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Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation

  • J. M. Green (a1), N. Biehal (a2), C. Roberts (a3), J. Dixon (a4), C. Kay (a1), E. Parry (a5), J. Rothwell (a1), A. Roby (a1), D. Kapadia (a1), S. Scott (a6) and I. Sinclair (a7)...
Abstract
Background

Children in care often have poor outcomes. There is a lack of evaluative research into intervention options.

Aims

To examine the efficacy of Multidimensional Treatment Foster Care for Adolescents (MTFC-A) compared with usual care for young people at risk in foster care in England.

Method

A two-arm single (assessor) blinded randomised controlled trial (RCT) embedded within an observational quasi-experimental case–control study involving 219 young people aged 11–16 years (trial registration: ISRCTN 68038570). The primary outcome was the Child Global Assessment Scale (CGAS). Secondary outcomes were ratings of educational attendance, achievement and rate of offending.

Results

The MTFC-A group showed a non-significant improvement in CGAS outcome in both the randomised cohort (n = 34, adjusted mean difference 1.3, 95% CI –7.1 to 9.7, P = 0.75) and in the trimmed observational cohort (n = 185, adjusted mean difference 0.95, 95% CI –2.38 to 4.29, P = 0.57). No significant effects were seen in secondary outcomes. There was a possible differential effect of the intervention according to antisocial behaviour.

Conclusions

There was no evidence that the use of MTFC-A resulted in better outcomes than usual care. The intervention may be more beneficial for young people with antisocial behaviour but less beneficial than usual treatment for those without.

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Copyright
Corresponding author
Jonathan Green, Room 3.311, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. Email: jonathan.green@manchester.ac.uk
Footnotes
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The project was funded by a grant from the UK Department for Children, Schools and Families to the Institute of Psychiatry (reference: PACLBMC). It was sponsored by the University of Manchester.

Declaration of interest

None.

Footnotes
References
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1 Warman, A, Roberts, C. Adoption and Looked After Children: An International Comparison. Oxford Centre for Family Law and Policy, 2003.
2 Sinclair, I, Wilson, K, Gibbs, I. Foster Placements. Why They Succeed and Why They Fail. Jessica Kingsley Publishers, 2005.
3 Pallett, C, Scott, S, Blackeby, K, Yule, W, Weissman, R. Fostering changes: a cognitive-behavioural approach to help foster carers manage children. Adopt Fostering 2002; 26: 3948.
4 National Institute for Health and Care Excellence & Social Care Institute for Excellence. Promoting the Quality of Life of Looked-After Children and Young People. NICE/SCIE, 2010.
5 Chamberlain, P. The Oregon multidimensional treatment foster care model: features, outcomes, and progress in dissemination. Cogn Behav Pract 2003; 10: 303–12.
6 Macdonald, G, Turner, W. Treatment foster care for improving outcomes in children and young people. Cochrane Database Syst Rev 2008; 1: CD005649.
7 Dixon, J, Biehal, N, Green, J, Sinclair, I, Kay, C, Parry, E. Trials and tribulations: challenges and prospects for randomised controlled trials of social work with children. Br J Soc Work 2013; March 4 (Epub ahead of print).
8 Gowers, SG, Harrington, RC, Whitton, A, Lelliott, P, Beevor, A, Wing, J, et al. Brief scale for measuring the outcomes of emotional and behavioural disorders in children. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Br J Psychiatry 1999; 174: 413–6.
9 Shaffer, D, Gould, M, Brasic, J. A Children's Global Assessment Scale (CGAS). Arch Gen Psychiatry 1983; 40: 1128–31.
10 Achenbach, T, Edelbrock, C (eds). Manual for the Child Behaviour Checklist and Revised Child Behaviour Profile. Department of Psychiatry, University of Vermont, 1983.
11 Winters, N, Collett, B, Myers, K. Ten year review of rating scales, VII: scales assessing functional impairment. J Am Acad Child Adolesc Psychiatry 2005; 44: 309–38.
12 Rubin, D. The design versus the analysis of observational studies for causal effects: parallels with the design of randomized trials. Stat Med 2007; 26: 2036.
13 Dmitrieva, J, Monahan, K, Cauffman, E, Steinberg, L. Arrested development: the effects of incarceration on the development of psychosocial maturity. Dev Psychopathol 2012; 24: 1073–90.
14 Berridge, D, Biehal, N, Henry, L. Living in Children's Residential Homes. Department for Education, 2012.
15 Green, J, Jacobs, BW, Beecham, J, Dunn, G, Kroll, L, Tobias, C, et al. Inpatient treatment in child and adolescent psychiatry – a prospective study of health gain and costs. J Child Psychol Psychiatry 2007; 48: 1259–67.
16 Green, J, Kroll, I, Imre, D, Frances, FM, Begum, K, Gannon, L, et al. Health gain and predictors of outcome in inpatient and daypatient child psychiatry treatment. J Am Acad Child Adolesc Psychiatry 2001; 40: 325–32.
17 Department for Children, Schools and Families. Outcome Indicators for Children Looked After, Twelve Months to September 2008 – England. Department for Children, Schools and Families, 2009.
18 Brann, P, Coleman, G, Luk, E. Routine outcome in a child and adolescent mental health service: an evaluation of HoNOSCA. Aust NZ J Psychiatry 2001; 35: 370–6.
19 Hanssen-Bauer, K, Langsrud, O, Kvernmo, S, Heyerdahl, S. Clinician-rated mental health in outpatient child and adolescent mental health services: associations with parent, teacher and adolescent ratings. Child Adolesc Psychiatry Ment Health 2010; 4: 29.
20 Green, J. The evolving randomised controlled trial in mental health: studying complexity and treatment process. Adv Psychiatr Treat 2006; 12: 268–79.
21 Everitt, B, Wessely, S. The randomized clinical trial. In Clinical Trials in Psychiatry (eds Everitt, BS, Wessely, S): 13–7. John Wiley 2008.
22 Department for Education. Impact of Sure Start Local Programmes on Five-Year-Olds and Their Families. DFE-RB067. HMSO, 2010.
23 Department for Education. Me and My School: Findings from the National Evaluation of Targeted Mental Health in Schools 2008–2011. Department for Education, 2012 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/184060/DFE-RR177.pdf).
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Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation

