An exploratory study protocol examining if assertive integrated service delivery better meets the psychosocial and mental health needs of young people in out of home care

Abstract

Young people in Out of Home Care (OoHC) have complex mental health and psychosocial needs due to a range of individual, systemic and intergenerational factors that may limit the effectiveness of usual clinic-based services. To address this, in 2017 an assertive-integrated service (AIS) model of care was adopted by the Child and Adolescent Mental Health Service (CAMHS) in South Western Sydney Local Health District (SWSLHD), Australia, through outreach to the young person in the community. This paper outlines the study protocol comparing AIS with clinic-based CAMHS usual care to meet the physical, mental health and wellbeing needs of young people in OoHC. Using routinely collected outcome data, the AIS model will be compared to clinic-based CAMHS treatment as usual care. Measures of overall functioning (e.g. Global Assessment Scale [CGAS]), psychological functioning (e.g. Strength and Difficulties Questionnaire [SDQ]), general health and social functioning (e.g. Health of the Nation Outcome Scales for Children and Adolescents [HoNOSCA]) and other relevant socio-demographic and clinical variables will be collected at intake and at 3-month intervals until discharge from the respective services. Semi-structured interviews will also be conducted with young people, their carers, and service providers, to examine qualitative themes about the suitability of service provision. It is expected that a better understanding of the key indicators of functioning for young people accessing AIS and clinic-based services will help inform what works for these young people so that they can receive targeted and tailored support from the start of service engagement.

Keywords

Child and adolescent mental health Out of Home Care intervention assertive outreach community mental health protocol engagement

Background

Young people in out of home care

In 2020 there were approximately 46,000 Australian young people in Out of Home Care (OoHC; AIHW, 2021). Young people may be removed from one or both of their biological parents and placed in alternative forms of care for a variety of reasons. The primary aim of removal is to reduce a child’s risk of exposure to significant harm from abuse or neglect, often due to parental substance use, family and domestic violence, or caregiver mental or physical ill health. The number of young people in OoHC has continued to increase between 2% and 10% each year since 2015 despite the increased provision of family services (AIHW, 2020). These numbers capture young people who are in emergency or respite care, foster care, kinship care arrangements, group homes, and residential care settings. Research suggests that the average time a young person spend in OoHC is increasing (Tilbury, 2009) with about two-thirds of young people in OoHC remaining in these services for two or more years (AIHW, 2021); this may partially account for the increasing number of young people in care.

Many young people in OoHC have complex needs due to a range of individual, systemic, and intergenerational factors. Approximately half of young people in OoHC have clinically significant mental health disorders, with another quarter approaching clinically significant levels (when assessed by the Child Behaviour Checklist [CBCL] and the Assessment Checklist for Children [ACC]; Tarren-Sweeney & Hazell, 2006; Tarren-Sweeney, 2017). Mental health diagnoses predominantly included conduct disorder, ADHD, depression, generalised anxiety, and PTSD (Tarren-Sweeney, 2008). Older children and young people tend to have more mental health difficulties compared to their younger counterparts (Tarren-Sweeny, 2017). The earlier a child comes into contact with child protection services, the more severe the mental health condition tends to be (Green et al., 2020). This may suggest that early abuse, maltreatment or neglect is more damaging to a child’s development (compared to later occurring mistreatment) or, worryingly, that engagement with these services and/or unstable or unsuitable OoHC placements may contribute to ill health. Green et al. (2020) found that children who had contact with child protection services had higher odds of receiving a mental health diagnosis in middle childhood, and these odds were highest for children who were in OoHC, even after controlling for a variety of contributing factors (including sex, socio-economic status and family history of mental health). Furthermore, young people in OoHC often have poorer physical health outcomes and educational attainment (Moeller-Saxone, et al., 2016) and this disadvantage can persist into adulthood (Brännström et al., 2017).

