Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20

Mental Health Care Interventions in Child Welfare:

Integrative Review of Evidence-Based Literature

Mari Lahti, Merle Linno, Janika Pael, Margit Lenk-Adusoo & Eeva Timonen-
Kallio

To cite this article: Mari Lahti, Merle Linno, Janika Pael, Margit Lenk-Adusoo & Eeva Timonen-
Kallio (2018): Mental Health Care Interventions in Child Welfare: Integrative Review of Evidence-
Based Literature, Issues in Mental Health Nursing, DOI: 10.1080/01612840.2018.1479902

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ISSUES IN MENTAL HEALTH NURSING
https://doi.org/10.1080/01612840.2018.1479902

Mental Health Care Interventions in Child Welfare: Integrative Review of

Evidence-Based Literature
Mari Lahti, PhD, Post Doca,b , Merle Linno, MSWc, Janika Pael, MNcd, Margit Lenk-Adusoo, MNcd, and
Eeva Timonen-Kallio, Lic.Soc.Sca
a
Health and Well-being, Turku University of Applied Science, Turku, Finland; bDepartment of Nursing Science, University of Turku, Turku,
Finland; cDepartment of Social Sciences, University of Tarto, Tarto, Estonia; dDepartment of Nursing, Tartu Health Care College,
Tarto, Estonia

ABSTRACT
Many of the youths living in vulnerable environments in child welfare settings are in need of
psychiatric treatment as well as child protection services. There is an urgent demand for closer
collaboration between these two sectors in order to ensure more effective work in child welfare
regarding to mental health care interventions is provided. The aim of this integrative review was
to describe the evidence-based literature related to mental health care interventions provided in
child welfare. Seven databases (PubMed, EBSCOhost, Ovid MEDLINE, Eric, CINAHL, Elsevier Science
Direct, Cochrane database) were searched, while search parameters included English-only manu-
scripts published prior to 20 May 2016. Out of 152 records, only eight studies met the inclusion
criteria. Mental health care interventions described varied and were listed as follows: crisis assess-
ment, respite child care, counselling, therapeutic interviews, cognitive and educational screening,
different therapies, psychoeducational support, psychological testing, behavioural assessment,
individual work and brief interval care. Despite using comprehensive searches in seven databases,
we found only eight studies related to acute psychiatric services targeted at child welfare. There is
not enough evidence to arrive at a definite conclusion on the effects of mental health care inter-
ventions in child welfare.

Introduction children live in residential child care (RCC) facilities or

Mental health issues will continue to drain the global economy
as the shift in burden from communicable to non-communic-
able diseases continues to grow (Patel et al., 2016). A serious
concern is that the costs may be doubled in just a couple of
decades as generations change (Bloom et al., 2011). Promoting
health of all European citizens is one of the main targets of
Europe 2020’s objectives for smart and inclusive growth.
Keeping people healthy has a positive impact on productivity
and competitiveness, thus innovations are needed to find
new solutions to promote good health and prevent ill health
(European Commission, 2010). The ongoing political and
economic discussion, promoting mental health in general, has
increased as mental health problems place immense burdens
on individuals, families, societies and economies (Wykes et al.,
2015). Approximately, 38% (165 million people) of Europeans
are affected by mental health problems, which cause losses of
hundreds of billions of euros to the society (Wittchen et al.,
2011). The concern is that half of the mental health problems
start before the age of 14 (Kessler et al., 2007). Therefore, the
focus needs to be shifted from the curative care to the preven-
tion of youth mental health disorders.
In Europe around 1.3 million children live in foster care
provided by child welfare services; about half of these
boarding schools (UNICEF, 2011). It is estimated that as
many as 80% of the young people involved with RCC have
emotional or behavioural disorders, developmental delays, or
other indications of needing mental health intervention
(Burns et al., 2004; Everson-Hock et al., 2012; Lahti &
Ellil€a€a, 2015). It has also been stated that these young people
living out of home care are in higher risk of mental health
care problems (Lahti & Ellil€a€a, 2015). Also some of these
children living out of home care face the fact that their
parents already have mental health issues which may affect
children as well (Simkiss, Stallard, & Thorogood, 2013).
There is relationship between mental health problems
and being part of education as student or being employed.
Two robust findings from the US indicate that there are
certain differences between young adults with foster care
histories and their general population peers in education
and employment outcomes: about four-fifths of young adults
who transitioned out of foster care have a high school dip-
loma which it is considerably lower than the percentage of
young adults who are college graduates in the general popu-
lation and it seems unlikely that they will “catch up” with
their peers in terms of educational attainment (Courtney
et al., 2011, p. 113). Furthermore, youth formerly in foster

