Program Components of Psychosocial Interventions in Foster and Kinship Care: A Systematic Review

Clinical Child and Family Psychology Review (2018) 21:13–40
https://doi.org/10.1007/s10567-017-0247-0
Program Components of Psychosocial Interventions in Foster

and Kinship Care: A Systematic Review
Jacqueline Kemmis‑Riggs1 · Adam Dickes1 · John McAloon1
Published online: 20 November 2017

© Springer Science+Business Media, LLC, part of Springer Nature 2017
Abstract
Foster children frequently experience early trauma that significantly impacts their neurobiological, psychological and social
development. This systematic review examines the comparative effectiveness of foster and kinship care interventions. It
examines the components within each intervention, exploring their potential to benefit child and carer well-being, particularly
focussing on child behaviour problems, and relational functioning. Systematic searches of electronic databases included Psy-
cINFO, MEDLINE, Web of Science Core Collection, the Cochrane Collaborations Register of Controlled Trials (CENTRAL)
and Scopus to identify randomised or quasi-randomised trials of psychosocial foster/kinship care interventions, published
between 1990 and 2016. Seventeen studies describing 14 interventions were included. Eleven studies reported comparative
benefit compared to control. Overall, effective interventions had clearly defined aims, targeted specific domains and develop-
mental stages, provided coaching or role play, and were developed to ameliorate the effects of maltreatment and relationship
disruption. Interventions effective in reducing behaviour problems included consistent discipline and positive reinforcement
components, trauma psychoeducation, problem-solving and parent-related components. Interventions effective in improving
parent–child relationships included components focussed on developing empathic, sensitive and attuned parental responses
to children’s needs. Given the prevalence of both behaviour problems and relational difficulties in foster families, targeting
these needs is essential. However, interventions have tended to measure outcomes in either behavioural or relational terms.
A more coordinated and collaborative research approach would provide a better understanding of the association between
parent–child relationships and child behaviour problems. This would allow us to develop, deliver and evaluate programs that
combine these components more effectively. Protocol Registration Number: PROSPERO CRD42016048411.
Keywords Interventions · Foster care · Kinship care · Systematic review · Looked after children · Maltreatment
Introduction Australian Institute of Family Studies 2016). The majority

of children taken into alternative care have experienced
The number of children in foster or kinship care placements complex trauma, which includes maltreatment (physical,
varies between regions, with an estimated 51,850 in England emotional or sexual abuse and/or neglect), traumatic loss
(as of March 2016; UK Department of Education 2015), and/or related experiences of maltreatment such as prenatal
43,009 in Australia (as of 30 June 2014; Australian Insti- exposure to drug and alcohol use and disrupted attachment
tute of Health and Welfare 2015), and 415,129 in the USA with their primary caregiver (Cicchetti and Valentino 2006;
(as of September 30 2014; U.S. Department of Health and Perry 2009). This early and multi-faceted trauma has a vast
Human Services 2015). This represents between 0.4 and 1% impact on the neurobiological, psychological and social
of child populations in these countries (ONS 2015; US Fed- development of foster children and is a significant risk fac-
eral Interagency Forum on Child and Family Statistics 2016; tor for poor outcomes throughout childhood and adulthood
(Fisher 2015; Van der Kolk 2005).
Compared to the general population, children in care have
* Jacqueline Kemmis‑Riggs
Jacqueline.M.Kemmis‑[email protected] an increased risk of executive functioning deficits (Pears
et al. 2008; Bruce et al. 2009a, 2013), alterations in neuroen-
1
Centre for Child and Adolescent Mental Health, University docrine stress-response functioning (Dozier et al. 2006a;
of Technology Sydney, Level 4 Building 7, 67 Thomas St, Fisher and Stoolmiller 2008), behavioural and emotional
Ultimo, NSW 2007, Australia
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14 Clinical Child and Family Psychology Review (2018) 21:13–40
problems such as conduct problems, anxiety disorders, While existing reviews have evaluated the efficacy of
depression and post-traumatic stress disorder (Burns et al. foster interventions as a whole, they have not yet examined
2004; Landsverk et al. 2002; Sawyer et al. 2007; Ford et al. different intervention components or investigated whether
2007; Lawrence et al. 2006; McMillen et al. 2005; Nathan- there is any evidence that certain content or delivery vari-
son and Tzioumi 2007; Osborn et al. 2008) and difficulties ables are associated with more effective outcomes for foster
in social/relational domains (Dozier et al. 2001; Bruce et al. children and their carers. This type of analysis would provide
2009b; Stovall and Dozier 1998). The large number of chil- integral information about which program components may
dren in foster/kinship care and the extent of their identified be more effective for specific foster populations or needs.
vulnerabilities indicate a clear need for effective interven- Given the huge individual, social and financial implications
tions that ameliorate the consequences of complex trauma that foster care carries, it is immensely important that the
in foster children. evidence base relating to treatments and their components
Foster/kinship carers are in a unique position to be able is adequately researched and that this research is translated
to offer reparative care to children who have been removed into beneficial treatment outcomes.
from their birth parents due to maltreatment. By providing Kaminski et al. (2008) analysed program components in
stable, safe and consistent environments, in which children their meta-analysis of 77 published evaluations of parent
may learn to develop trust in relationships and regulate their training programs for parents of children aged 0–7 years
emotions and behaviour, foster parents have the potential to with behavioural problems, examining which characteris-
help alleviate the sequelae of complex trauma. However, tics of program content and delivery method predicted larger
given the challenges of parenting children with complex effect sizes on parent and child behaviour measures. Their
needs, placement disruption is a common problem within analysis provided useful information for parenting programs
the child welfare system (Fisher et al. 2013). Foster chil- targeting behaviour problems; however, findings were not
dren who experience placement instability are at a much specific to either foster/kinship care or children exposed to
higher risk for problems in developmental, social, emotional, maltreatment, with only one included program involving fos-
behavioural and cognitive domains than children who do not ter and kinship carers (i.e. Lee and Holland 1991). This is
experience that instability (Ryan and Testa 2005; Harden important because traditional cognitive behavioural parent
2004; Rubin et al. 2007). While a higher number of place- training programs, despite success in other populations, have
ment changes is associated with poorer child outcomes and not been found to be effective in foster populations (Turner
may inhibit the development of these domains, the causal et al. 2007).
link is not well established. Fisher (2015) suggests that Given the established knowledge of the impact of mal-
causation may be bidirectional, with higher behavioural treatment and ensuing neurobiological, behavioural and rela-
problems and deficits in cognitive domains contributing to tional vulnerabilities that contribute to unique challenges for
disrupted placements. foster families, interventions for the foster population likely
Training that enhances carers’ capacity to meet these require additional or adapted components to target specific
demands and mitigate risk of placement breakdown has long needs. Thus, a systematic review of foster family-based
been argued a necessity for foster/kinship carers (Fisher et al. interventions focused on synthesising common interven-
2013; Turner et al. 2007). Multiple interventions for foster tion components and investigating if there is evidence that
care families have been developed, with several reviews pub- some content or delivery variables are more effective in this
lished examining the evidence of their efficacy (e.g. Craven population has the potential to inform both clinical practice
and Lee 2006; Dorsey et al. 2008; Goldman Fraser et al. and future intervention development for foster families.
2013; Kerr and Cossar 2014; Kinsey and Schlosser 2013;
Leve et al. 2012; Rork and McNeil 2011; Turner et al. 2007). Aims/Objectives
Findings from these reviews suggest that, while there are
promising indications that some interventions improve foster This review aimed to provide a systematic analysis of ran-
child well-being, not all interventions are equally effective domized or quasi-randomised trials of foster family inter-
in doing so. Reviews have highlighted significant hetero- ventions and their different therapeutic components. Spe-
geneity in research designs, outcomes measured, popula- cifically, this review aimed to answer four key questions:
tions and types of interventions, with varying effect sizes, (1) What psychosocial interventions have been delivered
which has not yet been sufficiently explained by program to improve the well-being of foster children and their car-
dosage, theoretical basis or delivery mode (Dorsey et al. ers? (2) What are the different components in these inter-
2008; Festinger and Baker 2013; Kerr and Cossar 2014). ventions? (3) What is the comparative effectiveness of
Sandler et al. (2011) recently highlighted the lack of research the identified interventions? (4) Is there any evidence that
investigating mediating processes of family-based preven- certain components are associated with more effective out-
tion programs. comes in the target population? Finally, the review aimed to
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Clinical Child and Family Psychology Review (2018) 21:13–40 15
provide recommendations for future research and program permanency, parent stress/mental health, parenting skills and
development. foster carer–child relationship.
Types of Study Design

