UNIVERSITEIT VAN AMSTERDAM
The effectiveness of institutional youth care for
children in primary school age and early
adolescence: A meta-analysis
Masterscriptie Forensische Orthopedagogiek Pedagogische en Onderwijskundige Wetenschappen Universiteit van Amsterdam
J.A.M. Huijs 10007768 Begeleiding: Prof. Dr. G.J.J.M. Stams (UvA), Dr. G.H.P. van der Helm (UvA) en
Drs. E. Strijbosch (Juzt) Tweede beoordelaar: Dr. I. B. Wissink Amsterdam, Juni 2013
Table of contents Abstract 3 Introduction 4 Method 6 Study selection 6 Inclusion criteria 6 Moderators 6 Publication bias 7 Analysis 8 Results 9 Discussion 13 References 16 2
Abstract
This multilevel meta-analysis of 19 controlled studies examined the effectiveness of institutional youth care for children in primary school age and early adolescence. These studies included 15.526 participants between the ages of 4 and 17 years. Effect sizes were based on comparisons between institutional Evidence-Based Treatment (EBT) and institutional Care As Usual (CAU), institutional EBT and non-institutional EBT, institutional CAU and institutional EBT and finally institutional CAU in comparison with non-institutional CAU. Only non-institutional CAU showed a small-to-medium negative significant effect comparison to institutional CAU (d = -0.342), which indicates that children in non-institutional CAU, which is mostly foster care, have better outcomes than children in regular group care. Furthermore, children in institutional youth care showed more delinquent behaviour compared to children in non-institutional youth care (d = -0.329). To conclude, children in primary school age and early adolescence seem to benefit more from institutional youth care. However, there is no difference between institutional and non-institutional youth care when non-institutional treatment is evidence-based. This implies that evidence-based treatment is necessary, because children in regular group care develop less favourably compared to children in non-institutional youth care.
Keywords: institutional youth care; effectiveness; meta-analysis; primary school age; early adolescence; evidence based
Introduction
Children have the right to grow up in a stable and safe environment where they get the warmth and support they need for their development. Unfortunately, not every parent is able to offer this security, and therefore some children temporarily live in institutional youth care (Manso, Garćia-Baamonde, Alonso, & Barona, 2011). Institutional youth care is carried out in 24-hour care facilities for children and youth with emotional and behavioural problems and their families (Preyde, Adams, Cameron, & Frensch, 2009). Most children in institutional care show externalizing behaviour (Lee & Thompson, 2007). They more often have an oppositional defiant disorder or a conduct disorder compared with children in non-institutional care. (Handwerk, Field, & Friman, 2001; Lee & Thompson, 2007). Children in institutional care live in a structured environment where they receive group care and/or individual treatment from a multidisciplinary team. This individual treatment is mostly based on behavioural, cognitive and solution focused models. Living in institutional youth care can have a great impact on the development of children (Preyde et al., 2009). For example, because of the separation from their parents, children may develop attachment problems (Van den Bergh, Weterings, & Schoenmakers, 2011; Van den Dries, Juffer, Van IJzendoorn, & Bakermans-Kranenburg, 2009).
There is no consensus in the literature about the effectiveness and appropriateness of institutional youth care (Preyde et al., 2011). In particular the long-term outcomes have been questioned (Dregan & Gulliford, 2012). There are studies with positive outcomes, but they are mostly based on small samples and control groups are often missing (Bean, White, & Lake, 2005). Some pre-experimental studies showed that there was a reduction of behavioural and emotional problems after treatment in institutional youth care (Larzelere et al., 2001; Leichtman, Leichtman, Barber, & Neese, 2001). Dregan, Brown and Armstrong (2011) have investigated the effectiveness of institutional youth care and foster care and showed that children in both treatments are at increased risk of behavioural and emotional problems in adulthood. Better outcomes and prognoses are related to the involvement of families during placement. A short length of stay and after-care services are also important factors that are associated with better outcomes of institutional youth care (Hoagwood & Cunningham, 1993).