CONTACT Mari Lahti mari.lahti@turkuamk.fi Health and Well-being, Turku University of Applied Science, Ruiskatu 8, 20720 Turku, Finland.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/imhn.
ß 2018 Taylor & Francis Group, LLC
2 M. LAHTI ET AL.
care earn about half and the employment rate is 20 points
lower (Okpych & Courtney, 2014). It is obvious, that these
young people are the most vulnerable ones in the society,
with weaker education, lower rate of employment and
poorer health outcomes than in case of other children
(Simkiss et al., 2013).
Residential child care (RCC) services, in child welfare,
place an enormous burden on the health care system due to
the repeated hospitalizations and referrals to mental health
services that could be avoided by implementing effective
mental health care interventions in RCC (James, 2015). As
the rate of children in RCC rise in many European coun-
tries, the pressure on child welfare services to maximize the
quality and supply of mental health care interventions in
residential child care increases (Gilbert et al., 2011). Mental
health care interventions can be for example general school-
based mental health promotion intervention (Dray et al.,
2017), well targeted parental programmes to support mental
health issues for young people (Furlong et al., 2013) or right
time offered mental health support in community settings
(Karukivi, M€akel€a, & Haapasalo-Pesu, 2013).
Earlier research indicates that there is a need for targeted
mental health care interventions in child welfare and espe-
cially in acute situations in residential child care. Mental
health care services provided by emergency departments are a
critical access point for mental health care for young people
who have been unable to receive care elsewhere or are in a
crisis (Janssens, Hayen, Walraven, Leys, & Deboutte, 2013;
Newton et al., 2012). Karukivi et al. (2013) pointed out that
there are limited amount of services targeted at young people
by outpatient psychiatric youth care. Therefore, more
emphasis should be placed on outpatient mental health care,
and the focus should be on improving the access of young
people to an urgent assessment of mental health (Karukivi
et al., 2013). In addition, it has also been shown that when
the mental health care providers consulted daily with the
caregivers and case managers at child welfare agencies and
educated them about the impact of a trauma on children’s
mental health, the rate of placement change for children
served in these agencies was much lower (Collado & Levine,
2007). Furthermore, providing for children in foster care
mental health care services may improve the rate of place-
ment stability (Bellamy, Gopalan, & Traube, 2010) thus pre-
venting placement changes. Therefore, improving the
outpatient mental health care services should be the major
objective for the collaboration between the residential child
care and the mental health care services.
A common interest for developing multidisciplinary child
care across Europe is due to the fact that residential child
care is costly (Courtney et al., 2011, p. 113). The cost of the
placement is the most substantive cost element, but children
also receive a range of different services, from a range of
providers to support them in their placement, for example,
the involvement of mental health services or educational
support services; thus the commissioning of services has
increasingly become a joint activity, particularly with the use
of multidisciplinary decision making panels (Holmes &
McDermid, 2012). Many countries recognize the importance
of the multidisciplinary nature of the child welfare work and
the necessity of mental health care professionals to work
together (Gilbert et al., 2011). It is widely known that collab-
oration between child protection and mental health agencies
can improve the use of children’s mental health services
(Bai, Wells, & Hillemeier, 2009). Furthermore, it is suggested
that care workers in residential care should be better able to
identify emotional or behavioural problems (to differentiate
them from mental health problems) and better informed
about evidence-based interventions, their availability and
how to access them (Dorsey, Kerns, Trupin, Conover, &
Berliner, 2012; Harder & Knorth, 2015; James, 2015; Nunno,
Sellers, & Holden, 2014).
Residential child care places a significant burden on the
health care system due to repeated hospitalizations and refer-
rals to mental health services that could be avoided by imple-
menting effective multidisciplinary collaboration. Many of the
children living in vulnerable living environments in families
and/or residential child care settings are in need of psychiatric
treatment and child protection services (Timonen-Kallio
et al., 2015). The common problem is that the professional
expertise stays in silos; professionals act in separate sectors
and thus effective multidisciplinary networking is difficult to
establish. Each care profession has a different working cul-
ture, values and behaviours (Hall, 2005).
The above-mentioned evidence raises a question whether
mental health care interventions and services offered at a
right time in RCC can benefit young people’s mental health.
However, there is a lack of research on what kind of mental
health interventions and services are targeted to the young
people in child welfare settings.
Aim
As far as we are aware, there have been no integrative
reviews to date describing mental health care interventions
for young people living in conditions provided by child pro-
tection. Since children and adolescents deal with a number
of different mental health problems and may even be taken
out of their home to an institution without adequate care,
this integrative review is important, as it presents a qualita-
tive analysis describing the relevant interventions and good
practices to determine the effects of different mental health
care interventions supporting the mental health care of
young people. Our aim was to describe the evidence-based
literature related to mental health care interventions pro-
vided in child welfare.
Methods
Design
This integrative review (Hopia, Latvala, & Liimatainen, 2016)
was conducted with methods described by Whittemore and
Knafl (2005). The Preferred Reporting Items for Systematic
Reviews and Meta-analysis (PRISMA) were used to guide the
search process to be more systematic (Moher, Liberati,
Tetzlaff, & Altman, 2009). Also the mental health
 ISSUES IN MENTAL HEALTH NURSING 3

