Scolaris Content Display Scolaris Content Display

Independent living programmes for improving outcomes for young people leaving the care system

Esta versión no es la más reciente

Contraer todo Desplegar todo

Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the effectiveness of independent living programmes for young people leaving the care system.

Background

The Child Welfare System
It is widely agreed that good parenting comprises a safe, secure and stable environment in which children can develop to their full potential (Smith 2001). However, not all parents are able to offer such secure and stable environment for their children. For these children the state intervenes at times, through the legal system. Sometimes this entails removing the child from the parent's care and placing them in public care, with the state assuming overall responsibility for their upkeep. As 'corporate parent' the state aims to ensure that the day‐to‐day care of these children is satisfactory, including their education, health, social interaction, safety and all the things that children need and would get were they to live with a family. While in public care these children are either placed in foster care or residential care.

Prevalence and Experiences of Children in Public Care
Each year a substantial number of children enter public care systems around the world. There were 523,000 children, representing 7.2 per 1,000 of population under 17 years, in public care in the United States in 2003 (CTD 2005) and 61,100 children, representing 6.2 per 1000 of the population under 16 years (ONS 2001), in public care in England as at 2004 (DfES 2005). These children come from very diverse backgrounds with different cultures, ethnicities, needs, abilities and pre‐care histories (Biehal 1995). Most enter public care because they had or are likely to have suffered maltreatment (DOH 1991). They are also more likely to come from multiply disadvantaged backgrounds (Bebbington 1989). Once in public care, the deleterious experiences that these children encountered prior to their entry into public care do not necessarily end. They are more likely to be diagnosed as having emotional or behavioural problems (Meltzer 2003, ONS 2003), and to experience unstable care placements (Biehal 1992) and accompanying difficulties at school (Jackson 1998, OFSTED 1995,). A survey by the national office of statistics of England reported that 45 percent of children aged 5‐17 years in public care had been assessed as having a mental disorder (ONS 2003). Several studies have also catalogued the poor educational attainment of young people living in and leaving the care system (Courtney 1998, Cheung 1994, Jackson 1994, Garnett 1992, Barth 1990, Festinger 1983). The difficulties that these children experience at school do not only lessen their education attainments but, more importantly, deprive them of exposure to potential protective factors that they may need to help counter the adverse effects of unpleasant experiences in care (Rutter 1990).

Young People Leaving Care
Every year about 20,000 (USGAO 1999) and 10,000 (Garnett 1992) young people graduate from the care systems in the United States and Britain respectively, of whom a significant number emerge severely disadvantaged and ill prepared for adult life (Courtney 1998, Cheung 1994,Garnett 1992, Barth 1990,Festinger 1983). Studies indicate that a significant proportion of these young people do not possess the social, vocational, life skills and resources to succeed independently. Upon leaving care they are more likely to be homeless, unemployed, depend on public assistance, have poor physical and mental health, engage in risky health behaviours, or be involved with the criminal justice system (Courtney 2005, Courtney 2001, Maunders 1999, Cook 1994, Barnado's 1996, Barth 1990, Festinger 1983). Coupled with this plethora (can we have another word than envelope??) of unfavourable outcomes, many of these young people leave care with little, if any, social, emotional or financial support from their families compared to their peers in the general population, who typically also leave home later (Cashmore 1996, Morrow 1996, Courtney 1996). Of these young people leaving care, many of their families are unable to offer any sustained and substantial support that would benefit their transition from adolescence to adulthood. In recognition of the difficulties facing young people leaving care, legislation and policies have been enacted to help prepare them for adulthood. These include the John H Chafee Foster Care Independence Program of 1999 in the United States of America (NRCYD 2004) and the Children (Leaving Care) Act of 2000 in the United Kingdom (DOH 2001) .

Independent Living Programmes
Independent Living programmes (ILPs) were designed to provide young people leaving care with the skills that would help limit their disadvantage and to promote successful transition into adulthood. In the main, ILPs utilise social skills training techniques in teaching young people skills acquisition and performance. Social skills training techniques incorporate the use of instructions, modelling, role play and feedback and have been found to be effective in teaching skills acquisition and improving performance in both clinical and non clinical settings (Spence 1995). Skills taught include personal development skills such as communication skills, decision making, conflict resolution, anger management; and independent living skills like career exploration, job and interview skills, money management, household management, accessing housing, accessing legal issues, and accessing community resources (USGAO 1999, Cook 1994). Independent living programmes also provide educational and vocational support.