Aboriginal and Torres Strait Islander young people are also disproportionately represented in OoHC – they are 11 times more likely to be in an OoHC setting, compared to non-Aboriginal and Torres Strait Islander young people (Child Family Community Australia, 2020), despite making up about 3.3% of the Australian population (Australian Bureau of Statistics, 2016). There were approximately 18,000 Aboriginal and Torres Strait Islander young people in care in 2019 (AIHW, 2020). Reasons for this over-representation are complex, but may include intergenerational trauma from Australian Government policies, including the Stolen Generation and forced removals (Child Family Community Australia, 2020); differing cultural views regarding parenting practices and definitions of what constitutes abuse or neglect (Child Family Community Australia, 2020); stigma indirectly perpetuated by welfare services, specifically with regard to Eurocentric conceptualisations of parenting practices and what is regarded as competent parenting (Choate, 2018), and; lack of culturally appropriate, self-determined, Aboriginal run research and clinical practice teams addressing specific mental and physical health needs (Shmerling et al., 2020).

Young people’s needs in OOHC and challenges in providing a mental health service

Typical child and adolescent mental health services are ‘acute’ in nature, meaning that intervention is time-limited to address the immediate concerns related to the referral. Therefore, these services are typically set up for short-term, 1:1 therapeutic work or case management which is usually in-office appointment-based.

Young people in OoHC often present with complex trauma histories (physical, sexual, psychological), disrupted attachment dynamics, and chronic nervous system dysregulation leading to a range of psychological, behavioural and social difficulties (Tarren-Sweeney, 2008; Bollinger et al., 2017). This range of comorbid concerns often means treatment needs are complex. Furthermore, the typical parental role of providing care, nurturance, guardianship, and decision making is often indistinctly shared between various services and stakeholders (such as the young person’s current carer, the biological parents, government departments and non-government care agencies). This can make the process of the young person being appropriately identified as needing treatment, being referred and gaining consent for treatment, and maintaining attendance at treatment difficult. These care arrangements can also shift or change unexpectedly, or be temporary or tenuous in nature, making it difficult for young people to establish meaningful relationships and experience long-term stability (Rubin et al., 2007; Fisher et al., 2013) Anecdotal evidence suggests that due to the diagnostic complexity, instability in their attachment relationships and variance in their living situation, standard mental health interventions may not meet the complex and substantial needs of young people in OoHC (Eadie, 2017; Tarren-Sweeney, 2010). As such, it is becoming more apparent that these young people and their carers require specialised services to provide mental health support.

To better meet the needs of young people in OoHC, the following service delivery adjustments have been suggested (Tarren-Sweeney, 2010) as possible remedies: promotion of specialised services with a narrower scope of practice to include only young people in, or previously in, OoHC, or at risk of being removed), services who are able to provide more in-depth multidisciplinary assessment and intervention, who have the time and resources to work collaboratively with a range of stakeholders, who are able to advocate for the young people amidst multiple changes, whose practices are deeply trauma-informed and attachment-based, and who are able to remain consistently involved for long-term periods. These adjustments are recommended for their improved ability to assess and identify the issues facing the young person as well as the ability to stabilise and offer consistent mental health care for the young person and their care system.

Promoting engagement in mental health services

Whilst gaining and maintaining engagement is a challenge for any mental health service (Dunne et al., 2017), it appears to be a particular barrier to working with young people in OoHC (Powell et al., 2021; Kerns et al., 2014). Poor engagement can limit the effectiveness of therapeutic services, thus maximising engagement should be an important goal in service design. Research has suggested that service delivery and models of care impact on quality of engagement. Schley et al. (2012) found that, for those young people considered at ‘high risk’ for disengagement, an intensive outreach-based service could establish sufficient engagement within 6 weeks and sustain this engagement until discharge. They identified key factors to successful engagement as ‘appointment keeping, client–therapist interaction, openness about difficulties, perceived usefulness of treatment, collaboration with treatment, and medication compliance’ (p. 176, Schley et al., 2012, citing, Hall et al., 2001). McLean (2012) interviewed 92 adults involved in support roles for young people in OoHC (carers, health professionals, foster parents.). When examining the challenges and factors leading to engaging and supporting young people with complex behaviours and mental health concerns, the main themes that emerged included power imbalance struggles between stakeholders, exchange and sharing of information, and appropriate resourcing. Therefore, services aiming to meet the needs of complex young people will likely require more intensive resourcing to be able to offer flexible appointments and a highly collaborative service to successfully engage the consumer.