interventions used in child welfare were described using the
Template for Intervention Description and Replication
(TIDieR) checklist and guide (Hoffman et al., 2014).
Search sources
Seven databases (PubMed, EBSCOhost, Ovid MEDLINE,
Eric, CINAHL, Elsevier Science Direct, Cochrane database)
were searched for potentially relevant abstracts. These data-
bases cover a wide range of published research from the
field of health and social care. Search parameters included
English-only manuscripts published (or in press) prior to 20
May 2016 and no other time restriction were done. For add-
itional references, we checked the lists of references in the
included studies manually.
Eligibility criteria
The integrative review was limited to texts published in
English with an abstract available (published in or before 20
May 2016). The inclusion criteria covered quantitative or
qualitative empirical studies and/or review articles, and the
population consisted of children and/or adolescents living in
residential child care or foster homes of psychiatric units.
The integrative review topic was limited to studies concern-
ing an intervention and/or phenomena of acute mental
health care action and/or acute team work and/or crisis
work and/or emergency psychiatric care. Studies were
excluded in case of a non-adolescent population and in case
the topic of interest was not in acute team work and/or cri-
sis work or mental health. Hits were excluded if they were
book chapters, editorial letters or conference proceedings
considered as grey literature (Adams, Smart, & Huff, 2017;
Egger, Juni, Bartlett, Holenstein, & Sterne, 2003).
Search words
The search terms (or equivalent index terms and free-text
words) for each of the databases were used to ensure a
broad coverage of studies in our integrative review. The
detailed terms for each database were searched by an infor-
mation specialist at Turku University of Applied Science.
Search terms for each database are presented in Table 1.
There are some differences between databases and search
words used due to the available thesaurus terms in the
specific databases.
Study selection
Out of 152 hits, any duplicates across all databases were
removed, leaving us with 138 abstracts. First, four authors
(ML, ET-K, ML, JP) screened the titles and abstracts independ-
ently for eligibility; ineligible hits were excluded (n ¼ 130).
Second, we found zero additional papers when an additional
hand search of lists of references was conducted. Third, 11 full
papers were obtained and screened by the four authors for the
inclusion and exclusion criteria. Finally, three papers had to be
excluded (see Table 2). The integrative review was conducted
on the eight retrieved papers. In case of discrepancies concern-
ing the decisions made between the reviewers, the papers were
discussed until a consensus was reached between reviewers.
Figure 1 outlines the search process of the literature, according
to PRISMA (Moher et al., 2009).
Quality appraisal
Quality appraisal of the included studies were assed accord-
ing to Mixed Methods Appraisal Tool [MMAT] (Pluye
et al., 2011). Authors (ML, E T-K) independently assessed
quality of the each included study by using Mixed Methods

Table 1. Databases, search terms, and references found.

Database Search Terms N
PubMed ("acute care team" OR "acute care teams" OR "acute team model" OR "acute team models" OR "acute care model" OR "acute 27
care models" OR "emergency psychiatric care" OR "crisis intervention service" OR "psychiatric open care" OR "Emergency
Services, Psychiatric"[Mesh]) AND ("child welfare" OR "child protection" OR "child custody" OR "residential child care" OR
"residential child treatment" OR "foster care" OR "foster home care" OR "families who care for neglected children" OR
"looked after children"). Filters: Adolescent: 13–18 years, Child: 6–12 years
Ovid MEDLINE ("acute care team" or "acute care teams" or "acute team model" or "acute team models" or "acute care model" or "acute care 10
models" or "emergency psychiatric care" or "crisis intervention service" or "psychiatric open care" or "Emergency Services,
Psychiatric").mp. AND ("child welfare" or "child protection" or "child custody" or "residential child care" or "residential child
treatment" or "foster care" or "foster home care" or "families who care for neglected children" or "looked
after children").mp.
CINAHL Complete (acute care AND ( team OR group OR model )) OR "acute team model" AND ("child welfare" OR "child protection" OR 7
"child custody" OR "residential child care" OR "residential child treatment" OR "foster care" OR "foster home care" OR
"families who care for neglected children" OR "looked after children" )
Elsevier Science "acute care team" OR "acute team model" OR "acute care model" OR "emergency psychiatric care" OR "crisis intervention 45
Direct service" OR "psychiatric open care" AND "child welfare" OR "child protection" OR "child custody" OR "residential child care"
OR "residential child treatment" OR "foster care" OR "foster home care" OR "families who care for neglected children" OR
"looked after children". Filters: since 2000.
Eric ("crisis intervention service" OR "psychiatric open care" OR "emergency psychiatric") AND ("child welfare" OR "child protection" 10
OR "child custody" OR "residential child care" OR "residential child treatment" OR "foster care" OR "foster home care")
EBSCOhost (acute care AND ( team OR group OR model )) OR "acute team model" AND ("child welfare" OR "child protection" OR 50
"child custody" OR "residential child care" OR "residential child treatment" OR "foster care" OR "foster home care" OR
"families who care for neglected children" OR "looked after children" )
Cochrane Library "acute care team" OR "acute team model" OR "acute care model" OR "emergency psychiatric care" OR "crisis intervention 3
service" OR "psychiatric open care" AND "child welfare" OR "child protection" OR "child custody" OR "residential child care"
OR "residential child treatment" OR "foster care" OR "foster home care" OR "families who care for neglected children" OR
"looked after children"
4 M. LAHTI ET AL.