  • J. M. Green (a1), N. Biehal (a2), C. Roberts (a3), J. Dixon (a4), C. Kay (a1), E. Parry (a5), J. Rothwell (a1), A. Roby (a1), D. Kapadia (a1), S. Scott (a6) and I. Sinclair (a7)...
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eLetters

Concerns regarding Green et al. (BJP 2014, 204:214-221) evaluation of MTFC-A for adolescents in English care

Gordon T. Harold, Professor of Psychology
12 August 2014

We are writing to highlight concerns regarding conclusions offered byGreen et al. in their evaluation of Multidimensional Treatment Foster Care for Adolescents (MTFC-A) relative to usual care (UC) for at risk youth in English foster care. We commend the authors for undertaking an independent review of MTFC-A. However, we offer some observations to help contextualise the efficacy of the evaluation with respect to the primary conclusion that MTFC-A did not result in better outcomes than UC. The Green et al. evaluation employed a two-arm single (assessor) blinded randomised control trial (RCT) embedded within an observational quasi-experimental case control study. An intent to treat (ITT) design was employed specific to the MTFC-A versus UC comparison. The authors state that the study was intended to be powered at ?=0.80 to detect a half-standard deviation difference in the RCT between ITT and UC (with a targetn = 130), and was powered ?=0.95 to detect the same effect between ITT andUC in the quasi-experimental study (with a target n = 90). However, the target allocation for the RCT was not met. The RCT randomized only 34 participants (n = 20 MTFC-A and n = 14 UC). Based on these numbers, we estimate the study was actually powered ?=0.29 in the ITT RCT to detect half a standard deviation difference between conditions assuming equal variances, and ?=0.28 assuming unequal variances. Substantive conclusions therefore appear to be based on a substantially under-powered design (as far as we can tell from details presented in the original manuscript). Further, the quasi-experimental arm was described as a case-control design. However, it was not a matched-case control design. This is evidentfrom multiple baseline differences between groups, some of which remained after an intensive set of propensity score weights were applied and after elimination of cases with probability of assignment to MTFC-A above 0.95 and below 0.05. Depending on the distribution of assignment probabilities,this may have resulted in relatively limited "data trimming" in order to attain desired allocation probabilities near 0.50. The observed differences included not only age but also the primary outcome scores. Notwithstanding concerns regarding statistical power for the RCT, the authors reported intervention by baseline risk interactions in the only adequately powered arm of the study (see Table 5). Given prior demonstration of MTFC-A intervention by baseline risk interactions (Leve et al., 2011), these results may have been more appropriately presented asa hypothesized replication. Statistical power is also a concern for the reported analyses of offending; ?=0.034 to detect the observed ITT odds ratio of 1.24 using an allocation of 20 and 14 cases, and ?=0.031 in the quasi-experimental arm to detect the observed ITT odds ratio of 1.07 with 93 and 92 cases. Interpretation of effects should therefore be treated with caution. We raise one additional point of clarification regarding prior MTFC-A implementations. The authors state that the context of intervention in the UK differs significantly from originating US studies since "these were focused on convicted delinquent youth where the alternative (to MTFC-A) was incarceration," thereby concluding that the "control condition in the US studies approximated to juvenile custody", p 219. Actually, similar to the UC condition in the Green et al. study, the standard control condition in US MTFC-A studies is group care (Chamberlain, 2003), rather than "incarceration". We offer these points byway of lending interpretation to the efficacy of the Green et al. results and to suggest caution with respect to accepting the conclusion that MTFC-A may not result in better outcomes than UC among at risk adolescents in English care.