Method
Randomised or quasi-randomised trials (e.g. randomised by
Protocol and Registration birthday, case number, alphabetical order), with sample size
greater than 20 participants.
This review was conducted in accordance with the PRISMA
guidelines (Moher et al. 2009, 2015). The review protocol Exclusion Criteria
was registered with PROSPERO [CRD42016048411] and
developed based on the recommendations outlined in the Foster and kinship carers’ have the potential to be the most
Cochrane Handbook for systematic reviews (Higgins and consistently present therapeutic influence in the lives of
Green 2011). the children they look after. For this reason, the focus of
this work is on the foster care family system, so interven-
Inclusion/Eligibility Criteria tions for children living in residential/group care, targeted
solely towards biological or adoptive parents were excluded.
Types of Participants We excluded work that focused on comparisons between
children institutionalised since birth who were randomly
Foster and/or kinship carers and foster children (aged 0–18) assigned to continue living in an institutional setting or to be
in their care with a history of maltreatment and/or who have placed in foster care, such as Romanian orphanages (e.g. the
had involvement with Child Protection Services and have Bucharest Early Intervention Project). Additionally, inter-
been placed in foster or kinship care because their needs ventions targeted towards children referred to foster care
were not being adequately met by their birth parents. Mal- from the juvenile justice system were excluded.
treatment is defined as any non-accidental behaviour by Because the scope of the review was constrained to
parents, caregivers, other adults or older adolescents that interventions delivered during the period of foster care we
is outside the norms of conduct and entails a substantial excluded interventions aimed at improving foster youth tran-
risk of causing physical, emotional or psychological harm sition to independence/exit from care or with the primary
to a child or young person. Such behaviours may be inten- aim of reuniting the child with his/her family of origin. We
tional or unintentional and can include acts of omission (i.e. also excluded interventions directed towards professionals or
neglect) and commission (i.e. abuse; Australian Institute of in-service delivery in order to focus on interventions deliv-
Family Studies 2012). ered at the family level. Given the focus was to evaluate
intervention components, we also excluded ‘wrap around’
Types of Interventions interventions (e.g. interventions that included comprehen-
sive mental health and/or substance use services, case man-
Psychosocial interventions involving foster and kinship car- agement, social support, educational assistance and/or psy-
ers that aimed at improving child and parent well-being dur- chiatric referral) because it was not possible to determine all
ing the period of foster care in areas of child behaviour, child additional supports provided and analyse their specific con-
mental health, child interpersonal skills, child biomarkers, tribution to the effectiveness of the intervention meaning-
foster parent–child relationships, foster parent well-being, fully. This criterion excluded Treatment Foster Care Oregon
parenting skills and placement stability. (TFCO), formerly known as Multidimensional Treatment
Foster Care for adolescents (Leve and Chamberlain 2005;
Types of Comparisons Chamberlain et al. 2007; Leve and Chamberlain 2007) and
TFCO-P, for preschoolers (Fisher et al. 2005, 2007, 2011;
Active control (e.g. other treatment) or inactive control (e.g. Fisher and Kim 2007).
wait-list, treatment as usual).
Identification and Selection of Studies
Types of Outcomes
To identify studies for possible inclusion, we conducted
This review considered studies that included at least one of systematic searches of electronic databases including Psy-
the following outcomes of child and/or carer well-being: cINFO, MEDLINE, Web of Science Core Collection, the
child behaviour problems, child mental health, child inter- Cochrane Collaborations Register of Controlled Trials
personal skills, child biomarkers, placement stability and (CENTRAL) and Scopus. The search strategy was restricted
13

to studies published in peer-reviewed journals, in the Eng- accordingly. The following information was extracted from
lish language, from 1 January 1990 to 30 September 2016. each study: authors, year of publication, design, country,
Search terms were modified to meet the requirements of setting (community or home-based), participant char-
individual databases. Search terms included all word varia- acteristics (child and/or carer; total number, mean age,
tions of (foster care or kinship care or foster child* or foster gender [proportion female], no. prior placements), type of
parent* or foster carer* or foster mother or foster father or intervention, theoretical basis, intervention aim, delivery
foster family or out of home care or looked after children) format (group/individual/dyad), duration of intervention,
AND (intervention or therap* or counsel?ing or cognitive timing of intervention relative to length of time in care,
behavior?ral therapy or psychotherapy or family therapy or attrition rates, outcomes and time points for outcomes,
treatment or training). See “Appendix” for the electronic and results.
search strategy for each database. In order to examine specific program aspects that
might be associated with more effective outcomes, we
Study Selection analysed programs and coded for key components that
were addressed by program curricula to meet the identi-
The first author initially screened all of the titles for all of the fied needs of foster children and their carers (shown in
studies to determine their relevance to this review. Studies Table 1). Adaptations to traditional parenting programs
that could be immediately excluded on the basis of title were for maltreatment populations include content focused on
discarded. For the remaining references, two authors (JK and parental factors, such as parental self-control, emotion
AD) independently reviewed abstracts to assess compliance management and attributions (e.g. Chaffin and Friedrich
of studies with eligibility criteria. Full text manuscripts were 2004; Chaffin et al. 2009), so these were also encoded.
then retrieved and evaluated independently against the inclu- We also coded programs for key delivery variables that
sion criteria. Disagreements were resolved through discus- have been shown to predict larger effect sizes on parent
sion. Authors of primary studies were contacted to obtain and child outcomes in general parenting programs, such
or clarify any missing data or uncertainties regarding its as in-session practice (e.g. role play and direct coaching
interpretation. Secondary sources cited in selected studies with child; Kaminski et al. 2008), as well as delivery vari-
as providing additional information about the intervention ables designed to maintain participation and engagement
were also retrieved (e.g. “see <xx> for more information on in foster populations, such as provision of child care dur-
intervention A) and used to provide additional information ing sessions, reimbursement for travel, credit towards fos-
specifically referenced in the original report. ter training requirements, and opportunities to catch up
on missed sessions (shown in Table 2). This information
Data Extraction and Management was extracted by JK and reviewed independently by AD.
Multiple reports of the same study were combined and
We developed a data extraction template that was considered as one study.
piloted with five randomly selected studies and modified
Table 1 Program content variables (coded as present or absent)

Code Description
Trauma psychoeducation Information about the impact of trauma on child development and implication of how this may affect child
responses to foster parents and others, including problem behaviour, dysregulation and attachment difficulties
Positive parenting skills Training to help parents increase child-centred play, following child’s interests, unconditional positive regard, and
build emotion coaching and active listening skills
Relational skills Training to develop parental skills to provide empathic, sensitive and attuned responses to child need and provide
nurturing care (including physical touch), even when child does not elicit nurturance
Behaviour management skills Coded specifically
1. Training that develops specific consistent discipline strategies for misbehaviour (time out, selective ignoring)
2. Training to increase specific positive reinforcement strategies (contingent reinforcement)
Problem-solving skills Training that assists parents and children with resolving on-going problems and sources of conflict, including
conflict with birth parents
Cognitive/academic skills Information, training, activities to assist with cognitive or academic domains
Social skills Information, training, activities to increase child social skills with peers and others
Parent-related factors Coded specifically
1. Skills taught to assist with parental self-regulation and stress management
2. Self-reflection and discussion of parental attributions about children and training to manage these effectively
13
Table 2 Program delivery variables (coded as present or absent) condition (p < .05). Calculation of effect sizes was not part
Code Description of this analysis.
In-session practice Opportunities to practice skills in session

and receive feedback on skill develop-
ment via Results
1. Role play or
2. Direct coaching with own child Study Selection
Strategies to main- Coded specifically where possible
tain participation in 1. Provision of child care during sessions
program 2. Reimbursement for travel
Figure 1 presents the flow chart of included studies. A total
3. Credit towards foster training require- of 3530 records were examined (excluding duplicates). 3251
ments were rejected at title and abstract, with a further 251 arti-
4. Opportunity to catch up on missed cles rejected after the full article had been reviewed. This
sessions
resulted in 17 studies (from 28 articles) that were included
in the final analysis.
Risk of Bias in Individual Studies

Study Characteristics
Risk of bias for the included studies was assessed using the
Characteristics of the included studies, grouped by inter-
‘Risk of Bias’ tool developed by the Cochrane Collaboration
vention, are presented in Table 3. Intervention names and
(Higgins and Green 2011). This tool allowed assessment of
abbreviations are provided in Table 4. Multiple foster inter-
potential sources of bias in each study, including (1) random
ventions were identified; the 17 studies included reported on
allocation; (2) allocation concealment; (3) blinding of par-
14 different interventions, aimed at a wide range of partici-
ticipants (4) blinding of outcome assessors; (5) incomplete
pants with diverse characteristics and needs. The majority
outcome data (assessment of completeness of outcome data
of studies were conducted in the USA (n = 11), with a much
for each main outcome, including attrition and exclusions
smaller number in the UK (n = 3), Romania (n = 1), and the
from the analysis) and (6) reporting bias. Each category
Netherlands (n = 2).
was coded as low, high or unclear. The assessment of study
quality was undertaken independently by JK and AD. Inter-
rater reliability was estimated with Cohen’s kappa, with an Research Design
average kappa of 0.70. Disagreements were resolved though
discussion. All included studies were randomised controlled trials
(RCTs). Twelve of the 14 interventions were evaluated in
Data Synthesis a single RCT. The remaining two interventions were evalu-
ated in two (ABC1 and ABC2) or three (KEEP1, KEEP2,
There was substantial clinical, methodological and statistical and KEEP3) RCTs (see Table 3). Of the 17 studies, only
heterogeneity in the identified foster care interventions, so two compared the intervention with an active control: ABC1
the use of pooled statistical analysis was not suitable. (For and PFR.
further discussion, see Dickes et al., in press). For example,
the I2 index was calculated for a subsample of trials deemed Sample Characteristics
relatively clinically and methodologically homogenous, to
gauge the amount of variability in the intervention effects Sample sizes per study ranged from 22 to 700 participants.
(Higgins and Green 2011). This included five studies of Half of the interventions reviewed were delivered to car-
multi-session interventions delivered to foster carers only ers only; the balance included carers and their foster child.
(without their children), within a social learning theoreti- The vast majority of the studies (78%) did not specify when
cal framework, with child behaviour problems as the out- interventions were delivered relative to when the child was
come of interest (Bywater et al. 2011; Chamberlain et al. placed in care with the participating foster families. Three
2008; Gavita et al. 2012; Maaskant et al. 2016; Price et al. interventions targeted children recently entering or changing
2015). However, even with this subsample of trials, statisti- placements, to help establish new parent–child relationships
cal heterogeneity was high (I2 = 60.40%). Thus, we did not (FFI, PFR, KEEP2; see Table 3).
conduct any meta-analysis and report a qualitative synthesis Eight studies reported including both foster and kinship
of results. We report magnitude of effect sizes as reported carers, whereas two studies reported excluding kinship/rela-
by study authors, where they report statistically significant tive carers. The remaining 41% of studies did not clearly
comparative benefit of the intervention compared to control report whether they included foster or kinship carers or both.
13