Table 2. Excluded studies.

Author, Year, Country
Stewart et al. 2001, Canada
Tatlow-Golden & McElvaney 2015, Ireland
Tarren-Sweeney 2006, New Zealand
Title
Suicidal Children and Adolescents with First
Emergency Room Presentations: Predictors of
Six-Month Outcome
A Bit More Understanding: Young Adults’ Views of
Mental Health Services in Care in Ireland
Patterns of Aberrant Eating among Pre-adolescent
Children in Foster Care
Reason for Exclusion
Did not have any interventions of mental health care
or psychiatric services provided or type of child
welfare action interventions
Wrong population age group
Did not have any interventions of mental health care
or psychiatric services provided or type of child
welfare action interventions

Figure 1. PRISMA flow diagram (Moher et al., 2009).

Appraisal Tool [MMAT] (Pluye et al., 2011). In case of dis-
agreement, the final rating was made by consensus, with the
involvement of authors ML, JP. Table 3 describes the quality
assessment of each included study.
Data analysis
A qualitative analysis was performed to the extracted papers.
We created a specific data extraction sheet to obtain detailed
information of the studies. First, the characteristics of the
studies were described (author, year, country of origin, title,
population, setting, sample, age range, methods, type of
intervention provided). Secondly, we described the types of
interventions related to the mental health care provided for
young people according to the TIDieR checklist and guide
(Hoffmann et al., 2014). The matrix used in our extraction
was based on a 12-item checklist and was constructed with
the following information: brief name, why (rationale or
theory), what (materials, procedures), who provided the
intervention, how, where, when and how much, tailoring,
modifications, and how well (planned, actual). For narrative
qualitative analysis, the data on each included study were
entered into the data extraction matrix; each study was
treated as a separate case. Descriptive characteristics of the
studies were categorized manually.
Result
Characteristics of studies
Eight studies were included in the integrative review. Four
studies were conducted in the United States (Cole &
Hernandez, 2011; Fawley-King & Snowden, 2012; Ornelas,
Silverstein, & Tan, 2007; Wattenberg, Luke, & Cornelius,
2004), three were conducted in the United Kingdom (Lamb,
2009; Pycroft, Wallis, Bigg, & Webster, 2015; Richards,
Wood, & Ruiz, 2006), and one was conducted in Australia
 ISSUES IN MENTAL HEALTH NURSING 5

(Milburn, Lynch, & Jackson, 2008). The participants in

et al. (2004)
Wattenberg
included studies were mostly looked after children (Cole &

Yes

Yes
NA
Hernandez, 2011; Fawley-King & Snowden, 2012; Richards
et al., 2006), children in shelters (Wattenberg et al., 2004),
data from referrals (Milburn et al., 2008; Pycroft et al., 2015)
or data from records (Ornelas et al., 2007). One study was a
systematic review with children and adolescent participants
et al. (2006)
Richards

(Lamb, 2009). Participants were aged between 0 and

Yes

Yes
Yes

No
18 years, and the total number of participants was 21 508;
however, one study (Fawley-King & Snowden, 2012) con-
sisted of data from records, covering 19 351 participant
cases. The details of the characteristics and methodology of
et al. (2015)

Can’t tell
the studies are presented in Table 4.
Pycroft

Yes

Yes

Yes

Interventions of mental health care or psychiatric

services provided
et al. (2007)

Can’t tell

Five articles described interventions of mental health care or

Ornelas

Yes

Yes
Yes

psychiatric services provided (Cole & Hernandez, 2011;

Milburn et al., 2008; Ornelas et al., 2007; Pycroft et al., 2015;
Wattenberg et al., 2004). Most of the mental health care
interventions were carried out in the early stage of the child
et al. (2008)

welfare process. Interventions were offered to foster families

Milburn

Yes

Yes
Yes

Yes

(Cole & Hernandez, 2011), to all child protection clients

(Milburn et al., 2008; Wattenberg et al., 2004), to children
living out of home care ( Ornelas et al., 2007) and to young
people (Pycroft et al., 2015). Several different methods were
(2009)
Lamb

