This is the first known study to test, in a rigorous randomized controlled trial, the impact of a mentoring and skills group preventive intervention on the mental health outcomes of preadolescent maltreated children placed in foster care. The intervention demonstrated significant impact in reducing mental health symptomatology, especially symptoms associated with trauma, anxiety, and depression in this high-risk population. These findings are strengthened by the fact that the study controlled for baseline functioning, and multiple informants reported on children’s mental health functioning. In addition, the pattern of results suggested that program participants were less likely to use mental health therapy and psychotropic medication.
Although mental health functioning improved among program participants relative to controls, the effect was not apparent until six months post-intervention. Group differences on primary outcomes were not expected at T2 for several reasons. First, we hypothesized that improved functioning on primary outcomes would follow improved functioning on secondary outcomes. It was also hypothesized that short-term mental health functioning among program participants might be adversely impacted by participants’ need to say goodbye to mentors and program staff upon completion of the program, which corresponded with the T2 follow-up. Although study hypotheses about mental health effects and their timing were supported, hypotheses about short-term effects on secondary outcomes were not. The overall pattern of results on short-term impacts, however, was in the expected direction, and a trend suggested that program participation was associated with higher perceived social support at T2.
Findings of program efficacy are consistent with a large body of evidence suggesting that skills training curricula are effective in reducing risk and promoting mental health. Skills groups have demonstrated efficacy in multiple contexts and with diverse populations, including maltreated youth.30–32
Social skills groups may be particularly useful for children in foster care, as they often lack critical social skills, may have recently changed schools and peer groups, and may know no other children in foster care.
On the other hand, the current study’s findings provide valuable information to inform the evidence base for mentoring, which has much less empirical support despite its ideological promise.33–34
Although some studies suggest that mentoring can have a positive impact on youth functioning,35–38
there is reason for caution. Experimental studies of mentoring programs, particularly randomized controlled trials, are rare, and some studies fail to produce evidence of efficacy.39–42
Two recent large-scale evaluations of programs with a mentoring component failed to demonstrate effectiveness and one of the studies produced iatrogenic effects.43–44
Although there has been little empirical research, there has been enormous public and private investment in mentoring programs. Over $100 million in federal dollars, annually since 2004, have been dedicated to mentoring programs nationally.45–46
A 2006 Social Policy Report by the Society for Research in Child Development on mentoring research concluded, “There are few other areas where the research-program/policy connection is as badly needed.”47
FHF is one of the first randomized clinical trials with a high-risk population to demonstrate the efficacy of a mentoring program on mental health outcomes. Although the FHF program employs a fairly traditional community-based mentoring model, the fact that it is paired with skills groups may be particularly effective. Furthermore, FHF mentoring incorporates those practices that appear to enhance the effectiveness of mentoring. A meta-analysis of mentoring programs found that program effects were significantly enhanced when programs targeted high-risk youth and incorporated several “best practices.” Programs that used mentors with prior experience in a helping role or profession, those that provided for ongoing training of mentors, and those that provided structured activities for mentors and participating youth had the most beneficial effect on youth identified as high risk.48
The study’s methodological approach also speaks to the generalizability of the study findings. All eligible children in participating counties were recruited and the high recruitment, retention, and program uptake rates suggest that this intervention was contextually sensitive and well received. Despite the fact that the participants were extremely heterogeneous on sociodemographic factors, maltreatment history, current living situation, and cognitive, academic, emotional and behavioral functioning, there were important program main effects. The generalizability of the findings is also strengthened by the fact that participants did not self-select into the program (as is the case with most community-based mentoring programs in which participants sign up).
The study also demonstrates that it is possible to conduct a rigorous RCT with intent-to-treat analyses in a child welfare population, and to obtain information from multiple informants, including teachers. There are many barriers to conducting trials with a foster care population, including changes in legal guardianship, ongoing court processes, multiple system involvement, and the need to report all suspected maltreatment. The ability to conduct this important research speaks to the strength of the collaboration between researchers and participating counties. Despite all the challenges to program completion, all but 5 children who began the 9-month prevention program graduated. In addition, over 80% of those who either refused the prevention program or dropped out were interviewed at follow-up and included in intent-to-treat analyses. Success in recruitment and retention may be due to the fact that there were small cohorts as we developed and tested FHF. Such formative work is critical in the development of novel interventions, especially those at risk for iatrogenic effects.49
A full-scale efficacy trial is currently underway, which will enable us to test whether the program remains efficacious on a larger scale.
The study was not without limitations. Despite randomization, there were a few key variables on which the two groups differed at baseline. Although analyses controlled for these differences, there may have been other, unmeasured factors, which affected the baseline equivalence of groups. In addition, those lost to follow-up had lower IQs and more mental health problems than those interviewed, which may limit the generalizability of the findings. Finally, the fact that children are in foster care presents some unique methodological challenges that may have influenced the results. Caregivers of children in foster care are not static, and some children had different caregivers at each of the three interview timepoints, while other children had the same caregiver. Because caregivers parented these children for variable amounts of time, their knowledge of the children’s current functioning and psychosocial histories varied greatly. To minimize the impact of the variability in caregiver familiarity with their children, which was not expected to differ between treatment conditions, the study asked questions of caregivers that focused on current functioning and recent mental health treatment. The addition of teacher reports, in which the informant is expected to vary each year, also mitigates concerns about reporter bias.
Despite study limitations, findings suggest that the FHF mentoring and skills group protocol holds promise and that future work examining program efficacy is warranted. Longer-term follow-up (currently underway) is needed to determine whether effects are sustained and/or whether new effects emerge. Despite the cluster of risks associated with maltreatment, including poverty, high-risk neighborhoods, parental psychopathology, substance use, and domestic violence, this study suggests that Fostering Healthy Futures promotes greater life satisfaction and better mental health functioning among maltreated youth placed in foster care. These are important findings given the dearth of evidence-based treatments for this vulnerable population. Although this study needs replication, it may be a promising model, not only for children in foster care, but for other high-risk youth populations as well.