Systematic review
Effects and experiences of interventions to promote continuity in residential child care institutions
Systematic review
|Updated
Continuity is seen as a central element of care for children and youth. This report aims to summarise the effect of interventions that influence continuity of care on the psychosocial development of looked-after children and youth (LACY), and how they experience such interventions.
Key message
Continuity is seen as a central element of care for children and youth. This report aims to summarise the effect of interventions that influence continuity of care on the psychosocial development of looked-after children and youth (LACY), and how they experience such interventions. Continuity of care as a concept is challenging to measure. We have operationalized continuity using five types of interventions: staffing patterns, and increasing/decreasing: degree of staff turnover, use of substitute caregivers, caregiver to child ratio, or availability of caregivers. Six studies met the inclusion criteria regarding the effect of continuity promoting interventions. The evidence for these findings was assessed to be of very low quality. • It is uncertain if reducing the number of children per caregiver has an effect on problem behaviours or the cognitive development of LACY. • It is uncertain if cohabitation compared to normal staffing patterns affect problem behaviour or satisfaction among LACY. • It is uncertain if multiple continuity promoting interventions, including increasing the caregiver to child ratio and changing the staffing model has an effect on cognitive og general development or attachment to caregivers among LACY. Nine studies met the inclusion criteria regarding experiences with the interventions: We identified six themes from the included qualitative studies. Youth highlighted the following issues: (a) stability and structure; (b) predictability; (c) wish for attachment to, and (d) availability of (e) fewer caregivers, and (f) a clear preference for the continuity that comes from the cohabitation model. These findings were assessed to demonstrate some evidence of credibility and transferability.
Summary
Background Continuity is seen as a central element of care for children and youth living in residential care who may otherwise have experienced significant changes in their lives. Continuity of care can be related to the number of institutional placements a child experiences or the degree to which public services coordinate regarding the child’s care. Continuity of care in this report refers to the continuity a child experiences within one institutional placement. Therefore, we have operationalized the concept continuity using five types of interventions: staffing patterns, and increasing / decreasing degree of staff turnover, use of substitute caregivers, caregiver to child ratio, and availability of caregivers. Interventions related to staffing patterns are of special interest for the commissioners of this report. In Norway, the three main staffing arrangements used in residential care are cohabitation (staff lives at institutions/homes), longer shifts (>24 hours), and ordinary staffing patterns (e.g., 3x8-hour shifts). Objective To summarise empirical research on the effect of continuity promoting interventions on the psychosocial development of children and youth in residential care, and on children and youth’s experiences with such interventions. Method We systematically searched relevant databases and the grey literature in December 2011, and again in November 2012. We also hand-searched the reference lists of included articles.Two researchers went through the resulting references (titles and abstracts) to assess inclusion based on predefined inclusion criteria: Population : Children, youth and young adults (0-22 years) living in institutions Intervention:Continuity promoting interventions (staffing patterns, and increasing/decreasing degree of staff turnover, use of substitute caregivers, caregiver-to-child ratio or the availability of caregivers) For studies on effect of interventions: Outcomes:psychosocial development (attachment, social and cognitive skills, school achievement; quality of life, criminality) Study design:studies with control conditions For studies regarding experience of interventions: Experiences: experiences and feelings related to continuity promoting interventions Study design:qualitative studies which use focus groups, interviews and surveys (with textual data) We assessed the methodological quality of the included studies using different checklists for quantitative and qualitative studies. The quality of the quantitative evidence was assessed using Grades of Recommendations Assessment, Development and Evaluation (GRADE). We applied CerQual, a novel approach currently under development, to assess the certainty of the qualitative evidence. Results Of the 4494 references that emerged from the systematic literature search we included 15 studies, six effect studies and nine qualitative studies. Effect The included studies examined the effect of either changing the number of children per caregiver, different staffing patterns, or implementation of more than one continuity promoting intervention at the same time (namely changing the number of children per caregiver plus changing the staffing pattern). None of the included studies examined the effect of turnover rates among caregivers or increased/decreased availability of caregivers. Based on the available research: It is uncertain if reducing the number of children per caregiver has an effect on problem behaviours or the cognitive development of LACY. The documentation was assessed to be of very low methodological quality. It is uncertain whether different staffing patterns have an effect on problem behaviour or general satisfaction with their living arrangements among LACY. It is uncertain whether multiple continuity promoting interventions including increasing the caregiver to child ratio and changing the staffing model affects cognitive og general development or attachment to caregivers among LACY. The evidence base from the effect studies was assessed to be very low since there were few and small studies and the included studies had methodological weaknesses or were insufficiently reported. This does not mean that such interventions have no effect, but that there is uncertainty concerning the effect, if any, of the interventions. Experiences Nine studies were included regarding children and youth’s experiences related to continuity promoting interventions (five from Norway). The methodological quality of the studies was assessed to range from low to high. Six main themes emerged from the primary studies. Youth (no children were included) highlighted the following issues regarding continuity promoting interventions: (a) stability and structure; (b) predictability; (c) wish for attachment to, and (d) availability of (e) fewer caregivers, and (f) a clear preference for the continuity that comes from the cohabitation model. Only two of these themes were examined in the effect studies, namely their preferences regarding the cohabitation model and child to caregiver ratios. We assessed the qualitative findings (the six main themes) as demonstrating some evidence of credibility. Most of the findings were seen consistently across the included studies, and the individual studies were generally moderately well conducted. Only two of the main findings were examined in the included effect studies, namely preferences regarding the cohabitation model and child to caregiver ratios. Discussion The results from this systematic review indicate that there is little research on the effect of continuity promoting interventions on the psychosocial development of looked-after children and youth. There exists, however, qualitative research on the children and youths’ experiences of such interventions, especially from the Norwegian context. Due to the very low quality of the evidence base from the effect studies we cannot conclude on the effect of continuity promoting interventions in residential care. The qualitative findings which emerged from the thematic analysis in this review, however, highlight possible themes for future effect studies. Conclusion It is uncertain whether continuity promoting interventions have an effect on the psychosocial development of looked-after children and youth. This review uncovered, however, a number of themes which youth in residential care are concerned with. Only two of these themes were examined in the effect studies. That the youths concerns have not been taken as a starting point for the design, implementation or evaluation of continuity promoting interventions means that such interventions may not fully cover the expressed wishes of the children and youth. Need for further research There is a need for more primary studies that examine the effect of continuity promoting interventions. Future research on this topic should employ control groups and have at least two points of measurement