Yes

Yes
Yes

Yes

used for offering the mental health care interventions such as

crisis assessment, respite child care, counselling, therapeutic
Fawley-King and
Snowden (2012)

interviews, cognitive and educational screening, different

therapies, psychoeducational support, psychological testing,
Yes

Yes
NA

behavioural assessment, individual work and brief interval

care. Most of the interventions were provided through multi-
disciplinary teams. (Cole & Hernandez, 2011; Milburn et al.,
Hernandez (2011)

2008; Ornelas et al., 2007; Pycroft et al., 2015; Wattenberg

et al., 2004). The summary of the interventions is provided in
Cole and

Yes

Yes
NA

Table 5 in accordance with the TIDieR checklist and guide

(Hoffmann et al., 2014).
2. Is the process for analyzing qualitative data relevant to address the

Narrative analysis
researchers influence through their interactions with participants?

acceptable response rate, or an follow-up rate for cohort studies?

3. Are measurements appropriate (clear origin, or validity known, or

1. Are participants recruited in a way that minimizes selection bias?

1. Is the sampling strategy relevant to address the quantitative

Overall, in the eight articles (Cole & Hernandez, 2011;

3. Is appropriate consideration given to how findings relate to

4. Is appropriate consideration given to how findings relate to

2. Is the sample representative of the population understudy?

3. Are there complete outcome data and when applicable, an

1. Are the sources of qualitative data relevant to address the

Fawley-King & Snowden, 2012; Lamb, 2009; Milburn et al.,

2. Are measurements appropriate regarding the exposure
4. Is there an acceptable response rate (60% or above)?

2008; Ornelas et al., 2007; Pycroft et al., 2015; Richards

research question (quantitative aspect of the mixed

et al., 2006; Wattenberg et al., 2004) results varied. Cole and

Hernandez (2011) described that the children whose families
Table 3. Quality appraisal of included studies.

received crisis nursery services prior to foster care placement

were twice as likely to be reunited with their biological fami-
Responses are Yes, No, Can’t tell or NA.

lies and, moreover, crisis nurseries can prevent the out-of-

home placement of infants and young children by reducing
Quantitative non-randomized

stress and enhancing parenting skills. Fawley-King and

Snowden (2012) showed that the placement change in foster
standard instrument)?
Quantitative descriptive

methods question)?

research question?

research question?

care is a significant predictor of the subsequent psychiatric

hospitalization, use of crisis services and psychiatric hospi-
and outcome?
the context?

talization later in children’s lives. However, Lamb (2009)