Fig. 1 PRISMA flow chart of selection of studies for inclusion in systematic review
None of the interventions were developed for or delivered trial (Mersky et al. 2015, 2016) used the Eyberg Child-
solely to kinship carers and children in their care. Behavior Inventory (ECBI; Eyberg and Pincus 1999). The
Target children ranged in age from infancy through to PMTO trial, (Maaskant et al. 2016) used the Strengths
adolescence; however, the majority of interventions were and Difficulties Questionnaire (SDQ; Goodman 2001). The
delivered to children whose average ages were between 4 CEBPT trial, (Gavita et al. 2012) used the Child Behav-
and 11 years. Only three studies included younger children iour Checklist (CBCL; Achenbach and Rescorla 2001).
in their infancy or toddler years. Macdonald and Turner One study, ABC2 (Sprang 2009), reported that all included
(2005) did not specify the child age for inclusion in their children had been diagnosed with an attachment-based dis-
CBT-based parent training intervention (CBT-PT) or report order, but did not report how these disorders had been
on any child demographic variables. determined or what the specific problems were, other than
The number of prior placements ranged from 1 to 20; being substantial enough to threaten placement disruption.
however, this was only partially reported, making it dif- Only 70% the studies reported on foster carer character-
ficult to provide an accurate estimate of this characteris- istics. This information was generally limited to gender,
tic. Child maltreatment history and age at first placement ethnicity, kinship status and years of experience. Of the
were rarely reported. Only three of the 17 studies specified studies that reported carer characteristics, carers were typi-
clinical diagnostic criteria for inclusion, namely clinically cally female, with estimates ranging from 70 to 100% of
significant externalising problems, based on clinical cut- the sample.
offs on three different parent-report measures. The PCIT
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Table 3 Characteristics of included studies
Study ID and country Author (year) Design, interven- Intervention: setting/for- Sample size, population, Child characteristics Carer characteristics Quality
tion/comparison mat/duration inclusion criteria
ABC1a Dozier et al. (2006b, RCT ABC: In home/Dyad N = 93 ABC: Mage 20.0 months, NR ? − − − ? +
USA 2008, 2009) and Bick ABC: 46 ABC: 10 × 1 h sessions Foster carer and child range 15–24 months,
and Dozier (2013) DEF: 47 DEF: 10 × 1 h sessions Inclusion: Infants and 59% female, DEF:
toddlers in foster careMage 19.5 months, 43%
female
# placement: NR
ABC1a Lewis-Morrarty et al. RCT As above N = 37 Mage 60.3 months, range Mage NR, 100% female ? − − − ? +
Follow up of ABC1 (2012) ABC: 17 Carer and child (carer 4–6 years, 49.2%
Control: 29 included birth, foster female
and adopted parents) No. Prior placement:
Inclusion: foster first placement: 54.1%;
children; previously second placement:
completed ABC1 27%; third placement:
18.9%
ABC2 Sprang (2009) RCT ABC: In home/Dyad N = 58 Mage 3.5 years, 49% Mage 40 years, 85% − ? + + − ?
USA ABC: 29 10 × 1 h sessions, Carer and child female female
WLC: 29 weekly + biweekly Inclusion: foster or adop- # placement: NR
carer support group tive parents of children
WLC: biweekly carer aged 0–6, maltreated;
support group risk of placement
breakdown, attachment
problems
CBT-PT Macdonald and Turner RCT Community/Group N = 117 NR Mage 45 years, range − − + + + ?
UK (2005) CBT-PT: 67 CBT-PT: 4 × 5 h ses- Foster carer 32–65, 92% female
WLC: 50 sions, weekly Inclusion: long-term
foster children
CEBPT Gavita et al. (2012) RCT Community/Group N = 97 Mage 9.5 years, gender NR − ? + + − ?
Romania CEBPT: 56 CEBPT: 4 × 4 h ses- Foster parent NR
WLC: 41 sions, weekly + 1 × 4 h Inclusion: Foster chil- # placement: NR
follow-up session dren aged 5–18, with
(3 months later) externalising disorders
FCCT Minnis et al. (2001) RCT Community/Group N = 160 FCCT: Mage 10.9 years, Mage 46 years, 97% − − ? − ? −
UK FCCT: 80 FCCT: 3 × 6 h ses- Foster parent 42% female, TAU: female
TAU: 80 sions (2 consecutive Inclusion: Foster carers Mage 11.6 years, 44%
days + 1 follow-up, of children aged 5–16, female
1 week later) likely to be in care # placement: NR
for > 1 year
13
19

20
Table 3 (continued)
13
FFI Van Andel et al. (2016) RCT In home/Dyad N = 123 Mage 18.8 months, 36% NR − − + − + ?
The Netherlands FFI: 65 FFI: 6 × 90 min sessions, Foster/kinship parent and younger than 9 months,
TAU: 58 fortnightly (maximum child gender 50% female
3 months) Inclusion: Foster and # placement: first OR;
kinship carers of chil- second placement: FFI:
dren aged 0–5, recently 77%; TAU: 88%
placed in care
IY Bywater et al. (2011) RCT Community/Group N = 46 IY: Mage 8.9 years, Mage 47 years, gender − − + + ++
UK IY: 49 IY: 12 × 2 h sessions, Foster parent range, 48% female; NR
TAU: 45 weekly Inclusion: Foster carers TAU: Mage 10.5 years,
of children aged 2–17 47% female
# placement: NR
IY + CP Linares et al. (2006) RCT Community/ N = 64 Mage 6.2 years, range Foster Carer: Mage ? ? + ? − ?
USA IY + CP: 40 Group + dyad Foster parent + biologi- 3–10 years, gender NR 46 years, female 99%
TAU: 24 IY + CP: Parenting cal parent dyads # placement: NR Biological parent: Mage
group: 12 × 2 h ses- Inclusion: Nonkin- 32 years, female 89%
sions, weekly + ship foster carers of
Co-parenting dyad: child with history of
12 × 1 h sessions, maltreatment; goal of
weekly family reunification
KEEP1 Chamberlain et al. RCT Community/Group N = 72 Mage 10.8 years, range Carer: Mage ‘early 40 s’, + ? + + + ?
USA (1992) KEEP + $: 31 KEEP: 2 h sessions, Foster parent 4–18 years, 61% gender NR
$ only: 14 weekly + $70 Inclusion: Foster child female
TAU: 27 $ only: $70 weekly in care for at least # placement: M = 1.5,
stipend 3 months range 0–9
KEEP2 Chamberlain et al. RCT Community/Group N = 700 KEEP: Mage 8.9 years, KEEP: Mage 50 years, ? ? + + − ?
USA (2008) and Price et al. KEEP: 359 KEEP: 16 × 90 min ses- Foster & kinship parents 50% female TAU: Mage 94% female;
(2008) TAU: 351 sions, weekly Inclusion: Foster chil- 8.7 years, 54% female TAU: Mage 47 years
dren aged 5–12 enter- # placement:
ing new placement, in MKEEP = 2.95,
care for > 30 days MTAU = 2.8
KEEP3 Price et al. (2015) RCT Community/Group N = 354 KEEP: Mage 7.8 years, 45 years, 93% female ? − + ? − +
USA KEEP: 179 KEEP: 16 × 90 min ses- Foster and kinship 47% female; TAU:
TAU: 175 sions, weekly parents Mage 7.3 years, 49%
Inclusion: Foster female.
children aged 5–12, in # placement: NR
care for > 30 days; not
‘medically fragile’
KITS Pears et al. (2012, 2013, RCT Community/Separate N = 192 Mage 5.3 years, 51% NR ? ? + − ? ?
USA 2016) KITS: 102 Parent and Child Foster/kinship parent and female
TAU: 90 Groups child # placement: NR
Child group: Inclusion: Foster
Phase 1: 16 × 2 h ses- children entering
sions, twice weekly kindergarten, English
Phase 2: 8 × 2 h ses- speaker, not previously
sions, weekly involved in KITS-asso-
Parent group: ciated intervention
Phase 1: 4 × 2 h ses-
sions, f/night
Phase 2: 4 × 2 h ses-
sions, f/night
MSS Kim and Leve (2011), RCT Community/separate N = 100 Mage 11.5 years, 100% NR − − + − − +
USA Smith et al. (2011) and MSS: 48 parent and child Foster/kinship parent and female
Kim et al. (2013) TAU: 52 groups + follow-up: child # placement:

individual child and Inclusion: Foster girls M = 4.3, range 1–20
group parent aged 10–12, in final
6 × 2 h sessions, twice year of elementary
weekly (3-week dura- school between 2004
tion) and 2007
Follow-up, 2 h sessions,
weekly (throughout
first year of school)
PCITb Mersky et al. (2015, RCT Community/ N = 129 Mage 4.6 years, 56% Mage 44 years, range − ? + − − ?
USA 2016) PCIT/brief: 48 Group + Dyad Foster parent and child female 23–79, 89% female
PCIT/extended:35 PCIT/brief: 8 weeks, Inclusion: Children aged # placement: NR
TAU: 46 2 × 7 h sessions + phone 3–6 years, in nonrela-
support for 8 weeks tive foster care, with
PCIT/extended: as significant behavioural
above + 1 × 7 h problems
booster session + 6
more weeks of phone
support
PFR Spieker et al. (2012, RCT Home/Dyad N = 210 Mage 18 months, 44% PFR: Mage 35 years, − − − − − −
USA 2014) PFR: 105 PFR: 10 × 60–75 min Carer (foster, kinship and female EES: Mage 37 years,
EES: 105 sessions, weekly birth) and child # placement: M = 2.7 gender NR
EES: 3 × 90-min visits, Inclusion: Infants aged
monthly 10–24 months; with
court-ordered place-
ment resulting in a pri-
mary caregiver change
within prior 7 weeks
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21

