( table 1). Protocols were established for contacting and following up those enumerated in the census and for risk management. The young person's case manager as identified by each agency made the initial contact with each young person and his or her carer(s). Recruitment was originally scheduled for completion in three months. In order to complete the agreed number of contacts and re-contacts for each potential participant to establish an appointment for the interview, the recruitment period extended to six months. During this period, an additional 43 young people who entered care during the recruitment period were identified and approached for interview using the same procedures. Interviews were obtained with 176 young people, 104 carers and 79 case managers. The details are reported separately.
Focus groups and interviews: main themes
CSO practitioners
24 CSO practitioners need a shared model to facilitate mental health support; time and space to build relationships. CSO practitioners expressed the need for a shared model with mental health clinicians to communicate about mental health support. They perceived that the trauma and attachment models familiar to them are not represented in the clinical and diagnostic framework used by mental health professionals.
Mental health clinicians
25 Mental health clinicians need to make time to see what is ‘on the agenda’ at the CSO and frame their interventions accordingly. They recognised the time and effort needed to build relationships with CSO carers and practitioners who work with trauma on a daily basis.
Carers
26Carers need early intervention, mental health promotion and acknowledgement of the impact of caring on their mental health. Stresses associated with caring for traumatised young people and dealing with unhelpful bureaucracies accumulated and undermined their mental health. They needed support from CSO practitioners who listened to their requests for early intervention for the young people in their care. They recognized the value of preventing mental ill-health and promoting well-being.
Young people
27Young people described the importance of carers who can build relationships so that they can establish the trust to work through problems that might arise later on. Providing a sense of home and community depended on carers who could create emotional safety and be supported to persist with caring. In particular, carers who had strong interpersonal and communication skills were preferred to ‘being sent for counselling’.
28 These findings contributed to the development of the Ripple intervention. Drawing on the main themes generated by practitioners, young people and carers, the main components focus on organizational collaboration to develop a shared language, multiple modes of delivery for the intervention that suit the needs of CSO staff; and training of staff and carers in communication and therapeutic skills that promote mental health and help to address early signs of mental ill-health.
29 The Ripple intervention is delivered by specialist mental health clinicians from Orygen Youth Health, The Royal Children's Hospital Melbourne and substance clinicians from the Youth Support and Advocacy Service, all of whom work in a designated catchment area. They have received additional training in trauma and attachment models and are adapting the way the intervention is being delivered at each site to suit CSO needs. The process evaluation is incorporating these findings into monitoring the progress of the intervention.
Discussion
30The Ripple project aims to study the implementation and outcomes of a collaborative, complex mental health intervention for young people in OoHC. It is one of the first studies of its type in Australia or elsewhere to our knowledge and one of the largest of any type in this group of young people. It represents an important opportunity to deliver improved mental health support to a highly vulnerable group of young people. The complexity of the systems involved in supporting young people in OoHC requires an innovative approach to mental health service delivery.
31 Findings from the needs assessment with practitioners, carers and young people demonstrate the importance of a shared understanding of mental health between the OoHC and mental health sectors. Support from mental health and substance abuse specialists is helpful in contributing to the capacity of CSO practitioners and carers to work effectively with young people in their care. Yet, practitioners in the OoHC sector do not feel that their needs are met by the typical mental health sector approaches to care. Additional training for mental health professionals in working with the social services sector including common approaches to managing difficulties related to trauma history and attachment are designed to assist in developing shared models and language that meet the needs of CSO staff. Adapting the mode of delivery to suit CSO needs, through supervision, reflective practice and training helps meet the needs of CSOs and build more effective relationships between the sectors. This intervention was designed to complement existing social services led specialist therapeutic approaches provided to selected individuals and settings, and with awareness of specific programs to which the participating CSOs had access.
32 In order to assess the effectiveness of the Ripple intervention, a controlled trial design involving two cross-sectional data collection points is established. The wave 1 census demonstrates the disproportionately high numbers of young Aboriginal and Torres Strait Islander people in care. The Ripple intervention is being delivered in close collaboration with the Victorian Aboriginal Child Care Agency to ensure that care is appropriate to the needs of these young people.
33 The census also found a high rate of placement instability, and low numbers of young people with a registered disability. The relatively low number of young people with a registered disability (as defined by registration in the state system) found in the census was unexpected. These rates are similar to those registered among young people in the general population. Yet, previous estimates and reports suggest that disability rates are higher among young people in OoHC [22]. The low rates with these CSOs may indicate that young people with disabilities are not being registered. This may mean that young people living with disabilities are missing out on support services that they need or are being managed through other parts of the Child Protection and OoHC sectors.