Programmes usually provide supervised living conditions under which young people can practise the skills they have learnt (Mauzerall 1983). Some authors have, however, criticised the over reliance on the acquisition of independent living skills as an inadequate preparation for young people leaving care and have advocated the inclusion of interpersonal and relationship training (Propp 2003, Courtney 1996). It is yet to be seen how this suggestion is incorporated into the programme.

Programmes are usually taught in groups, in diverse settings such as community centres, group homes, transition placements, and supervised practice placements, with individual support (mentoring and counselling) provided on one‐to‐one basis (Biehal 1995,Meston 1988). ILPS may also be delivered to young people living in independent tenancies. There may be variations in content, context and delivery of ILPs depending on the legislation or policy context in a particular country.

Notwithstanding the wide use of independent living programmes their effectiveness is unknown (USGAO 1999) and the extent to which the acquisition of independent living skills by young people leaving care is associated with easier transition to independent and self sufficient living remains uncertain. Some evidence suggests that such programmes may be successful in improving outcomes such as education, employment, housing, health and life skills for young people leaving care (Loman 2000, Mallon 1998, Scannapieco 1995, Biehal 1995), but this evidence is based on narrative reviews and non‐experimental studies.

This review aims systematically to determine the effectiveness of these independent living programmes in increasing the life chances of young people leaving care. Knowing the effectiveness of such programmes is important given the numerous challenges associated with living in and leaving public care.

Objectives

To assess the effectiveness of independent living programmes for young people leaving the care system.

Methods

Criteria for considering studies for this review

Types of studies

Randomised or quasi‐randomised studies (i.e. where allocation is by date of birth, alternate numbers, case number, day of the week, or month of the year) will be eligible for inclusion. Included studies will have to compare an Independent Living Programme to a control group. The control group could be a 'standard/usual care', another intervention (e.g. mentoring alone), no intervention or waiting list.

Types of participants

Young people leaving the care system at their respective country's statutory ages of discharge from the care system.

Types of interventions

Independent living programmes (as described above), containing the provision of training and/or support in the acquisition of personal development Programmes specifically targeted at young people with special needs such as physical or learning disabilities, teenage parents, young offenders, and those in psychiatric institutions will be excluded.

Types of outcome measures

Studies will only be included if they are explicitly targeted at improving at least one of the following:

Educational attainment (example, high school diploma, national vocational diploma, higher education )
Employment (example, full time employment, unemployment rates, income levels)
Health status (example, teenage pregnancy/fatherhood rates, drug use, mental health)
Housing (example, homeless, own accommodation, or living with family)
Life skills including behaviour outcomes (examples: coping skills; financial skills and knowledge; knowledge of state benefits systems; accessing community resources; dependence on public assistance; involvement with the criminal justice system)

Some possible outcomes of ILPs such as housing and employment can be assessed immediately after intervention. Other outcomes such as higher education attainment, health status, holding on to employment and housing, and behaviour outcomes need to be assessed over longer time periods. Outcomes will therefore be assessed as short term (immediately after intervention) and long‐term (12 months after intervention) to determine whether immediate outcomes can be sustained.

Data sources will include both such as agency records, self reports using psychometrically sound and validated scale of assessment. Political influences e.g. government targets, and the high mobility of care leavers may affect the reliability of agency records as a source of outcome measurement.

Search methods for identification of studies

The following electronic databases will be searched without language restrictions:

Cochrane Register of Controlled Trials (CENTRAL)
MEDLINE
EMBASE
CINAHL
PsycINFO
Sociological Abstracts
Applied Social Science Index and Abstracts (ASSIA)
Dissertation Abstracts

Further identification of studies will be done through bibliographies of studies and reviews. Experts and authors in the field will be contacted for information on unknown published and unpublished studies, as well as ongoing studies.

The following search terms will be used in finding the relevant studies for inclusion in the review. These terms will be adjusted as necessary to suit the index of individual databases.