22
13
PMTO Maaskant et al. (2016) RCT Community/Individual N = 88 PMTO: Mage 7.9 years, PMTO: Mage 47 years, − − + − − +
The Netherlands PMTO: 47 PMTO: Mno. sessions Foster/kinship carers 64% female TAU: Mage 50 years,
TAU: 41 21.42, weekly (dura- Inclusion: Foster TAU: Mage 7.5 years, gender NR
tion: 6–9 months) children aged 4–12, in 50% female
long-term care, with # placement: PMTO:
significant behavioural M = 0.96; TAU:
problems M = 1.05
PSB Linares et al. (2015) RCT Community/Dyad (sib- N = 22 PSB: Mage Younger PSB: Mage 48 years, + ? + − − ?
USA PSB: 13 pairs lings) + Family group Foster/kinship parent and sib 7.2, Older sib TAU: Mage 55 years,
TAU: 9 pairs (siblings + parent) child 9.7 years, 39% female gender NR
8 × 90 min sessions, Inclusion: Sibling pairs TAU: Mage Younger
weekly aged 5–11, with history sib 7.3, Older sib
of maltreatment placed 8.5 years, 61% female
in same foster home # placement: NR
Quality = risk of bias coding where − = low risk of bias, + = high risk of bias, and ? = unclear risk of bias on the following indices: (1) random allocation; (2) allocation concealment; (3)
blinding of participants; (4) blinding of outcome assessors; (5) incomplete outcome data and (6) reporting bias. Countries: USA = United States of America, UK = United Kingdom. Active
controls. DEF: Developmental Education for Families Intervention. EES: Early Education Support
NR not reported, ns non-significant, RCT randomised controlled trial, TAU treatment as usual, WLC wait-list control, # placement number of prior placements
a
ABC1 had multiple reports with different sample sizes and reported participant characteristics. Correspondence with primary author confirmed these are from the same RCT. Client character-
istics reported are from Dozier et al. (2008)
b
Sample size differed between reports; sample size and characteristics are reported from Mersky et al. (2015)
Table 4 Abbreviations for Abbreviation Name

Included Interventions
ABC Attachment and biobehavioural catch-up
CBT-PT Cognitive–behavioural parent training
CEBPT Short enhanced cognitive–behavioural parent training
FCCT Foster carers’ communication training
FFI Foster carer-foster child intervention
IY Incredible years (basic parenting program)
IY + CP Incredible years (basic parenting program) + co-parent adaption
KEEP Keeping foster parents trained and supported
KITS Kids in transition to school
MSS Middle school success
PCIT Parent child interaction therapy
PFR Promoting first relationships
PMTO Parent management training Oregon
PSB Promoting sibling bonds
Overview of Intervention Components
Table 5 presents the synthesis of components across each

intervention and summary of main outcomes, grouped by
theoretical basis.
Theoretical Basis of Interventions
Interventions were categorised according to broad theoreti-

cal basis, where possible. This included attachment, social
learning, social learning combined with educational and/
Fig. 2 Risk of bias graph, summarising authors ratings of included
studies on risk of bias dimensions, presented as percentages across all or developmental theories and cognitive behavioural. One
included studies intervention did not report a theoretical basis (see Table 5).
Intervention Components
Risk of Bias Within Studies
All interventions were delivered as multi-sessions to fos-
Risk of bias ratings is shown in Table 3. The methodologi- ter and kinship carers who were currently caring for foster
cal quality of the studies varied greatly, as illustrated in children, as opposed to pre-service training (i.e. training
Fig. 2. Ten studies (59%) reported adequate detail of ran- received prior to becoming a foster parent). No randomised
dom allocation methods, 53% reported sufficient allocation or quasi-randomised trials of pre-service training that met
concealment detail, 12 and 53% reported necessary blinding our criteria were identified in the literature.
of participants and outcome assessors, respectively, to be Nine of the 14 interventions were delivered in a group
classified as low risk of bias. The majority of studies (59%) format, some of which had group components and additional
were classified as low risk of bias for incomplete outcome individual and/or dyadic components. Of the six interven-
data. Most studies were classified as having unclear (59%) tions delivered to dyads, four were delivered to parent–child
risk of reporting bias, as the majority of trials were not pre- pairs (ABC, PCIT, FFI and PFR), one was to sibling pairs
registered and/or reported on multiple outcome measures (PSB), and another to pairs of foster and biological parents
without stating a priori primary outcomes of interest, so (IY + CP; see Table 5). The PSB intervention (Linares et al.
it was not possible to determine if studies were subject to 2015) had three delivery components in each 90-min ses-
selective outcome reporting. Overall, only one study was sion: sibling pairs, individual foster parent and joint fam-
classified by reviewers as low risk of bias on all six indices. ily (with the sibling pair and the foster parent). The sib-
Three studies were classified as low risk on four indices, ling pair and parent sessions were delivered concurrently;
three studies on three, six studies on two and four studies on siblings had a session with one clinician, while the parent
none or one bias measure. engaged in an individual session with another clinician in
13

Table 5 Programme components and main outcome summary
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Attributi Role Direct
Discipline Reward Self-reg ons Play Coach
Attachment security =
Infants
Parent and
PFR Dyad x x x x 2, 4 x Parent sensitivity +
Child
Placement =
Parent sensitivity +
Attachment:
avoidant + / secure =
Attachment
Behaviour problems +
Parent and Psychological function +
Infants/ Toddlers
ABC Dyad x x x x 2, 3 x
Child Self regulation +
Cognitive functioning +
Social Competence +
Parent Skills +
Parent psych. function +
Parent-child relationship +
Parent and
FFI Dyad x x x x x x x x Self regulation =
Child
Parent psych. function =
Preschool/ Early
Social Learning
Attachment +

primary
Parent and Group 1, 2, Parent skills +

PCIT x x x x x
Child + Dyad 3 Behaviour problems +
Psychological function +
n
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Behaviour problems =
Preschool/ Early Primary
Psychological function =
IY Parent Group x x x x x
Parent skills =
Group
IY+CP Parent x x x x x x x Coparenting relationship =
+ Dyad
Social Learning
Parent skills +
Primary
Psychological function =
PMTO Parent Individ x x x x x
Parent skills =
Parent skills +
Primary
1, 2,
KEEP Parent Group x x x x x x x x x Parent psych. function =
3, 4
Placement: positive exits +
negative exits =
Adolescents
Primary/
NR
FCCT Parent Group x x x Psychological functioning =
13
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Po
Pa
Pa
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C
Placement breakdown =
Adolescents
Cognitive-
Behavioral
Primary/
CEBPT Parent Group x x x x x x
Parent skills +
Behavioral &
Placement breakdown =
Cognitive
Learning
Social
NR
CBT-PT Parent Group x x x x Behaviour problems =

Parental knowledge +
Developmental &
Social Learning,
Academic function +
Educational
Preschool
Parent and Social competence =

KITS Group x x x x x x x
Child Self-regulation +
Delinquent behaviour = / +
Psychological function +
Delinquent behaviour = / +
Social Learning &
Developmental
Preadolescent
Substance use +
Group
Parent and Behaviour problems +
MSS + x x x x x 4 x
Child Psychological function +
Individ
Social competence +
Placement +
Sibling interaction:
Social Learning,
Family Systems,
positive + / negative -
Regulation
Primary
Emotion
Parent and Individ

PSB x x x x x x 2 x Sibling aggression:
Child + Dyad
physical + / verbal =
Parent skills +
Percentage of interventions that included each
64% 71% 21% 71% 79% 57% 14% 36% 29% 43% 43% 64% 36%
component
NR = not reported. Participation strategies, numbers listed: 1 = provision of child care during sessions. 2 = reimbursement for travel or partici-
pation. 3 = credit towards foster training requirements. 4 = opportunity to catch up on missed sessions. Outcomes key: +: a statistically signifi-
cant difference in the desired direction compared to control post-intervention; = : no significant difference between intervention and control; −: a
significant difference in the opposite direction
another room nearby. The joint family sessions occurred at effectiveness altogether, 52 outcome measures were directly
the beginning and end of each 90-min session. The IY + CP related to stated primary aims of the intervention and are
intervention (Linares et al. 2006) was an adaptation of the reported on Table 6. The heterogeneity in outcomes pre-
Incredible Years parent training program (Webster-Stratton sented a challenge to synthesising intervention effectiveness
2001), designed to deliver a joint training format to foster within this review. To address this challenge, the results are
and biological parent pairs to develop more collaborative structured to report the effectiveness of interventions on
parenting relationships between them. They delivered group three core domains that best reflected the primary aims of
parent training to groups of foster/biological parents and an the interventions: child behaviour problems, attachment/
additional co-parenting component that included the biologi- relational problems and placement status. In addition,
cal parent, foster parent and target child. PMTO (Maaskant observable relationships between components and outcomes
et al. 2016) was the only intervention that solely used an are reported within these domains.
individual format to deliver the parent management training
intervention. Child Behaviour Problems
The Relation Between Intervention Effectiveness Twelve of the 17 RCTs specifically aimed to reduce child
and Intervention Components behaviour problems (e.g. externalising, disruptive behav-
iours). Eleven of these aimed to do so by strengthening par-
Overall, 11 of 17 trials reported comparative benefit of the ent skills within a social learning or cognitive–behavioural
intervention compared to a control group in eighteen dif- framework (CBT-PT, CEBPT, IY, IY + CP, KEEP1/2/3,
ferent domains of child and carer well-being (see Table 5). KITS, MSS, PCIT, PMTO; see Table 5). One RCT,
While 100 outcome measures were used to assess program ABC2 (Sprang 2009), aimed to assess the effects of an
13