When working with young people, caregiver participation and engagement is also an integral part of trauma-informed care (Ingoldsby, 2010; Bendall et al., 2020). There are often multiple stakeholders involved in the care of young people in OoHC; biological parents, foster parents, other relatives and carers, doctors (GPs, paediatricians, psychiatrists), schools, private psychologists and allied health providers, child protection services, and government and non-government organisations (related to health, disability, and education). Given the number of stakeholders, mental health services need to have models of care equipped to flexibly accommodate different family arrangements and integrate complex support systems within service delivery.

The existing research into mental health service delivery for young people in OOHC

Given the complex and highly changeable needs of this population, longitudinal research into therapeutic outcomes specific to young people in OoHC is limited (Webster & Temple-Smith, 2012; Baidawi et al., 2014; Schmied et al., 2006). Existing research tends to focus on evaluating specific types of therapy that can be used with this population (see Hambrick et al., 2016; Green et al., 2014; Grace et al., 2018; Herrman et al., 2016). However, given the suggestion that young people in OoHC may not be suitable for or respond to typical intervention, more thought needs to be given to the models of care used in OoHC services. In this regard, research which investigates service design and accessibility is needed; such as investigating how best to engage young people and their carers; or which factors are most strongly related to service engagement and response to treatment.

Delfabbro and Osborn (2005) posited that Multi-Systemic Therapy (MST) and Wraparound models appeared most appropriate for young people in OoHC. The Wraparound model is where a service provides a team of professionals who do not provide therapy, per se, but who coordinate the services involved with the young person, managing and overseeing the work of each service to best support the young person and their caregivers. It has been extensively researched in the United States, with two separate meta-analyses (Suter & Bruns, 2009; Olson et al., 2021) revealing that the Wraparound model has small-to-medium effect sizes for mental health outcomes (such as symptoms and functioning), school engagement, placement outcomes, and costs (compared to usual care/TAU). Like the Wraparound model, MST is similar in its goal of coordination; however, the provider might also offer therapeutic intervention and the service tends to be offered in a shorter-term. However, Delfabbro and Osborn (2005) also noted that there has been limited Australian research. Australian research is critical due to the legal and ideological differences between international jurisdictions (particularly compared to the United Kingdom and the United States of America) and the high percentage of Aboriginal and Torres Strait Islander young people in the Australian OoHC context. Additionally, United States trials of MST are provided in a context where there is sparse other preventative social welfare services. The effect sizes of MST are therefore likely to be smaller in countries such as Australia, where co-occurring social welfare provisions are more likely.

We have identified three models of care and service delivery for young people in OoHC in an Australian context which have been explored in the literature. Turnaround (Wyles, 2007) – a Wraparound adaption in the Australian Capital Territory, Evolve Therapeutic Services (Klag et al., 2016; Eadie, 2017) another Wraparound model evaluated in Queensland, and TrACK (Treatment and Care for Kids; McPherson et al., 2018) in Victoria. All report promising results when evaluated with young people in OoHC, with the common factors of these models expanded on below.

The shared factors underpinning the success of these models relate to the specialisation of services to meet the mental health needs of young people in OoHC and other relevant support people (such as carers, extended family or foster parents). These service delivery specialisations are believed to be beneficial for various reasons. Narrowed service eligibility criteria (i.e. tertiary service) means focused and tailored clinical work and the ability to hire and train a specialist multidisciplinary team to effectively work with the complex trauma and disrupted attachment related presentations associated with young people in OoHC (Tarren-Sweeney, 2010). Young people in OoHC also have a higher risk of non-trauma-related mental health problems, such as neurodevelopmental difficulties (e.g. Dinkler et al., 2017). Therefore clinician expertise needs to be varied enough to demonstrate proficiency for the full range of child and adolescent mental health problems, as well as nuanced trauma-related problems. Interventions focused on high engagement, through an assertive outreach model (i.e. clinicians working flexibility in regard to location, time, modality, rather than clinic-based, 1:1 ‘talk therapy’ appointment style) provide maximal opportunities for therapeutic efficacy by meeting the consumer ‘where they’re at’ – both literally and metaphorically (Malvaso et al., 2016; Schley et al., 2008). These service models also have resource or funding models that allow intensive work for staff with small, capped caseloads to allow for frequent and close collaboration with the range of other service providers and stakeholders assisting the young person in care (such as in Wraparound or MST Models above; Wyles, 2007; Eadie, 2017; McPherson, Gatwiri, Tucci, Mitchell & Mcnamara, 2018).