Most studies are less positive about institutional youth care. Whitehead, Keshet, Lombrowski, Domenico and Green (2007) describe negative peer influences on children. They also believe that institutional youth care focuses too much on the child instead of the entire system of the child. Manso et al. (2011) showed that many children in institutional youth care have problems with their personal, school and social functioning. Dregan and 4
Gulliford (2012) concluded that children in institutional youth care develop less favourably compared to children in foster care. They gave three explanations for these results. First, foster care provides more positive care experiences, because it is a relatively stable placement with early admission to care. Second, children in foster care experience less serious behavioural and emotional problems. Third, not every caretaker in institutional youth care is a professional caregiver, because it is still unclear what characteristics a professional caregiver should have (Dregan & Gulliford, 2012).
Preyde et al. (2009) concluded that there is a lack of well-designed research describing the effectiveness of institutional youth care. This makes it unclear if institutional youth care is really less effective in comparison with non-institutional youth care. Moreover, institutional youth care is a very costly placement of last resort, and there is a growing number of alternative non-institutional treatments. Therefore, it is important to investigate the effectiveness of institutional youth care (James, 2011).
This multilevel meta-analysis builds on the meta-analysis of De Swart et al. (2012), who examined the effectiveness of institutional youth care over the past three decades in children and adolescents under 21 years. In the present study the focus is on children in primary school age and early adolescence. Research showed that 14% of the primary school aged children and early adolescents have mental health disorders (Waddell, Offord, Shepherd, Hua, & McEwan, 2002). Half of these children have two or more other disorders (Dilsaver, Henderson-Fuller, & Akiskal, 2003). Serious emotional and behavioural disorders interfere with children’s development and functioning in their homes, schools and communities. Some of these children receive treatment in institutional youth care (Preyde et al., 2009). It is therefore important to investigate the effectiveness of institutional youth care for children in primary school age and young adolescence, but a meta-analytic study was still missing. Therefore, this multilevel meta-analyses is conducted, which makes it possible to describe the effectiveness of institutional youth care for this group of children. Unlike the meta-analysis by De Swart et al. (2012), who conducted a regular meta-analysis, the present study uses multilevel meta-analytic techniques in order to be able to include more effect sizes of the same study, which increases statistical power and enables the examination of more moderators than can be achieved in regular meta-analysis.
The purpose of this multilevel meta-analysis is to determine the effects of institutional youth care on behaviour problems (externalizing and internalizing), skills (social and cognitive) and delinquency in primary school-aged children and early adolescents. To accomplish this, four comparisons are made. First, institutional Evidence-Based Treatment
(EBT), which is structured treatment based on theoretical and empirical evidence, is compared to institutional Care As Usual (CAU), which is mostly regular group care. Second, institutional EBT is compared to non-institutional EBT, such as Functional Family Therapy. Third, institutional CAU is compared to non-institutional EBT. Fourth, institutional CAU is compared to non-institutional CAU, such as foster care. Besides, the following moderators are examined as well: year of publication, journal impact factor, study quality, study design, time of measurement, type of intervention, data source, sex, mean age, percentage of girls, target group, ethnicity and control for pre-test differences in outcomes between the experimental and control group.
Method
Study selection
Three search methods were used to collect the studies. First, we searched for the studies with children and youth between 4 and 17 years old that De Swart et al. (2012) selected in their meta-analysis. Second, we searched for studies about a broad domain of institutional youth care in the period from 1970 to 2013 in electronic databases, such as ScienceDirect, PsychInfo, Picarta, Springerlink, ERIC, Medline and Google Scholar. We used the following keywords in various combinations: residential care, institutional care, group care, foster care, child, youth, comparison and effectiveness. Finally, we searched in the reference lists of all eligible studies.
Inclusion criteria
Studies were included if (1) the (quasi-)experimental group received institutional EBT or institutional CAU; (2) the control group received institutional CAU, non-institutional EBT, or non-institutional CAU; (3) the average age of the children was under age 15, with a range between 4 and 17 years; (4) studies provided at least post test scores or follow-up scores, in order to be able calculate effect sizes for differences between the experimental and control group; (5) studies had been published. This search resulted in 19 studies (N=15,526 children and youth) that met the inclusion criteria.