Qualitative

review stated that intensive community treatment works

best for individuals with severe and complex needs when a
range of treatment modalities is available, including the
Table 4. Characteristics of included studies.
Author, year,
country of study Title
Cole & Hernandez Crisis Nursery Effects on Child
2011, USA Placement after Foster Care
Fawley-King & Relationship between Placement
Snowden, Change during Foster Care and
2012, USA Utilization of Emergency Mental
Health Services
Lamb 2009, UK Alternatives to Admission for
Children and Adolescents:
Providing Intensive Mental
Healthcare Services at Home and
in Communities: What Works?
Population, setting, sample, age range
Population: Children
Setting: Administrative data of the
five crisis nurseries in Illinois, the
Illinois Department of Children and
Family Services CANTS and CYSIS.
Sample: Looked after children
Number: 198 Age range: 0–5
Population: Children
Setting: Medi-Cal paid claims and
foster care placement records.
Sample: Looked after children in
foster care
Number: 19,351
Age range: 6–18
Population: Children, adolescent
Setting: Services admitting young to
psychiatry
Sample: All types of study were
included.
Number: 58 included studies.
Age range: 5–18
Outcome measures
Outcome measures: The length of stay;
Child placement outcome Child and
caregivers variables
Outcome measure: Placement change
leads to future crisis service use or
psychiatric hospitalization. Use of
crisis services or psychiatric
hospitalization as risk factors for
future placement change.
Systematic review
6
Different interventions of
mental health care or
psychiatric services
provided // or type of
child welfare
Results interventions
Children whose families received crisis Crisis nursery service:
M. LAHTI ET AL.
nursery services prior to foster care Nurseries as ‘open
placement were twice as likely to be family services’, part
reunited with their biological families of a continuum of
when compared to children whose care of child welfare
families received only foster care services. CNs grew
services. Receiving crisis nursery reflecting the family
services may have positive effects on and support needs of
the children’s ultimate placement local communities.
outcome after foster care. The Most CNs offer initial
greater likelihood of children crisis assessment and
returning to their families when the intervention services,
families received crisis nursery after-crisis
services prior to placement in out-of- interventions such as
home care shows that the impact of follow-up care, and/or
crisis nursery service use can extend referral to community
beyond immediate use of the service. services. The family
When families use crisis nursery can be assigned to
services, crisis nurseries can prevent intact child welfare
the out-of-home placement of infants services and receive
and young children by reducing both child welfare
stress and enhancing parenting skills. and crisis nursery
services or the child
could be placed in
out-of-home care
(e.g., foster or
kinship care).
While placement change in foster care Foster care &
is a significant predictor of emergence mental
subsequent psychiatric health services: Crisis
hospitalization, use of crisis services services and inpatient
and psychiatric hospitalization are psychiatric
predictors of subsequent placement hospitalization.
change. This indirect relationship
suggests that children in foster care
could benefit from both interventions
that promote placement stability and
improved mental health treatment
following psychiatric crises.
Day unit care demonstrate its flexibility Eight distinct models of
to adapt to different disorders and care: 1. Multi
circumstances. Support use of Systemic Therapy
alternatives to inpatient care. Multi (MST) at home 2. Day
Systemic Therapy and ACT have the hospital care 3. Case
strongest evidence base. Intensive management 4.
community treatment works best for Specialist outpatient/
individuals with severe and complex outreach service 5.
needs when a range of treatment Home-based
(Continued)
Table 4. Continued.
Author, year,
country of study Title
Milburn et al. Early Identification of Mental Health
2008, Australia Needs for Children in Care: A
Therapeutic Assessment
Programme for Statutory Clients
of Child Protection
Ornelas et al. Effectively Addressing Mental Health
2007, USA Issues in Permanency-Focused
Child Welfare Practice
Pycroft et al. Participation, Engagement and
2015, UK Change: A Study of the
Experiences of Service Users of
the Unified Adolescent Team
Population, setting, sample, age range
Population: Children, adolescents
Setting: Multi-centre
Sample: Referrals from child
protection to care
Number: 161
Age range: 0–17
Population: Children
Setting: The centre, single-centre
Sample: Data from records
Number: 0–6 yrs n ¼ 387; 6–12 yrs
n ¼ 212
Age range: 0–6, 6–12
Population: Adolescents
Setting: Single-centre
Sample: Adolescents who had been
referred to the Unified Adolescent
Team and had received support or
therapy from a clinician in the team
Number: 6
Age range: 12–20
Outcome measures
Outcome measures: Strengths and
Difficulties Questionnaire (SDQ);
Strengths and Difficulties
Questionnaire (SDQ) Parents/Carers
version; Self or Teacher Report
versions of the Strengths and
Difficulties Questionnaire
Outcome measures: Performance
Outcome Measures (POM); Ages and
Stages Questionnaire; The Kinship
Center Attachment Questionnaire
(KCAQ); On the Child and Adolescent
Functional Assessment Scale (CAFAS);
Randolf Attachment Disorder
Questionnaire; The Child Behaviour
Checklist (6–18 years).
Qualitative interview: Talk freely about
their involvement with the UAT and
their perspectives on the services
that they received
Different interventions of
mental health care or
psychiatric services
provided // or type of
child welfare
Results interventions
modalities is available, including psychiatric treatment
access to specialized hospital care. service 6. Family 7.
Need for different models of Preservation service 8.
intensive mental health care Therapeutic foster
provision inc. intensive outreach care as short-term
services, crisis intervention teams and residential
age-appropriate day patient and care programme
inpatient (acute and planned
treatment) provision. Need for
evidence on the therapeutic content
of interventions delivered within the
models of care.
Parents and carers reported over twice Pilot program: to
the level of pathology in children in provide an early
their care than the children assessment, input
themselves reported. Parents and into planning and
carers identified a higher level of referral where
pathology than teachers did of appropriate for all
children in their classroom. Teachers children who entered
identified fewer difficulties than care in a metropolitan
parents and carers. region of a major city.
Analysis of the Ages and Stages Kinship Center:
Questionnaire looks at developmental permanency-focused
milestones and demonstrated that, children’s clinics in
on all the measures, age-appropriate response to the need
functioning was attained following at for specialized mental
least six months of treatment. With health services for
children whose data was available children moving, or
from all administration times having moved, from
(n ¼ 34), a significant linear decrease temporary foster care
occurred, indicating improvement in into the permanence
attachment to caregivers over time. of adoption or
guardianship.
Interviews revealed sub categories such The Unified Adolescent
as: Super-ordinate themes: In crisis Team (UAT): A
and out of control; New helping multidisciplinary team
relationships; Building new lives. At designed to prevent
the point of referral, the participants’ young people with
lives had become unmanageable for severe and complex
themselves and for others. One of needs from ‘falling
the suggestions of this study is that through the gaps’
these adolescents have been ‘hard to between services.
reach’ precisely because services have Service was provided
not been open/able to be open to for young people
their particular needs. That working demonstrating a
in a person-centred way with even significant degree of
the most vulnerable children and psychological
ISSUES IN MENTAL HEALTH NURSING
adolescents can bring about a disturbance relating
(Continued)
7
Table 4. Continued. 8
Different interventions of
mental health care or
psychiatric services
provided // or type of
Author, year, child welfare
country of study Title Population, setting, sample, age range Outcome measures Results interventions
change in their self-perception to adolescent
M. LAHTI ET AL.