FOSTER HOME CARE OR

foster* OR

(care home*) OR

(institution* near care*) OR

(social near care) OR

(children* near home*) OR

((child* near home*) near care) OR

(substitute near parent*) OR

(substitute near care) OR

(home near placement*) OR

(residential near care) OR

(child* near care) OR

(home care) OR

(welfare care) OR

AND

ADOLESCENT OR

(child* or adolescen* or youth* or teen*) OR

((young next person) or (young next people))

AND

AFTERCARE OR

Leaving OR

(after* near care) OR

(look* near after*) OR

support* OR

aftercare* OR

(independent living)OR

((independent near live*) or (independent near living))

Data collection and analysis

Selection of trials
Titles and abstracts of studies yielded by the searches will be checked by both authors (CD and PM) to determine their eligibility for inclusion in the review. Full copies of relevant studies will then be obtained by CD and judged independently against the set inclusion criteria by both reviewers. The review group's editorial base will be consulted where there is uncertainty or disagreement regarding the eligibility of a study.

Quality assessment
Both authors will critically assess the methodological quality of studies against a set of criteria that considers their degree of allocation concealment; follow up, intention to treat, and blindness of assessors. Quality categories will be assigned to each criterion, for example allocation of concealment will be assessed, as illustrated in the Cochrane Collaboration Handbook (Alderson 2005) as follows:

(A)Indicates adequate allocation concealment; e.g. by telephone randomisation or sealed envelopes.
(B)Indicates uncertainty about the adequacy of allocation concealment; e.g. where method of concealment is not reported
(C)Indicates allocation was inadequately concealed; e.g. open random number lists or quasi‐randomisation such as alternation, day of the week, case number.
Since studies using quasi randomisation methods will be considered for inclusion, evidence of baseline differences and attempts made to control them will be described.
Given the nature of the intervention, it is unlikely that providers and participants in the intervention can be blinded hence this will not be used as a quality criterion. Additional information will be sought from authors as necessary. Uncertainty and disagreements will be discussed between the authors, and then with the editorial team, as necessary.

Data management
Data extraction will be done independently by both authors with the aid of a pilot tested extraction form. Information will be extracted on: participants' characteristics at baseline, methods, details of intervention (features and duration), outcomes and their measurement. The extracted data will be shown in a table of included studies.

Incomplete data
In cases where data are missing the study authors will be contacted. Where such information could not be obtained from the authors and missing data are more than 30% of the allocated participants the data will not be included in the meta‐analyses because of possible bias.

Measures of treatment effect
For dichotomous outcome data, a relative risk ratio with a 95% confidence interval will be calculated. Continuous data will be analysed if means and standard deviations are available and the data are not skewed. Where the same outcomes are measured in different ways standardised mean differences will be calculated and compared across studies. Where outcomes are measured in the same way, weighted mean differences will be calculated.

Assessment of heterogeneity
Heterogeneity will be assessed using the chi square test of heterogeneity along with visual inspection of the graph and the use of the I2 statistic (Higgins 2002), which will determine the percentage of variability that is due to heterogeneity rather than sampling error where a value greater than 50% indicates heterogeneity. Where heterogeneity is found the possible reasons for its occurrence will be assessed.

Data syntheses
Meta‐analyses will be carried out if there are sufficient data, and it is appropriate to do so. Both fixed effect and random effects models will be considered in conducting the analyses. The random effects model will be used when there is indication of heterogeneity and the source of such heterogeneity cannot be explained. On the other hand, the fixed effect model will be used where there is no source of heterogeneity beyond differences in the observed covariates.

Sensitivity analyses
Sensitivity analyses will be conducted to assess the impact of the quality of included studies on the outcome of the review. The quality criteria that will be used in the analyses will be the method of concealment allocation and intention‐to‐treat.

Subgroup analyses
Outcomes of ILPs may vary depending on covariates such as gender, ethnicity, and care placement history i.e. foster care vs. residential care. Where heterogeneity is found, then subgroup analyses will be performed to explore the differential impact of the above covariates, which are often associated with differential outcomes for young people leaving care (Barn 2005, Courtney 2005, Biehal 1995). i.e.

  • Boys vs. girls

  • Majority vs. minority ethnicities

  • Foster care vs. residential placement histories

Assessment of bias
Funnel plots (effect size against standard error) will be drawn if sufficient studies are found. Asymmetry could be due to publication bias, but they can also be due to a relationship between trial size and effect size. In the event that a relationship is found, clinical diversity of the studies will also be examined as a possible explanation (Egger 1997).