Moderators
Two researchers started coding the studies. Subsequently, the researchers coded the studies independently. Additionally, a third researcher randomly coded part of the studies in order to ensure interrater reliability. When coding the studies, the institutional group was always the experimental group and the non-institutional group was the control group. In case of two institutional groups, the group receiving evidence-based treatment was seen as the experimental group. A moderator was added where the pre-test effect size was subtracted from the post-test effect size to account for initial group differences between the experimental and control group.
Several moderators can influence the effectiveness of institutional care. For this reason each study included in the meta-analysis was coded for methodological and sample characteristics. Methodological characteristics were year of publication, journal impact factor, study quality, study design, time of measurement, comparison group, type of intervention, and the data source. A study quality index (QI) was used to evaluate the study quality (Downs & Black, 1998). Sample characteristics were mean age, percentage of girls, target group, ethnicity and the outcome variables.
These moderators were divided into continuous moderators and discrete moderators. Continuous moderators were year of publication, journal impact factor, study quality, mean age, percentage of girls and ethnicity. Discrete moderators were sex (boys or mixed), time of measurement (post-test or follow-up), control on pre-test (yes or no), type of comparison (institutional EBT vs non-institutional EBT, institutional EBT vs institutional CAU, institutional CAU vs non-institutional EBT and institutional CAU vs non-institutional CAU), study design (matched, non-matched and RCT), type of intervention (treatment, cognitive behaviour therapy, skills, system and no treatment), target group (civil, criminal, psychiatric and mixed), data source (official report, parent report, professional report and mixed) and the outcomes (total problems, externalizing behaviour, internalizing behaviour, social skills, cognitive skills and delinquency).
Publication bias
Studies reporting strong significant associations are more likely to be accepted for publication in a journal. Therefore, studies that report less strong significant associations are more difficult to find. Subsequently, conclusions of this meta-analysis may be incomplete, which is called the file drawer problem (Rosenthal, 1979). File drawer bias was examined using a funnel plot of the distribution of effect sizes. Each individual study’s effect size is 7
plotted on the horizontal axis against its sample size, standard error or precision (the reciprocal of the standard error) on the vertical axis. The distribution of effect sizes should be shaped as a funnel if no publication bias is present, since the more numerous studies with small sample sizes are expected to show a larger variation in the magnitude of effect sizes than the less numerous studies with large effect sizes. A violation of funnel plot symmetry reflects publication bias, that is, a selective inclusion of studies showing positive or negative outcomes (Sutton, Duval, Tweedie, Abrams, & Jones, 2000). Funnel plot asymmetry was tested by regressing the standard normal deviate, defined as the effect size divided by its standard error, against the estimate’s precision (the inverse of the standard error), which largely depends on sample size (see Egger, Smith, Schneider, & Minder, 1997). If there is asymmetry, the regression line does not run through the origin and the intercept significantly deviates from zero.
Analysis
For each of the studies Cohen’s d was calculated for the effectiveness of institutional youth care on the basis of differences between institutional and non-institutional youth care and difference between evidence based treatment and care as usual. Both the post-test data and the follow-up data were used. Effect sizes were calculated on the basis of means and standard deviations, percentages and t-, F-, χ2-, p-values. For this purpose, Wilson’s effect size determination program (2001) was used. Outliers were checked on the basis of z-values larger than 3.29 or smaller than -3.29 (p < 0.005; Tabachnick & Fidell, 2001). No outliers were found. After that, categorical variables were turned into dichotomous dummy codes and continuous moderator variables were centered around their mean in order to be able to conduct multilevel meta-analysis.
The homogeneity of the combined, total effect size was tested with a z-test of the between study variance (total study variance divided by its standard error). If this z-test is significant, than there is heterogeneity. In case of significant heterogeneity, moderators may account for differences between studies, and it is imperative to conduct categorical and/or continuous moderator analyses.