Leve, L. D., Chamberlain, P., Smith, D. K., & Harold, G. T. (2011). Chapter 9: Multidimensional Treatment Foster Care as an intervention for juvenile justice girls in out-of-home care. In S. Miller,L. Leve, & P. Kerig (Eds.), Delinquent girls: Contexts, relationships,and adaptation (pp. 147-160). New York: Springer Press.

Chamberlain, P. (2003). Treating chronic juvenile offenders: Advancesmade through the Oregon multidimensional treatment foster care model. Washington, DC: American Psychological Association.

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Conflict of interest: The authors have respectively collaborated with US colleagues on projects using the MTFC-A programme.

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Treatment for young people is investment

Paul A McArdle, Consultant Child and Adolescent Psychiatrist
28 March 2014

The failure of a new intervention, multidimensional treatment foster therapy, to improve outcomes to a greater degree than standard care is on the face of it disappointing1. This is not least as the group of young people served was quite impaired and likely quite distressed; the pre-intervention Clinical Global Assessment Scale (CGAS) score of 48 indicates'moderate degree of impairment of functioning in most social areas...'

However, both the new, led by mental health personnel, and comparisoninterventions, likely led by social care, appear to have been at least moderately effective. The rise in CGAS to 56, with an effect size of approximately 0.7 (moderate) is comparable to the change achieved by combined antidepressant and specialist outpatient care for depressed adolescents2, if short of that achieved by inpatient care (young peoples services offer a more therapeutic community than their adult counterparts)with an effect size at follow up of 1.43.

Perhaps 3% of children and young people have a mental disorder of comparable severity to those treated in these studies4; of the 5 million or so young people in the 12 - 17 year age groups in England and Wales, over 100, 000 young people, with all the consequences for their life chances.

Obviously this is not a modern phenomenon but globalisation has raised the bar in terms of the capabilities required to compete for jobs or even long term relationships and stable family life; the consequence ofpsychosocial impairment is substantially greater than in simpler times. Toinvest effectively in the human potential of these young people could allow them to compete with educated immigrants, become socially mobile and, perhaps because we had helped them overcome adversity, even a social resource.

1.Green J., Biehal N., Roberts C., Dixon J., Kay C., Parry E., Rothwell J., Roby A., Kapadia D., Scott S. & Sinclair I. (2014) Multidimensional treatment foster care for adolescents in English care: randomised trial and observational cohort evaluation. British Journal of Psychiatry 204:214-221.2.Goodyer I., Dubicka B., Wilkinson P., Kelvin R., Roberts C., Byford S.,Breen S., Ford C., Barrett B., Leech A., Rothwell J., White L. and Harrington R. (2007) Selective serotonin reuptake inhibitors and routine specialist care with and without CBT in adolescents with major depression BMJ 335(7611):1423.Jacobs B., Green J., Kroll L., Tobias C., Dunn G., Briskman J. (2007) The effect of inpatient care on measured health needs in children and adolescents. The Journal of Child Psychology and Psychiatry 50:1273-1281.4.Roberts R., Attkisson C. & Rosenblatt A. (1998) Prevalence of psychopathology among children and adolescents. American Journal of Psychiatry 155:715-725.

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Conflict of interest: None declared

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