and identity. development or

Richards et. al. The Mental Health Needs of Looked
2006, UK after Children in a Local Authority
Permanent Placement Team and
the Value of the Goodman SDQ.
Wattenberg et al. Brief Encounters: Children in Shelter
2004, USA for 7 Days or Less
Population: Children, adolescent
Setting: Permanent placement team
(PPT) recruited the participants
Sample: Looked after children
Number: 41
Age range: 4–16
Population: Children
Setting: Administrative data from
records
Sample: Children in shelters
Number: 1,306
Age range: 0–17
Outcome measures: Strengths &
Difficulties Questionnaire (SDQ)
Outcome measures: Circumstances
serious mental illness;
high-risk behaviours
including some of the
following: repeated
self-harm,
lawbreaking, drug
and alcohol abuse,
excessive dangerous
behaviour; social
instability, unstable
home placements; a
significant history of
inconsistent
education.
The mental health needs of looked after The permanent
children are significantly higher than placement team: Are
those of the general population. The responsible for long-
research highlighted the complex term looked after
and multi-factorial nature of the children’s needs.
experiences of the looked after Team is responsible
cohort that contribute to overall for assessing the
emotional well-being and positive mental health care
mental health. Over 80% of sample needs for looked
had previously received some after children.
psychological support.
This study of children removed under Emergency shelter care:
emergency situations and who Licensed family foster
experienced shelter care for a brief care homes or
period disclosed three distinct but institution. They offer
interrelated issues: the nature of the 24h crisis intervention
relationship between police and child service and can
protection; the impact of parental conduct child
arrests on children; and factors of protection
race and ethnicity in the emergency investigations.
removal of children from their
families. Results show that brief
emergency crisis shelter care is
needed in child welfare system.
 ISSUES IN MENTAL HEALTH NURSING 9

access to specialized hospital care. Interestingly, Milburn

California, three
Illinois, USA.

clinics, USA.
nurseries in

Hampshire,
and South-
et al. (2008) found in their results that parents tend to

Australia.

Portsmouth
Where

Minnesota,
Melbourne
region,
Five crisis
report twice the level of pathology in their children in their

USA.
east

UK.
care than children themselves. This may be due to the fact
that children and adolescents enter out of home care in dis-

entering to out of home care.

tried to work outside of usual

tressing circumstances where they have often suffered trau-

and collaborated. UAT teams

framework and tried to find

the process of engagement
Support and respite for caring

Multidisciplinary team worked

Licensed family foster homes

matic experiences. Moreover, children and adolescents and

group sessions, individual

Service was provided within

Care provided face-to-face,

their families have specific mental health needs at this time
week to 10 days after
for fragile infants and

session and camps.

offer 72 hours care.

but few have attended a mental health service (Milburn
How

young children.

et al., 2008). Richards et al. (2006) demonstrated that the

and change.
mental health needs of looked after children were signifi-
cantly higher than those of general population. Moreover,
after six months of treatment in out of home care, the
attachment to caregivers was improved (Ornelas et al.,
2007). It is also indicated that a brief emergency crisis shel-
service and therapeutic assessment,
and they provide feedback reports

shelters by multidisciplinary teams

offer assessment for the situation.

ter care period provided for children is needed in acute sit-
Crisis nursery foster families provide

aiming to give brief interval and

Multidisciplinary teams provide the

Care was provided in emergency

uations faced in child protection (Wattenberg et al., 2004).
Multidisciplinary team provide

Pycroft et al. (2015) point out that unified adolescent teams

multidisciplinary groups.
Who Provided

can work especially with ‘hard to reach’ children and

with recommendation.

Multi-agency perspective,

adolescents.
the service.

Discussion
the care.

To our knowledge, this is the first integrative review con-

ducted on the evidence-based literature related to mental
health care interventions targeted to looked after children.
Therapeutic interviews with parents
or carers. Infants were seen with
A range of emergency and follow-

Our search strategy allowed us to capture and screen a large

assessment, respite child care,

Individual work with client using

parents or carers. One session

support, psychological testing

with child including cognitive

Therapies, therapeutic camps,

and educational screening.

number of studies and explore their characteristics, interven-

parent psychoeducational

multi-agency perspective.
up services such as crisis

behavioural assessment.

tion used, outcome measures, and quality. Eight studies ful-

and assessment, case
Methods

filled the criteria and were included. All studies described

Brief interval care.

different interventions related to acute psychiatric services.

management,
counselling.