Finally, multilevel analysis was conducted by using the program MLwiN (Hox, 2002). The multilevel random effects model takes the hierarchical structure of the data into account, in which the effect sizes (the lowest level) are nested within studies (the highest level). Iterative maximum likelihood procedures were applied to estimate unknown parameters.
Results
This meta-analysis included 19 studies of which the results are based on N = 15.526 children and youth between the ages of 4 and 17 years. Table 1 shows a representation of the overall mean effect size and the significant discrete moderators. An effect size of d = 0.20 was considered as small, an effect size of d = 0.50 was considered as medium and an effect size of
d = 0.80 was considered as large (Cohen, 1988). The overall mean effect size was d = -0.018.
This effect is small and not significant, which indicates that children in institutional youth care do not have better outcomes than children in non-institutional youth care and/or do not profit from residential treatment if compared with general group care (institutional care as usual). Possible publication bias was examined by testing funnel plot asymmetry. The standard normal deviate was regressed against the estimate’s precision. As the intercept did not significantly deviate from zero (t = 1.879; p = 0.08), there was no indication of funnel plot asymmetry and therefore no indication of publication bias. These findings suggest that the mean effect size can be considered robust. Finally, the overall mean effect size proved to be heterogeneous (z = 2.875), which indicated that the effect was not the same in all studies.
Table 1 shows that type of comparison was a significant moderator: χ2 (3) = 8.932,
p < 0.05. The reference group was the comparison between institutional evidence-based
treatment and non-institutional evidence-based treatment (d = 0.342, ns). The institutional Care As Usual (CAU) versus non-institutional CAU comparison differed significantly from the reference group comparison (z = 2.601, p < 0.01), yielding a small-to-medium negative significant effect (d = -0.342; z = 2.280, p < 0.05). This means that children in non-institutional CAU, which is mostly foster care, had better outcomes than children in institutional CAU. A one-sided trend was found for institutional Evidence Based Treatment (EBT) compared to institutional CAU (d = 0.285; z = 1.397, p = 0.08), which indicated that institutional EBT may be expected to have better outcomes than general group care for children in primary school age and early adolescence.
Another moderator variable with a significant effect was study design: χ2 (2) = 9.656,
p < 0.01. Non-matched studies differed significantly from matched studies: z = 3.217,
p < 0.01. Matched studies yielded a negative and significant effect size (d = -0.309; z = 2.255, p < 0.05), whereas non-matched studies showed a positive and significant effect size
(d = 0.299; z = 2.300, p < 0.05). The non-matched studies showed better outcomes for children in institutional youth care and the matched studies showed better outcomes for children in non-institutional youth care.
Finally, type of outcome was a significant moderator: χ2 (5) = 25.115, p < 0.001. Delinquency differed significantly from the reference group, which was total problems:
z = 2.318, p = 0.05, yielding a small-to-medium negative significant effect (d = -0.329;
z = 2.179, p < 0.05). This means that children in institutional youth care show more
delinquent behaviour compared to children in non-institutional youth care. The other outcomes did not show a significant effect.
Table 2 shows the results for the continuous moderators. Year of publication was a significant moderator (z = 2.692, p < 0.01), which indicated that earlier published studies were associated with larger effect sizes (β1 = -0.035). With regard to the sex of the child a
significant moderating effect was found (z = 2.500, p < 0.05). Studies with a high percentage of females were associated with smaller effect sizes (β1 = -0.015).