26
Table 6 Summary of intervention outcome domains, measures and main findings

Study Outcome domain Measures Main findings
13
ABC1 Self-regulation Diurnal cortisol, saliva sampling (b)1 Improved cortisol regulation post-intervention,
Dozier et al. (2006b1, 20082, 20093) and Bick and effect size NR
Dozier (20134) HPA functioning (b)2 pre- and post-exposure to Lower salivary cortisol (more normative) pre expo-
Strange Situation (SS) (b) sure to SS in intervention group, effect size NR
No significant differences between groups 15 or
30 min post-SS
Attachment behaviour PAD3 (p) Reduced avoidant behaviour post-intervention, effect
size NR
No significant differences in secure behaviour post-
intervention
Parent sensitivity Play task (MS)4 (o) Improved caregiver sensitivity post-intervention,
effect size NR
Lewis-Morrarty et al. (2012) Cognitive functioning Cognitive flexibility: DCCS (cp) Higher post-switch performance 2 years post-inter-
Follow up of ABC1 vention, large effect size (d = 1.06);
No significant difference on pre-switch performance
2 years post-intervention
Social competence Theory of mind task (TOM) (cp) Higher TOM performance 2 years post-intervention,
large effect size (d = 1.08)
ABC2 Behaviour problems CBCL-E (p) Fewer externalising problems post-intervention,
Sprang (2009) medium effect size (partial eta squared = 0.51)
Psychological functioning CBCL-I (p) Fewer internalising problems post-intervention,
medium effect size (partial eta squared = 0.44)
Parent skills CAPI (p) Reduced self-reported risk of child abuse potential
post-intervention, large effect size (partial eta
squared = 0.79)
Parent psychological functioning PSI (p) Reduced self-reported parental stress post-
intervention, medium effect size (partial eta
squared = 0.59)
CBT-PT Placement Parent-report No significant differences in no. of unplanned place-
Macdonald and Turner (2005) ment breakdowns post-intervention
Behaviour problems CBCL (p) No significant differences in behaviour problems
post-intervention
Parental knowledge KBPAC (p) Improvement in self-reported knowledge of behav-
ioural principles post-intervention, effect size NR
CEBPT Placement Case records (cr) No significant differences in placement disruption

Gavita et al. (2012) rate post-intervention or at 3-month follow-up
Behaviour problems CBCL-E (p) Fewer externalizing problems post-treatment,
medium effect size (d = 0.67)
Parent skills PS (p) Improvement in discipline skills post-treatment,
large effect size (d = 0.97)
Parent psychological functioning PED (p) Improvement in distress levels post-treatment,
FCCT Psychological functioning SDQ (p & c & t) No significant differences on foster carer, teacher
Minnis et al. (2001) and child self-report on SDQ 9 months post-
intervention
MRS (c) No significant differences on self-esteem 9 months
post-intervention
RAD (p) No significant differences on attachment disorders
immediately and 9 months post-intervention

FFI Self-regulation Diurnal cortisol response No significant differences on diurnal cortisol post-
Van Andel et al. (2016) intervention
Parent psychological functioning NOSI-R (p) No significant differences on parent stress post-
intervention
Parent–child relationship EAS (o) Improvements on following emotional availability
subscales post-intervention, medium-to-large
effect sizes:
Sensitivity (d = 0.82); Structuring (d = 0.73);
Non-intrusiveness (d = 0.60); Responsiveness
(d = 0.46); Involvement: no significant differences
IY Behaviour problems ECBI-Intensity (p) No significant between group differences on child
Bywater et al. (2011) SDQ Hyperactive (p) behaviour problems post-intervention, effect size
NR for intervention versus control effects
Psychological functioning SDQ Total (p) No significant between group differences post-inter-
vention on child psychological functioning, effect
size NR for intervention versus control effects
Parent psychological functioning BDI (p) No significant between group differences on parental
depression, effect size NR for intervention versus
control effects
Parent skills PS (p) No significant between group differences on parental
skills, effect size NR for intervention versus con-
trol effects
13
27

28
13
IY + CP Behaviour problems CBCL-E (p); ECBI (p); No significant differences on externalizing problems
Linares et al. (2006) SESBI-R (t) at post-treatment and 3-month follow-up on any of
the behaviour problem outcome measures
Co-parenting relationship Composite of measuresa (p) Improvements in co-parenting relationship indices
post-intervention, small to medium effect sizes;
Flexibility (d = 0.42); Problem-Solving (d = 0.52);
Total (d = 0.48); these became ns at 3-month
follow-up
Parent skills PPI (p), foster & biological parent outcomes Increased support for positive discipline post-
combined intervention, medium effect size(d = 0.40), and
3-month follow-up (d = 0.59)
Increased use of clear expectations at 3-month
follow-up, medium effect size (d = 0.54)
Appropriate discipline: no significant difference
post- or at 3-month follow-up
Harsh discipline: no significant difference post- or
3-month follow-up
KEEP1 Behaviour problems PDR (p) Reduced problem behaviour compared to other two
Chamberlain et al. (1992) conditions, effect size NR
Placement Placement change (cr) More successful days in care than children in the
other two conditions (less negative placement
changes), effect size NR
KEEP2 Behaviour problems PDR5 (p) Improvement in child behaviour post-treatment,
Chamberlain et al. (20085) and Price et al. (20086) small effect size (d = 0.26)
Parent skills Positive reinforcement ratio5 (p) Increased ratio of positive reinforcement to disci-
pline post-treatment, small effect size (d = 0.29)
Placement Parent report6 Improvement in positive exits, effect size NR
No significant differences in negative exits
KEEP3 Behaviour problems PDR (p) No significant difference in child behaviour in post-
Price et al. (2015) intervention group compared to control, using
data from the same target child pre and post-
intervention
Parent psychological functioning PDR-Stress (p) HLM analysis showed significant group x time inter-
action for parent stress with the same target child
assessed pre and post-intervention
KITSb Behaviour problems Latent variable of: TRF-O + A; CTRS:S(t)7 Fewer oppositional and aggressive behaviours at
Pears et al. (20127; 20138; 20169) follow-up (approx. 6–9 months post-intervention),
Academic functioning Early literacy measuresc (p & cp)8 Improved early literacy skills post-phase 1 of the
intervention, small effect size (standardised mean
change = 0.26. Note, this is not a standardised
mean difference score)
Social competence Prosocial measuresd (p & cp)8 No significant differences on prosocial skills
between groups post-phase 1 of the intervention
Self-regulation Composite measuree (p & cp)8 Improved self-regulation post-phase 1 of the
intervention, small effect size (standardised mean
change = 0.18. Note, this is not a standardised
mean difference score)
Delinquent behaviour Attitudes towards alcohol use (c)9 Lower scores on positive attitudes towards alcohol
use in the third grade, up to 4 years post-baseline,
effect size NR
Attitudes towards antisocial behaviour (c)9 No significant differences between groups on posi-
tive attitudes towards antisocial behaviour in third
grade, up to 4 years post-baseline
Involvement with deviant peers (c)9 No significant differences between groups on
involvement with deviant peers in third grade, up
to 4 years post-baseline
Psychological functioning SPCC (c)9 Higher child-report of self-worth, up to 4 years post-
baseline, effect size NR
13
29