Involvement of young people in research

The importance of a client-centred approach to research and intervention is integral to trauma-informed practice (Wall et al., 2016); however, young people’s voices are often missing from research. In a recent meta-analysis, only three of 39 (13%) studies included direct interviews with young people as part of their research (Smales et al., 2020). Grace, et al. (2019) found a similar gap when completing a systematic review between 2000 and 2018, finding that voices of culturally and linguistically diverse and Aboriginal and Torres Strait Islander young people were further under-represented, as were young people and adolescents (with most participants being those in ‘middle childhood’). Some papers include the qualitative reporting of health professionals (Malvaso & Delfabbro, 2016), carer’s views (McLean et al., 2020), or interviews with family members (MacArthur & Thomson, 2011). Unfortunately, it appears most research does not include the voices of children and young people that are the subject of study. Rafeld, et al. (2019) engaged thirteen young people with experience in OoHC in qualitative interviews. A common theme which emerged from those interviews was that it was important for young people with experience of OoHC to have their voices heard and to be able to impact service delivery; however, there are few opportunities to do so and their involvement is often hindered by poor research design.

The current study

Given the specific needs of young people in OoHC, a considered remedy trialled by NSW Health SWSLHD in 2017 was to adopt an assertive-integrated service model of care (AIS), whereby service delivery occurs through outreach to the young person. AIS is delivered flexibly across different settings, including the young person’s school or home, ‘neutral’ settings such as outdoor spaces, cafes, and shopping centres, and also the consulting rooms at the service office. Clinicians are specially trained in trauma-informed and attachment-focused intervention and have reduced caseloads to allow for intensive support and systemic practice. Active collaboration between stakeholders in the young person’s system (e.g. statutory children’s agencies, carers and schools) is an integral component of AIS, and much of the workload involves substantial consulting and liaising with the services supporting the young person.

Whilst this AIS team has been in effect for 4 years, most young people in OoHC continue to access mental health services within a clinic-based model of care, through their local iCAMHS (Infant, Child and Adolescent Mental Health Service) unit.

To this end, the paper outlines a proposed protocol of a longitudinal cohort study to investigate whether AIS is better able to meet the mental health and wellbeing needs of young people in OoHC compared to usual care through clinic-based iCAMHS.

The proposed study focuses on the following three aims:

(a) to increase the quality of engagement of young people in OoHC with mental health services through exploring the key factors of service design that contribute to wellbeing and engagement.

(b) to further understand the needs of young people in OoHC accessing mental health services by examining the differences in clinical profiles and outcomes for general health and psychosocial functioning of young people aged 8–17 years in OOHC who are accessing AIS as opposed to clinic-based services (i.e. Treatment as Usual; TAU).

(c) to more deeply understand and disseminate the voices of young people utilising these services (including their carers and health professionals) by conducting semi-structured interviews with the young people regarding their experiences of an AIS or centre-based community mental health service.

By exploring key indicators of functioning for young people accessing AIS and centre-based services, we hope to become better informed on what works for these young people so that they can receive focused, intensive and effective support from the onset of mental health service engagement. It is hoped that these insights will contribute to shaping future mental health services in order to enhance engagement that will, in turn, increase positive health outcomes for young people in OoHC.