However, different interventions were found to be used with

looked after children. Nonetheless, there is not enough
evidence to arrive at a definite conclusion.
Interestingly, our results showed that there is large variety
of different mental health care action provided in child wel-
provide mental health response

72 hours hold for maintaining a

A multidisciplinary team designed
health services for children out

child away from parents under

from ‘falling through the gaps’
Table 5. Description of mental health care interventions provided in child welfare.

to prevent young people with

protection clients. Aim was to

fare services. Despite the fact pointed out in Karukivi et al.

child protection jurisdiction.
nursery services in order to

To provide specialized mental

Emergency shelter care offers

reduce stress and enhance

severe and complex needs

(2013) study that there is an urgent need for outpatient

To offer foster families crisis

assessment for all child

acute mental health care for young people, our results did
To provide therapeutic
Rationale

not find existing models for that purpose. Moreover, earlier

between services.
parenting skills.

findings raised the question of the correlation between well-

of home care.

targeted mental health care services in child welfare and the

to trauma.

placement stability (Collado & Levine, 2007). Similar find-

ings were found in our results. As Cole and Hernandez
(2011) point out, children and families who had access to
mental health services were more likely to reunited as family
Crisis nursery services
for foster families.

adolescent team.

again after foster care placement. Moreover, the placement

The Stargate Early
Brief Name

change can be a serious predictor of later need for mental

Kinship Center.

shelter care.
Programme.
Intervention

health care services (Fawley-King & Snowden, 2012).

Emergency

Existing studies suggest that multidisciplinary team work

Unified

between child welfare services is needed, especially in resi-

dential child care and mental health care (Gilbert et al.,
2011), but it seems that the collaboration between these two
Milburn et al. (2008)
Hernandez (2011)

Ornelas et al. (2007)

Pycroft et al. (2015)

agencies has yet to be realized. These findings are in line

et al. (2004)

with our results, as majority of the studies involved multi-

Wattenberg

disciplinary teams providing mental health care action in

Cole and

child welfare services (Milburn et al., 2008; Ornelas et al.,

Study

2007; Pycroft et al., 2015; Wattenberg et al., 2004). Still, the

10 M. LAHTI ET AL.
question remains how these services are combined in child
welfare and how the knowledge between different professio-
nals can be shared and transferred into practice (Lahti,
Kontio, Pitk€anen, & V€alim€aki, 2014).
Generally, welfare states provide a spectrum of services,
expertise, programmes and interventions in the child protec-
tion and mental care sectors. However, for cost-effectiveness
and child-focused quality care, there is still a serious chal-
lenge across countries to ensure multidisciplinary collabor-
ation. In spite of the obvious need for cooperation, the
multidisciplinary collaboration between residential workers
and mental health practitioners is poorly explored in the
international research. This study shows that there is a lack
of research on the collaboration and practical everyday
activities between residential child care and mental care
services. Thus, more practical experiments of incorporating
the expertise and ‘hidden’ ‘good practices’ between child
protection and mental health sectors are needed.
Limitations
There are limitations to our integrative review. Only eight
studies fulfilled the inclusion criteria. Using the English lan-
guage studies may have resulted in our results being biased
toward the Western countries. It is possible that the analysis
of the studies produced in languages other than English
could yield different findings; however, we believe studies in
this field are hardly available. The methodological quality of
the included studies was assessed, and we identified a high
risk of reporting bias due to the missing outcomes or the
non-availability of study protocols.
Implication to practice
There are some implications for practice. Based on the results
of this integrative review, policy makers and decision makers
in the field of child welfare and youth psychiatric health care
can utilize these findings in practice by creating new guide-
lines for collaboration. Moreover, based on this novel infor-
mation in this integrative review, there is a need for
conducting more robust and system level research in this
area. There is only a limited amount of good quality research
available, and more focus should be placed into large scale
research studies. Professionals and managers in the area of
child welfare and youth psychiatric service can use these
results to help develop new good practices related to mental
health care interventions provided in child welfare. Moreover,
both agencies can learn to collaborate with each other so that
looked after children will benefit from the shared information
and knowledge and mental health services provided.
Acknowledgements
Special thanks to Hannele Mikkola, Information Services Librarian
(Turku University of Applied Science, Turku, Finland), for her invalu-
able contribution to the development and implementation of the sys-
tematic search.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This research was supported by Interreg Central Baltic Programme
[grant number: CB338].
ORCID
Mari Lahti http://orcid.org/0000-0002-3403-5418
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