30
13
MSSb Delinquent behaviours SRD10 (c) No significant direct effect of MSS on delinquency
Kim and Leve (201110), Smith et al. (201111) and 36 months post-baseline
Kim et al. (201312) Health-risking sexual behaviour12 (c) Significant direct effect of intervention on health
risking sexual behaviour 36 months post-baseline,
Substance use Tobacco, alcohol, marijuana composite 10 (c) Lower levels of substance use 36 months post-base-
line, medium effect size (d = 0.47)
Placement Case records10 (cr) Fewer placement changes 6–12 months post-base-
line, medium effect size (d = 0.50)
Psychological functioning CBCL-E + CBCL-I10 No. sig difference in combined internalizing/
externalizing problems at 12 and 24 months post-
baseline
PDR-I11 (p) Fewer internalizing problems 6 months post-base-
line, effect size NR
Behaviour problems PDR-E11(p) Fewer externalizing problems 6 months post-base-
line, effect size NR
Social competence PDR-PS10, 11 (p) Increased frequency of prosocial behaviour
6–12 months post-baseline (on average)10, medium
effect size (d = 0.46)
No significant differences on prosocial behaviour
6 months post-baseline11
PCITf Parent psychological functioning PSI-SF13(p) Reduced parent stress post-intervention, medium
Mersky et al. (201513, 201614) effect size (d = 0.45)
Parent skills DPICS-II13 (o) Increased positive parent behaviours post-interven-
tion, med effect size (d = 0.72)
Reduced negative parent behaviours post-interven-
tion, large effect size (d = 0.92)
Behaviour problems ECBI-I (p) 14 No significant differences post-intervention on ECBI
Intensity scale
ECBI-P (p) 14 Fewer externalising problems on ECBI-P, small
effect sizes (r2 = 0.06)
CBCL-E (p) Fewer externalising problems on CBCL-E, medium
effect size (r2 = 0.09)
Psychological functioning CBCL-I14 (p) Fewer internalising problems post-intervention,
medium effect size (r2 = 0.08)
PFRg Attachment behaviour TAS4515 (o) No significant differences on child attachment secu-
Spieker et al. (201215, 201416) rity at post-intervention or 6-month follow-up
Parent sensitivity NCATS15 (o) Improved parental sensitivity post-intervention,
No significant differences on sensitivity at 6-month
follow-up
Placement Case records: stability16 (cr); permanency16 (cr) No significant effect of intervention on both place-
ment outcomes (2 years post-randomization)
PMTO Behaviour problems CBCL (p); TRF (t) No significant differences post-intervention or at
Maaskant et al. (2016) 4-month follow-up
Psychological Functioning CBCL-I (p); TRF-I (t) No significant differences post-intervention or at
4-month follow-up
Parent psychological functioning NOSI-R (p) Reduced parent stress post-intervention but became
ns at 4-month follow-up
Parent skills PBQ (p) No significant differences on parenting behaviour

post-intervention or 4-month follow-up
PSB Sibling interaction SIQ (o) Higher positive sibling interactions, effect size NR
Linares et al. (2015) Higher negative sibling interactions, effect size NR
Less conflict during low-competition play, effect
size NR
Sibling aggression SAS (p) Lower sibling physical aggression from older
towards younger child, effect size NR
No significant differences for verbal aggression from
older towards younger child, or verbal and physical
aggression from younger to older child.
Parent skills Conflict mediation CC (p) Higher use of mediation strategies, effect size NR
No sig. differences in non-mediation strategies
(p) Parent self-report; (c): child self-report; (cp) child performance measure; (b) biomarker measure (t): teacher report about child; (cr) case records/professional report; (o) observational meas-
ure. Main findings: Unless otherwise noted, findings reported are between group differences and the experimental condition resulted in significantly better outcomes than comparison group
(p < .05). Effect sizes include statistically significant (p < .05) effects reported by study authors. Interpretation of effect sizes as small, medium or large is defined as Cohen’s d = 0.20, 0.50, 0.80
and correlation coefficient, r = 0.10, 0.30, 0.50, respectively (Cohen 1988). Where partial eta squared was used as an estimate of effect size, we report the interpretation provided by the authors.
Numerical subscripts pair reports with outcomes
HLM hierarchical linear modelling, ns = non-significant, BDI Beck Depression Inventory, CAPI Child Abuse Potential Inventory, CBCL: Child Behavior Checklist, Total; Externalizing sub-
scale (CBCL-E); Internalizing subscale (CBCL-I); Oppositional and Aggressive subscales (CBCL-O + A); Social Competence subscale (CBCL-SC), CC Parent Conflict Mediation Conflict
Checklist, DCCS The Dimensional Change Card Sort, DPICS-II Dyadic Parent–Child Interaction Coding System, EAS Emotional Availability Scales, ECBI Eyberg Child Behavior Inventory,
Intensity subscale (ECBI-I); Problem subscale (ECBI-P). KBPAC Knowledge of Behavioral Principles as Applied to Children, MS Observational play task, NCATS Nursing Child Assessment
Teaching Scale, NOSI-R Dutch adaptation of Parenting Stress Index, PAD Parent Attachment Diary, PBQ Parenting Behavior Questionnaire, PDR Parent Daily Report Checklist; Externalizing
subscale (PDR-E); Internalizing subscale (PDR-I); Prosocial subscale (PDR-PS); Parental stress subscale (PDR-Stress), PED Profile of Emotional Distress, PPI Parenting Practices Interview,
PS Parenting Scale, PSI Parenting Stress Index, RAD Reactive Attachment Disorder Scale, RSES Modified Rosenberg Self-Esteem Scale, SAS Sibling Aggression Scale, SDQ Strengths and
Difficulties Questionnaire, Hyperactivity subscale (SDQ-H), SESBI-R Sutter-Eyeberg Student Behavior Inventory-Revised, SIQ Sibling Interaction Quality, SPCC Self-perception profile for
children, global self-worth subscale, SRD Self-report Delinquency Scale, TAS45 Toddler Attachment Sort-45, TOM Theory of Mind Task, TRF Teacher Report Form, Total Problems subscale;
Externalizing subscale (TRF-E); Internalizing subscale (TRF-I); Oppositional and Aggressive subscales (TRF − O + A)
13
31

attachment-based intervention on child behaviour. All RCTs

assessed intervention effects on behaviour problems in the
short to medium term (up to 6 months post-intervention),
with the exception of KITS, which reported significant
improvement in child behaviour problems around 12 months
Composite score from combination of items from the Family Functioning Style Scale (FFSS); Family Adaptability and Cohesion Scale (FACES III), and 2 newly developed items
Self-regulation—composite of three subcomponents: emotion regulation (composite measure); behaviour regulation (composite measure), inhibitory control (composite measure)
post-baseline (Pears et al. 2012).
Of the 12 RCTs that measured child behaviour, only
six showed significantly fewer behaviour problems in the
Early literacy skill measures included: Concepts About Print (CAPS); Dynamic Indicators of Basic Early Literacy Skills (DIBELS); Caregiver rating of literacy skills
intervention group compared to control, with effect sizes

ranging from small to large (i.e. ABC2, CEBPT, KEEP2,
KITS, MSS and PCIT; see Table 6). Three RCTs reported
Multiple child and caregiver outcomes are reported in the PFR intervention. This table includes stated primary outcome variables relevant to this analysis
no statistically significant improvements in child behaviour

Outcomes reported are linear interaction contrasts comparing trends of WLC to the average of both treatment conditions (PCIT/brief + PCIT/extended)
in the intervention group compared to the control (CBT-PT;

Studies used path analysis to examine effects of intervention on outcomes; results reported above are the direct effects of intervention on outcome
IY + CP; PMTO; see Table 6).

While three other RCTs reported the intervention was
effective in reducing child behaviour problems (i.e. KEEP1,
Prosocial skill measures included. Preschool Penn Interactive Peer Play Scale (PPIPPS); CBCL-SC and emotion understanding vignettes
KEEP3, IY), results from these trials did not show interven-
tion versus control effects. The IY trial (Bywater et al. 2011)
reported significantly larger pre-post reductions in the inter-
vention group compared to pre-post reductions in the control
group; however, results between intervention and control
groups on post-intervention mean scores on child behaviour
problems were not significant. Large differences between
baseline scores were noted in their results, with the inter-
vention group having higher baseline child behaviour prob-
lems. KEEP1 (Chamberlain et al. 1992) reported significant
reduction in number of problem behaviours in the ‘enhanced
support and training’ group (i.e. KEEP intervention + $70
weekly stipend; ES&T) compared to the increased payment
only (IPO) and TAU groups. However, the authors reported
significantly higher behaviour problem scores at baseline in
the intervention group (ES&T) compared to the other two
groups (IPO and TAU) and the significant reduction in prob-
lem behaviour reported reflect these differences rather than
differences in post-intervention mean scores, a point noted
previously by Turner et al. (2007). The KEEP3 study (Price
et al. 2015) reported that the intervention was effective in
reducing child behaviour when delivered by a community
agency yet, when results were analysed using the same focal
child at pre- and post-intervention, the interaction between
group and time was no longer significant. Authors reported
significantly higher behaviour problem scores at baseline for
focal children in the intervention group compared to focal
children in the control group.
As shown on Table 5, all of the interventions aiming to
improve behaviour problems included behaviour manage-
ment components, with the exception of ABC2 (Sprang
2009). Given the mixed evidence of effectiveness, this
analysis suggests that behaviour management components

alone are not sufficient to improve child behaviour prob-
lems. The six interventions that were effective had more
comprehensive content. Three or more of these six interven-
tions included a combination of components in addition to
b
g
a
13
behaviour management such as providing trauma psychoe- Placement