Method

Procedure, aims and scope

This study is an exploratory cohort study investigating the quality and effectiveness of AIS compared to TAU for young people in OoHC aged 8–17 years old who have mental health difficulties. The study will incorporate both quantitative and qualitative research components. All young people in OoHC who are receiving community mental health treatment in SWSLHD will be invited to participate in the study. The study will analyse outcome data at admission to the service and at 3-month intervals for an 18-month period (or until discharge). We also aim to collect qualitative data regarding consumer’s and clinician’s opinions on service delivery.

Routinely collected outcome data will be extracted from electronic medical records. Clinical and socio-demographic characteristics, measures of engagement, drop out, duration of intervention, school attendance, placement stability and type of care placement (e.g. kinship care, group home, etc.) will also be collected. Service experience and engagement will also be examined through interviews with carers, young people, and clinicians from both groups. The qualitative aspect of the study aims to explore perspectives pertaining to: what aspects of service delivery participants found useful/not useful; participants’ experience of being cared for; ease of access to the service; method of service delivery; views on whether the service worked for them/was beneficial, and health professionals' perspectives on service design and needs of young people in OoHC. Interviews will be offered to all young people, carers and clinicians accessing the AIS and TAU services; however, due to service limitations and research being a low priority for the clinical workforce, the number of completed interviews will be largely dependent on consumer and clinician motivation to engage.

Study site and sample

The sample will comprise young people in OoHC who are accessing either the OoHC Mental Health Team (OOHCMHT, AIS group), or a iCAMHS team within SWSLHD (TAU group). The study aims to collect data for n = 29 young people from each group, with a total N = 58. A sample size of 58 participants (using an alpha of .05 and a power of β = 0.8) would enable the detection of a large effect size, Cohen’s d = 0.75. This is comparable with previous studies (Green et al., 2014) that showed differences in CGAS and HoNOSCA scores ranging from 0.8 to 0.4 resulting from a multi-component intervention.

Inclusion criteria

• Age range: 8–17 years (inclusive)

• In any form of OoHC, including foster care, kinship care, previously removed and now self-placed with biological parent(s), group home, single or emergency placement

• Admitted to a SWSLHD community mental health service between January 1 2020 and May 31 2021

• For the qualitative study: willingness to give written informed consent to participate and comply with the study’s processes.

Exclusion criteria

• Diagnosis of Intellectual Disability (Moderate or Severe) prohibiting informed consent

• Did not engage in at least one assessment session or incomplete intake data available

Recruitment and screening

All young people involved with the OoHC AIS team from January 1 2020 until May 31 2021 will be recruited to the AIS group initially. All young people in OOHC who are admitted to a SWSLHD iCAMHS team from January 1 2020 until May 31 2021 will be recruited to the TAU group initially. Once participants have been enrolled in either the AIS or TAU group, their electronic medical records (eMR) will be checked by a research assistant for their suitability to participate in the study (as indicated by the inclusion and exclusion criteria). If they are deemed suitable to participate, the participant will receive a study ID number and this will be recorded on all study documents. The research assistant or allocated clinician will arrange a session to explain the research study to the young person and their carer. During this session, informed consent from the young person and their carer will be sought to participate in the study, and for the young person’s eMR to be accessed. Once consent in gained, the research assistant will then conduct an audit of their medical records and extract basic demographic information as well as de-identified data from routinely collected outcome measures conducted at the time of intake, which are mandated by the Ministry of Health. About three to 6 months after admission the research assistant will contact the young person’s carer to arrange a time for the young person to come in and participate in the structured interview.

Additional recruitment

In order to most accurately capture the needs and experiences of young people in OoHC a provision was proposed to capture the data of young people who would otherwise meet selection criteria but circumstances prevent them from being contacted by their allocated/previous iCAMHS clinician or the research assistant. It is expected that young people who move into a different LHD catchment area, have placement changes or breakdowns, or are limited in their engagement with the mental health service for various reasons will be less likely to be available to consider informed consent, thus leading to a skewed participant pool. Additionally, the consent process might not be adequate to capture possible young people who are discharged before contact is made. HREC granted an exemption to informed consent for these clients with the proviso that their data was in no-way identifiable. Thus, data mandatorily collected by NSW Health clinicians and entered into eMR will be extracted and de-identified with an allocated numerical study ID. eMR will also be screened to assess the reason for non-engagement, placement breakdown, catchment move or discharge from service. This information will provide subset data to improve how SWSLHD/iCAMHS services meet the needs of young people in OoHC. This data is important as it details the real-life circumstances and difficulties of these young people.