Table 1
Results for the overall mean effect size and discrete moderators (bivariate models)
Note. RG = reference group; # Studies = number of studies; # ES = number of effect sizes; Mean d = mean effect
size; Z = significance of moderator; RC = slope ; Z = differences in mean d with reference group;
Heterogeneity = within class heterogeneity (Z); Fit = difference with model without moderators (χ2); * p < 0.05; ** p < 0.01; *** p < 0.001; + = one-sided trend = 0.08
Moderator variables # Studies # ES Mean d Z RC Z Heterogeneity Fit χ2
Overall 19 63 -0.018 0.176 2.875**
Type of Comparison 2.804** 8.932*
Inst EBT vs
Noninst EBT (RG)
3 20 0.342 1.591
Inst EBT vs Inst CAU 4 8 0.285 1.397+ -0.057 0.193 Inst CAU vs Noninst EBT 6 21 -0.038 0.252 -0.380 1.445 Inst CAU vs Noninst CAU 6 14 -0.342 2.280* -0.684 2.601** Study Design 2.814** 9.656** Matched (RG) 7 15 -0.309 2.255* Non Matched 8 35 0.299 2.300* 0.608 3.217** RCT 4 13 -0.131 0.712 0.177 0.773 Type of Outcome 2.833** 25.115*** Total problems (RG) 11 14 0.035 0.343 Externalizing behaviour 10 13 0.168 1.680 0.133 2.180* Internalizing behaviour 10 13 -0.051 0.510 -0.085 1.393 Social skills 4 6 0.089 0.605 0.054 0.409 Cognitive skills 9 12 0.051 0.490 0.016 0.208 Delinquency 5 5 -0.329 2.179* -0.364 2.318* 11
Table 2
Results for the continuous moderators (bivariate models)
Moderator variables # Studies # ES β0 (SE) β1 (SE) Z Heterogeneity Fit χ2
Methodological moderator
Year of publication 19 63 0.055 (0.089) -0.035 2.692** 2.800** 6.806**
Sample characteristic
Girls exp group 19 45 -0.060 (0.089) -0.013 2.167* 2.558* 4.966* Girls cont group 19 45 -0.070 (0.089) -0.013 2.167* 2.545* 4.586* Total girls 19 63 0.022 (0.092) -0.015 2.500* 2.840** 5.696*
Note. # Studies = number of studies; # ES = number of effect sizes; β0 (SE) = intercept; β1 (SE) = slope;
Z = significance of moderator; Heterogeneity = within class heterogeneity (Z); Fit = difference with model without moderators (χ2); * p < 0.05; ** p < 0.01
Discussion
The purpose of the present meta-analysis was to examine the effectiveness of institutional youth care for behaviour problems (externalizing and internalizing), skills (social and cognitive) and delinquency of children in primary school age and early adolescence. Effect sizes were based on comparisons between institutional Evidence-Based Treatment (EBT) and institutional Care As Usual (CAU), institutional EBT and non-institutional EBT, institutional CAU and non-institutional EBT and finally institutional CAU in comparison with non-institutional CAU.
The first conclusion is that only institutional CAU showed a small-to-medium negative significant effect in comparison with non-institutional CAU (d = -0.342), which indicates that children in non-institutional CAU, which is mostly foster care, had better outcomes than children in group care. This conclusion is in line with the study of Dregan and Gulliford (2012). They concluded that children in institutional youth care develop less favourably compared to children in foster care. This finding is also fairly similar to the study of De Swart et al. (2012). They found that non-institutional CAU had better outcomes than institutional CAU, although this difference was not significant.
The second conclusion of this study is that evidence based treatment is necessary. De Swart et al. (2012) found a significant difference between institutional EBT and institutional CAU, with better outcomes for institutional EBT. The current study showed not a significant difference between those groups, but a trend (d = 0.285). Both meta-analyses indicate that it is more effective to provide children with evidence-based treatment during their stay in institutional youth care.
Moderator analyses indicated that the design of the studies influences the conclusion about the effectiveness of institutional youth care. Institutional youth care showed better outcomes in non-matched studies, whereas matched studies showed less favourable outcomes for institutional youth care. The main potential benefit of matching studies is a gain in efficiency, because the participants in the experimental group and control group are more equivalent. For this reason, more value is attached to the outcomes of the matched studies, which are less positive about institutional youth care. This finding is also in line with the first conclusion.