ducation, training to build social skills and/or incorporat-
ing specific participation strategies (see Table 5). Five of Six RCTs reported on placement outcomes. Of these, two
them were delivered as group training, although two of these reported significant improvements on placement stability,
combined group with an additional format. PCIT (Mersky compared to control. In KEEP2, Price et al. (2008) assessed
et al. 2016) had additional dyad (parent–child) coaching ses- child exits within 200 days of baseline assessment. They
sions and MSS (Smith et al. 2011) had additional individual found that children in the KEEP intervention group were
child sessions. The ABC2 (Sprang 2009) intervention for almost twice as likely to experience a positive placement
toddlers and preschoolers was theorised to improve child change (e.g. reunion with biological parent or adoption) than
behaviour through focusing on strengthening sensitive, children in the control group. They reported that there were
responsive and nurturing parenting behaviour to teach the similar overall rates of negative exits between the KEEP
child to depend on their foster carer for external regulation and control groups. Kim and Leve (2011) reported that the
assistance while they learn self-regulation strategies. Only MSS intervention group was significantly related to fewer
interventions that reported inclusion of these extra compo- placement changes in preadolescent girls compared to the
nents showed significant intervention versus control effects control group, up to 24 months post-baseline. One other
in child problem behaviour. For these interventions that did RCT, KEEP1 (Chamberlain et al. 1992) reported children
not show comparative benefit, the most noticeably absent in the KEEP + $70 weekly stipend group had significantly
common components were participation strategies and more successful days in care compared to unsuccessful days
trauma psychoeducation. (e.g. ran away, moved placement to more restrictive setting)
than children in the other two conditions (i.e. $70 stipend
Attachment and Relational Problems only and TAU groups). This analysis was based on the 54
children (of 72) who had not rejoined their families during
Three RCTs specifically aimed to build parent–child rela- the 2-year study period. However, there were substantial
tionships and remediate the negative effects of relationship baseline differences between these groups, indicating these
disruption, by enhancing carer sensitivity, responsiveness results should be interpreted with caution. The other studies
and nurturance (i.e. ABC1, FFI and PFR; see Tables 5 and examining this domain reported no significant differences
6). All of these interventions were broadly based on attach- on placement outcomes in the short–medium term (up to
ment theory and were targeted towards infants and toddlers 6 months of follow-up; Macdonald and Turner 2005; Gavita
and delivered to parent/child dyads in their own homes. et al. 2012) or longer term (2 years post-randomization;
ABC1 reported significant improvement in carer sensitiv- Spieker et al. 2014). Few patterns were observed between
ity (Bick and Dozier 2013) and reduction in child avoidant content and delivery variables and the effectiveness of inter-
behaviour in the intervention group compared to an active ventions on placement outcomes.
control 1-month post-intervention; however, there were
no significant differences between groups in child secure
behaviour (Dozier et al. 2009). Van Andel et al. (2016) Discussion
reported significant improvements on several parent–child
relationship indices in the FFI group compared to those who Summary of Findings
received TAU in the short term (up to 3 months post-inter-
vention), with medium-to-large effect sizes. Spieker et al. This review aimed to examine the comparative effectiveness
(2012) reported significant differences between PFR and an of foster and kinship care interventions and for the first time
active control on parental sensitivity post-intervention with a analyse the components within each intervention, exploring
small/medium effect size, but these differences became non- their potential impact on target outcomes. Seventeen stud-
significant at 6-month follow-up. Their findings did not show ies were identified, representing RCTs of 14 different inter-
significant comparative improvement on attachment security ventions. Overall, 11 RCTs showed comparative benefit of
post-intervention or at 6-month follow-up. It is notable that the intervention compared to an active or inactive control
this study was rated as having the lowest risk of bias of all group on one or more targeted outcomes aligned with the
studies reviewed. broad aim of each interventions. In respect to program con-
Common content across these three interventions was tent, effective interventions were developed specifically to
trauma psychoeducation, positive parenting, relational skills, meet the needs of foster and kinship families with children
direct coaching/feedback on parent skills and a focus on who had experienced maltreatment and relationship disrup-
parental self-reflection and acknowledgement of the impact tion. They had clearly defined aims, were targeted towards
of parental attributions and perceptions of the foster child specific domains and developmental stages, and included
on the parent–child relationship. content components that specifically targeted this domain.
13

Interventions that were effective in improving parent–child complex trauma on family relationships, and addressing
relationship quality (e.g. attachment behaviours, parental it specifically within foster family interventions. These
sensitivity) used relational skills components that were findings augment previous reviews that have criticised
focused on developing empathic, sensitive, nurturing and traditional parent training programs treating child behav-
attuned parental responses to child need. Effective interven- iour problems for having little benefit in foster populations
tions also provided opportunities for carer skill development (Kinsey and Schlosser 2013; Turner et al. 2007).
via in-session practice with role play and/or direct coach- Three trials specifically aimed to build parent–child rela-
ing. The substantial heterogeneity in the included studies tionships and remediate the negative effects of relationship
presented significant difficulties in evaluating foster inter- disruption. All of these were found to enhance one or more
ventions, consistent with observations made by previous of the following outcomes directly post-treatment: carer sen-
reviewers (Kerr and Cossar 2014; Kinsey and Schlosser sitivity, attachment behaviour and parent–child relationship.
2013). In response to the diverse intervention aims, partici- Informed by attachment theory, these interventions were
pant characteristics and outcome measurement, we synthe- strongly focused on helping parents manage their own emo-
sised intervention effectiveness for three key domains: child tional reactions to perceived rejection from their foster child
behaviour problems, attachment and relational issues and and learning to sensitively interpret child cues. Overall, rela-
placement outcomes. tional skill components focusing on developing empathic,
Twelve trials reviewed aimed to reduce child behaviour sensitive, nurturing and attuned parental responses to child
problems (e.g. externalising, disruptive behaviours). This need were relatively rare across all of the interventions
aim is hardly startling, given the increased rates of behav- reviewed and were only apparent in the attachment-based
iour problems identified in foster children that present sub- interventions. Other common content across these interven-
stantial challenges to foster parents (Landsverk et al. 2002), tions was trauma psychoeducation, positive parenting, direct
and the reciprocal association between placement stability coaching and feedback on parent skills and parent-related
and child behaviour problems (Fisher 2015). However, only factors.
six of the 12 trials were found to have significant benefits Improving foster parent–child relationships was also
on child behaviour problems compared to control groups targeted indirectly by social learning interventions. Those
post-intervention. which were successful in reducing child behaviour aimed
Common components across the studies that were effec- to enhance positive parenting skills, such as teaching about
tive in addressing behaviour problems included content the impact of trauma, increasing carers’ capacity to follow
specifically designed to address these problems (i.e. spe- their child’s lead and encouraging them to reflect on factors
cific discipline strategies and a focus on contingent posi- impacting their parenting responses. Social learning theory-
tive reinforcement for desirable behaviour) and increase based programs have been shown to promote parental sen-
positive family interactions by building parental engage- sitivity in normative populations (O’Connor et al. 2013),
ment skills. Trauma psychoeducation, problem-solving suggesting these components build foster carer sensitivity
and social skill development, and parent-related factors and stronger relationships with their foster children. Given
(i.e. parental self-regulation, stress management and self- maltreated children’s recognised impairment in early bond-
reflection) were also relatively common. They all included ing (Perry 2009) and their experience of disrupted attach-
specialised content designed to respond to the needs of the ment with their primary caregiver, this is an especially
foster population that they were treating. All were group- important target. However, because programs that aimed
based, although two also combined group with an addi- to address child behaviour did not measure the quality of
tional format. Effective interventions targeting behaviour foster parent–child relationships, the association between
problems typically drew on social learning theory and/ improvements in foster family relationships and reductions
or incorporated, other theoretical models relevant to the in child behaviour problems remains unknown. This reflects
target population and intervention aim. The one excep- the current lack of research into the mechanisms underlying
tion to this was ABC2 (Sprang 2009), which was based change within effectiveness research (Henggeler and Shei-
on attachment theory. Sprang theorised that strengthening dow 2012).
sensitive, responsive and nurturing parenting behaviour Of the six RCTs that measured placement, only two
helps to regulate child behaviour. Interventions found to showed positive effects of the intervention on placement
have little benefit on problem behaviour were more tradi- stability and/or permanency, compared to control. In the
tional parenting management training programs developed context of the well-identified negative implications of place-
for parents of children where developmental trauma was ment disruption on child mental health (Fisher et al. 2013),
not indicated, with little adaptation for foster carers or the few observable associations between intervention com-
children who have experienced maltreatment. This contrast ponents and placement outcomes clearly indicates a striking
highlights the importance of acknowledging the impact of need for further research in this area.
13
Existing reviews have been based on evaluations of the content. However, we aimed to mitigate this by collecting
efficacy of foster interventions as a whole. In contrast, this additional intervention information from secondary sources
review examined intervention components through a tran- (e.g. published intervention model descriptions).
stheoretical lens, finding evidence that certain program The exclusion criteria also restricted ‘wrap-around’ ser-
components were associated with effectiveness. By focus- vices so as to focus on the components within foster/kin-
ing on the associations between program components and ship care interventions. However, this excluded a number
outcomes, these findings support and extend prior research. of noteworthy interventions in foster/kinship populations.
For example, we found that effective interventions were Treatment Foster Care Oregon (TFCO), formerly known as
those targeting specific domains and developmental stages, Multidimensional Treatment Foster Care (Leve and Cham-
consistent with reviewers’ conclusions that foster interven- berlain 2005; Chamberlain et al. 2007; Leve and Cham-
tions that target specific developmental, neurobiological and berlain 2007) and TFCO-P, for preschoolers (Fisher et al.
behavioural needs appear to have the most promising results 2005, 2007, 2011; Fisher and Kim 2007) have both produced
(Dorsey et al. 2008; Leve et al. 2012). This is of particular positive outcomes for adolescent delinquent and preschool
importance because developmental trauma results in a wide populations, respectively. These programs involve compre-
range of complex needs (Van der Kolk 2005), and foster hensive, lengthy and intense training and support for special-
children frequently receive interventions with questionable ised foster caregivers and incorporate coordinated treatment
effectiveness that are not targeted to meet their specific needs with a team of professionals, in the home and educational
(Bellamy et al. 2014). Also consistent with previous research settings, with peers and permanent placement resources (e.g.
are our findings that suggest enhancing parent–child rela- birth family, adoptive family, permanent foster family).
tionships was integral to intervention effectiveness. A range
of researchers have argued that approaches to both behav-
ioural and emotional concerns are most effective when they Implications for Future Research and Clinical
are able to strengthen parent–child relationships, either indi- Practice
rectly by enhancing carer understanding of their children’s
emotional needs (Kelly and Salmon 2014; Luke et al. 2014) In order to advance the field, research needs to occur in a
or directly through dyadic interventions (e.g. ABC). This more coordinated and collaborative fashion, where one study
is vital because secure, loving, and sustained parent–child can build upon another. Only two of 14 interventions were
relationships play an integral role in supporting foster chil- evaluated in more than one RCT, indicating a clear need for
dren’s mental health and well-being (Tarren-Sweeney 2014). more replication. Population subgroups need to be clearly
identified and programs need to be developed and empiri-
Limitations cally validated to be able to answer what works for whom
and for which particular domain. There remains a need to
The robustness of these findings is limited by variation in identify better ways of matching interventions for particular
the methodological quality, procedures and outcome meas- groups of children, based on their vulnerabilities. The needs
ures used to assess effectiveness. The quality of the stud- of children in care due to physical abuse may well be distinct
ies varied, with only five interventions rated as having low from those who have experienced neglect or those seeking
risk of bias on more than three internal validity indicators. asylum. Moreover, clinicians working in the field of early
Reporting often lacked clarity and sample characteristics intervention often hope they are changing the trajectory of
were often poorly reported. Outcome measurement varied the children they treat, but without high-quality longer-term
enormously, with over 100 outcome measures used across follow-up, we are unable to know if this is really the case. A
the included studies to assess 18 different domains. Many more consistent approach to these factors would allow quan-
studies did not clearly articulate the rationale between the titative analysis across studies with the capacity to provide
aim of the study and the outcomes used to assess its efficacy. more definitive conclusions.
Finally, most outcomes reported were short-term assess- Empirical questions yet to be answered are numerous.
ments (less than 6 months post-intervention) and longer term For example, does including a relational focus and improv-
follow-up was limited. A thorough review of methodological ing parental sensitivity and responsiveness add to potential
challenges in the field has been presented elsewhere (Dickes improvements in problem behaviour? Does the addition of
et al., in press). This variation and lack of consensus made it parent-focused components improve child behaviour or men-
more difficult to draw definitive conclusions. tal health outcomes? Do engagement strategies reduce attri-
Published information about intervention components tion and improve outcomes? The clearest way to examine
was limited. The degree to which programs contained unre- the individual benefit of certain components on outcomes
ported components is unknown, and there may be minor dif- is to dismantle the components within an intervention and
ferences between our coded content and delivered program compare them in a well-designed, high-quality RCT.
13