34 The Ripple intervention works across traditional practice sectors. It aims to foster more emotionally attuned OoHC environments, provide better access to early intervention to prevent and treat mental illness, and contribute to better mental health among young people in OoHC. Enhancing capacity of the case managers and carers to respond in an attuned and informed way should contribute in the longer term to improved quality of life and better productivity for the young people, and reduce suicide attempts and self-harm; high prevalence mental ill-health including depression, anxiety, drug and alcohol abuse; and social isolation, homelessness and delinquency.
35 Implementing and evaluating the Ripple intervention investigates the capacity for collaborative and evidence based mental health support using a modest allocation of specialist mental health staff within OoHC systems that look after young people with multiple and complex needs. The approach is potentially adaptable to the needs in other regions in Australia and elsewhere. The evaluation of this intervention is continuing with the process evaluation and the second cross-sectional wave of assessments.
Acknowledgements
36The following research, community service and government organizations are collaborating in the study: Orygen, The National Centre of Excellence in Youth Mental Health; Orygen Youth Health; School of Social Work, The University of Melbourne; Royal Children's Hospital Melbourne; Youth Support and Advocacy Service; Foundation House – The Victorian Foundation for the Survivors of Torture; Deakin Population Health, Faculty of Health, Deakin University; MacKillop Family Services; Anglicare Victoria; The Salvation Army Westcare SalvoCare Eastern Services; Take Two–Berry Street; Victorian Aboriginal Child Care Agency (VACCA); Mindful, Centre for Multicultural Youth; CREATE Foundation; Victorian Commission for Children and Young People; Victorian Department of Health and Human Services.
37 We are grateful for the contribution of the members of the Ripple Project Aboriginal Advisory Group including Connie Salamone, Peter Lewis, Sue Anne Hunter and Andrew Jackomos, Victorian Commissioner for Aboriginal Children and Young People.
38 Special thanks to our colleagues Professor Patrick McGorry, Professor Sue Cotton, A/Prof Cathrine Mihalopoulos, Dr Penny Mitchell, Tony Glynn, Dr Anne Magnus, Lenice Murray, Josef Szwarc, Dr Elise Davis, Professor Sam Tyano and Professor Simon Davidson for their roles in the project conception and investigation; and for the work of Simon Malcolm, coordinator of the Bounce Project 2014-2016; Larry Hendricks in database construction; Dr Angela Scheppokat in database management; and Dr Margaret Kertesz in convening and reporting focus and working group activities, and evaluation and qualitative analysis.
39 We acknowledge with gratitude the personal and creative contributions of numerous people in collaborating organisations including Bernadette Marantelli, Centre for Multicultural Youth; Micaela Cronin and Dr Nick Halfpenny, MacKillop Family Services; Jacki Buchbinder, The Salvation Army – Westcare; Dr Tatiana Corrales, Anglicare Victoria; Annette Jackson, Take Two; Bernie Geary and colleagues at Victorian Commission for Children and Young People, Josh Fergeus, Dr Ric Haslam, Royal Children's Hospital; Arry Valastro, Andrew Bruun and Peter Wearne, YSAS; Robyn Miller and Jan Snell and colleagues from Victorian Department of Health and Human Services central, and north and east regions; Deb Tsorbaris and colleagues from Centre of Excellence in Child and Family Welfare.
40 The Ripple Study is funded by the National Health and Medical Research Council of Australia, Targeted Call for Research grant number 1046692.
41 The Bounce project is funded by Australian Rotary Health; and the Bounce co-design study that preceded it was funded by the Melbourne Social Equity Institute at The University of Melbourne.
Conflicts of interest
42not specified.
Glossary
Foster care: Foster care is provided in the private home of a substitute family receiving payment intended to cover the child’s living expenses [13]. Foster care can be divided into two types: traditional foster care and therapeutic foster care. Therapeutic foster care is when home-based treatments are provided by therapeutic carers who have received specialised training [23].
Kinship care: Kinship care is a care arrangement where the caregiver is a family member or a person with a pre-existing relationship with the child [13].
Lead tenant: Lead tenant involves a volunteer carer who lives in a house with one or two young people who are learning independent living skills.
Residential care: Residential care involves out-of-home care provided in a residence where there are paid staff, including rostered staff or live-in carer. Also known as ‘congregate care’ and ‘staffed group care’. Residential care is provided in community-based residential homes, in which workers provide direct care of young people on a rostered or shift-work basis. In Australia, these models have not typically received input or support from multidisciplinary teams or consultants, and do not necessarily provide a therapeutic or treatment aspect to young people by design [24].
CSO practitioners: Staff employed in community support agencies to provide support for young people in out-of-home care. Mental health clinicians: Clinicians employed by mental health services to provide specialist mental health support.