In contrast to the study of De Swart et al. (2012) this study found a significant moderator effect for delinquency. Children in institutional youth care showed more delinquent behaviour compared to children in non-institutional youth care. This can be explained by the fact that this meta-analysis focused on children in primary school age and early adolescence, 13
in which delinquency is expected to occur less. The differences between the effect sizes on other types of outcomes did not influence the effectiveness of institutional youth care in this meta-analyses, which is in line with De Swart et al. (2012).
Finally, a significant moderating effect was found for year of publication and sex of the child. Studies that were published more recently, and studies with a higher percentage of females were associated with smaller effect sizes. This first finding may be explained by the fact that statistical techniques have become more advanced over time, such as propensity score matching, which enables control for multiple confounders that are responsible for differences between institutional and non-institutional care. In addition, and probably even more important, growing insights into offering qualitatively good institutional care may have diminished the differences between institutional and non-institutional youth care (Farrington & Welsh, 2006). The association between sex of the child and magnitude of the effect sizes could be explained by the fact that girls in institutional youth care seem to suffer more from neglect (Ressler, 2011; Gunter-Moor, 2011) and more often have a history of trauma and sexual abuse, resulting in a combination of internalizing and externalizing problems (Zurbriggen, 2010). Research showed that children with externalizing behavioural problems seem to make more progress after institutional youth care than youth with internalizing behavioural problems, which are mostly girls (Knorth, Harder, Zandberg & Kendrick, 2007). This could be an explanation for the differences between institutional and non-institutional youth care when the percentage of girls increases.
Unfortunately, the influence of therapeutic alliance and group climate in young children in institutional youth care were not measured, because there was no sufficient information available to code these moderators. It may be expected that these factors influence treatment outcomes. For example, Van der Helm, Klapwijk, Stams, and Van der Laan (2009) showed that an open living group climate had a positive effect on the treatment of juvenile prisoners. Within such a climate adolescents have the feeling that they are being taken seriously, because the group workers pay attention to their needs. Research also showed that therapeutic alliance is a predictor of treatment outcomes of individual therapies (Karver, Handelsman, Fields, & Bickman, 2006). It may be expected that group climate and therapeutic alliance also influence the treatment of young children in institutional youth care, but research is still limited. It is therefore important that these factors are investigated in future research. Also remarkable is the fact that in none of the controlled studies that could be included in the current meta-analysis, self-reports of the children were used. This could be a valuable supplement to the official, parental and professional reports.
There are some limitations of this meta-analysis that should be noted. First, the number of effect sizes was very small in some moderator categories, which may have resulted in less reliable outcomes. Second, not every study reported the range of the age of the children. When a mean age lower than 15 years was reported without the exact age range, the study was nevertheless included. As a result, we do not know whether these studies contained mainly children in primary school age or early adolescence, which hampers more specific generalizability of our study findings. Another limitation is that evidence based treatment and care as usual are broadly defined categories. The limited number of studies and effect sizes, did not allow making more refined comparisons between different kinds of treatments.
Despite these limitations, this meta-analysis has several strengths. It provides better and new insights into the effectiveness of institutional youth care for children in primary school age and early adolescence. Second, applying multi-level analysis made it possible to include more effect sizes than can be achieved with regular meta-analysis and to code more moderators as well. Therefore, the current meta-analysis presents a more substantial way of investigating the effectiveness of institutional youth care compared to a regular meta-analysis.
To conclude, some children in early adolescence with severe behavioural and emotional problems may benefit more from institutional youth care, which provides both a structured environment and intensive evidence-based treatment. In general, most children in primary school age and early adolescence seem to benefit more from non-institutional youth care than from institutional youth care. It is therefore important to first consider the possibility of non-institutional youth care, because this type of care seems to be most effective. It is likely that children in primary school age develop better in foster care, because a more stable (family) environment may provide better conditions for their development (for instance, the development of secure child-caregiver attachment relationships). Additionally, within such an environment children are thought to be less affected by negative peer influences (Whitehead et al., 2007). However, more research is needed to investigate the influences of group climate and therapeutic alliance, because these factors may increase the effectiveness of institutional youth care.
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