Conclusions MJ (foster care OR kinship care OR foster child* OR

foster parent* OR foster carer* OR foster mother OR foster
Results from this review extend previous research by pro- father OR foster family OR out of home care OR looked
viding a comprehensive, systematic overview of foster/kin- after children) AND MJ (intervention OR therap* OR
ship interventions and the components within them. Find- counsel?ing OR cognitive behavior?ral therapy OR psy-
ings from this review suggest that interventions should be chotherapy OR family therapy OR treatment OR training).
developed specifically to meet the needs of the children
who have experienced maltreatment, targeting specific Limiters Published Date: 19900101-; Publication Type:
domains and developmental stages. Additionally, interven- All Journals; English;
tions that provide opportunities for parent skill develop- Expanders—Apply related words; Search modes—
ment via in-session practice with role play and/or direct Boolean/Phrase.
coaching are likely to be more effective. These results fur-
ther highlight the need for clinicians to conduct thorough
Cochrane Collaborations Register of Controlled
assessments and deliver targeted care (Luke et al. 2014;
Trials (CENTRAL)
Tarren-Sweeney 2014). Given the importance of the par-
ent–child relationship, future interventions should include
foster care or kinship care or foster child* or foster parent*
the aim of enhancing parent–child relationship quality, by
or foster carer* or foster mother or foster father or foster
focusing on developing empathic, sensitive, nurturing and
family or out of home care or looked after children:ti,ab,kw
attuned parental responses to child need. Child behaviour
and intervention or therap* or counsel?ing or cognitive
problems are highly prevalent in children who have expe-
behavior?ral therapy or psychotherapy or family therapy or
rienced maltreatment and multiple placement breakdowns.
treatment or training:ti,ab,kw.
Equipping parents with education and skills to meet these
behavioural challenges is essential. A better understand-
Limits: Publication Year from 1990 to 2016 (Word vari-
ing of the association between parent–child relationships
ations have been searched).
and child behaviour problems would allow us to develop,
deliver, and evaluate programs that combine these com-
ponents more effectively.
Medline
Compliance with Ethical Standards
(exp Foster Home Care/px [Psychology] OR out of home
Conflict of interest The authors declare that they have no conflict of
interest.
care.mp. OR looked after children.mp.) AND (intervention.
mp. OR therapy.mp. OR Counseling/OR Cognitive Therapy/
Ethical Approval Ethics approval was obtained by the University of OR treatment.mp. OR training.mp. OR Family Therapy/).
Technology Sydney Human Research Ethics Committee.
Limits: 1990—current; English.
Appendix: Electronic Search Strategies

Social sciences citation/web of science core
collection
PsychINFO
TOPIC: (“foster care” or “kinship care” or “foster child*”
AB (foster care OR kinship care OR foster child* OR fos-
or “foster parent*” or “foster carer*” or “foster mother” or
ter parent* OR foster carer* OR foster mother OR foster
“foster father” or “foster family” or “out of home care” or
father OR foster family OR out of home care OR looked
“looked after children”) AND TOPIC: (intervention or ther-
after children) AND AB (intervention OR therap* OR
apy OR therapies or counsel?ing or “cognitive behavioral
counsel?ing OR cognitive behavior?ral therapy OR psy-
therapy” or psychotherapy or “family therapy” or treatment
chotherapy OR family therapy OR treatment OR training).
or training).
Limits: Published Date: 19900101-; Publication Type:
Limits: Refined by: LANGUAGES: (ENGLISH); Times-
All Journals; English.
pan: 1990–2016.
Expanders—Apply related words; Search modes—
Indexes: SCI-EXPANDED, SSCI, A&HCI, CPCI-S,
Boolean/Phrase.
CPCI-SSH, ESCI, CCR-EXPANDED, IC.
13
Scopus welfare clients. Child Maltreatment, 14(4), 356–368. https://

doi.org/10.1177/1077559509332263.
Chamberlain, P., Leve, L. D., & Degarmo, D. S. (2007). Multidi-
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child OR foster parent* OR foster carer* OR foster mother system: 2-year follow-up of a randomized clinical trial. [Ran-
OR foster father OR foster family OR out of home care OR domized Controlled Trial; Research Support, N.I.H., Extra-
mural; Research Support, Non-U.S. Gov’t]. Journal of Con-
looked after children) AND TITLE-ABS-KEY (intervention
sulting and Clinical Psychology, 75(1), 187–193. https://doi.
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vices and stipends for foster parents: Effects on retention rates
and outcomes for children. Child Welfare: Journal of Policy,
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Practice, and Program, 71(5), 387–401.
GUAGE, “English”)) AND (LIMIT-TO (SRCTYPE, Chamberlain, P., Price, J., Leve, L. D., Laurent, H., Landsverk,
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for children in foster care: Outcomes and mediation effects.
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Program Components of Psychosocial Interventions in Foster and Kinship Care: A Systematic Review

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Clinical Child and Family Psychology Review (2018) 21:13–40

Program Components of Psychosocial Interventions in Foster

Published online: 20 November 2017

Introduction Australian Institute of Family Studies 2016). The majority

Types of Study Design

Table 1 Program content variables (coded as present or absent)

In-session practice Opportunities to practice skills in session

Risk of Bias in Individual Studies

Fig. 1 PRISMA flow chart of selection of studies for inclusion in systematic review

Kim et al. (2013) TAU: 52 groups + follow-up: child # placement:

Table 4 Abbreviations for Abbreviation Name

Overview of Intervention Components

Table 5 presents the synthesis of components across each

Theoretical Basis of Interventions

Interventions were categorised according to broad theoreti-

Table 5 Programme components and main outcome summary

Parent psych. function +

Parent and Group 1, 2, Parent skills +

Attributi Role Direct

FCCT Parent Group x x x Psychological functioning =

CBT-PT Parent Group x x x x Behaviour problems =

Parent and Social competence =

Parent and Individ

Table 6 Summary of intervention outcome domains, measures and main findings

CEBPT Placement Case records (cr) No significant differences in placement disruption

immediately and 9 months post-intervention

Parent skills PBQ (p) No significant differences on parenting behaviour

attachment-based intervention on child behaviour. All RCTs

intervention group compared to control, with effect sizes

no statistically significant improvements in child behaviour

in the intervention group compared to the control (CBT-PT;

IY + CP; PMTO; see Table 6).

analysis suggests that behaviour management components

behaviour management such as providing trauma psychoe- Placement

Conclusions MJ (foster care OR kinship care OR foster child* OR

Appendix: Electronic Search Strategies

Scopus welfare clients. Child Maltreatment, 14(4), 356–368. https://

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Table 1 Program content variables (coded as present or absent)

Fig. 1 PRISMA flow chart of selection of studies for inclusion in systematic review

Table 4 Abbreviations for Abbreviation Name

Table 5 Programme components and main outcome summary

Table 6 Summary of intervention outcome domains, measures and main findings