Treatment group

AIS group

The Out of Home Care Mental Health Team (OoHCMHT) is a specialist multidisciplinary mental health team which provides mobile assertive specialist assessment and treatment for young people referred to the service (see Devlin et al. (in press) for further details of the service). The team consists of a clinical manager (clinical psychologist), child psychiatrist, advanced trainee in child psychiatry, clinical nurse consultant and other senior nurses, clinical psychologists, senior social workers, Aboriginal health workers, dual drug and alcohol and mental health trained clinicians and other senior allied health staff. The young people in OoHC are referred to the team directly from the statutory child protection service in NSW (Department of Communities and Justice; DCJ), and typically have significant emotional and behavioural issues which are severely impacting their functioning in placement, school and in the community causing significant distress. The OoHCMHT delivers high quality specialist interventions that are trauma-informed, strengths-based and recovery-focused. Interventions aim to repair or improve the young person’s developmental path by building skills in individual coping, problem solving, emotional regulation, social skills, attachment and academic engagement.

The OoHCMHT has established strong links to other community-based, government and non-government services and agencies. Care planning and coordination for the young person is integrated with the services in their community network. The OoHCMHT is committed to delivering outreach care in the home, school, other community spaces whenever possible to encourage continued engagement and service delivery.

The OoHCMHT is based at Ingleburn, NSW with the catchment area extending over the entirety of South Western Sydney LHD. This health district spans a large geographical area (over 6000 square kilometres), has a population of almost one million people, with half of those speaking a language other than English at home. The team operates 8.30 am–5 pm, Monday–Friday. It is a tertiary level service and receives referrals exclusively from DCJ Caseworkers and Manager Caseworkers. Referrals are made to the team through an allocated DCJ intake officer.

TAU group

This group will consist of young people in OoHC who are already accessing community Mental Health intervention and support with their local South Western Sydney iCAMHS team. These teams accept referrals from local GPs, specialist doctors, NGOs, educators, DCJ and psychologists for young people in the moderate–severe range of psychopathology including children in OoHC that meet the inclusion criteria for iCAMHS. The teams have a predominantly clinic-based model of care with catchment areas encapsulating surrounding suburbs. Young people in OoHC accessing iCAMHS services will be identified by team leaders, mental health clinicians and by electronic medical record screening.

Clinicians

Any health professional employed by SWSLHD in an iCAMHS or AIS team who does client-facing work with young people in OoHC will be identified and invited to participate in a qualitative interview regarding their views on meeting the needs of young people in OoHC. We aim to conduct 20 interviews (10 from the OoHCMHT and 10 from iCAMHS)

Measures

Outcome data will be assessed at admission and at 3-month intervals until discharge (or end of study period) and include the following measures:

Children’s Global Assessment Scale (CGAS) – The CGAS is a clinician rated measure used to evaluate a child’s global impairment on a scale from 0 to 100 (Shaffer et al., 1983). Higher scores indicate high functioning and low scores lower functioning. The CGAS has high interrater reliability (0.84) and test-retest reliability (0.85) and authors report good discriminant validity (Shaffer et al., 1983).

Strengths and Difficulties Questionnaire (SDQ) – Adolescent and Caregiver version. The SDQ is a screening measure for emotional and behavioural difficulties. There are 25 questions (comprising five subscales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationships, and prosocial behaviour), answerable as either ‘not true’, ‘somewhat true’ or ‘certainly true’. It is completed by both the adolescent and the caregiver. Research suggests it displays good validity and is recommended to use as a screener (Child Outcomes Research Consortium, 2019)

Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) – Clinician report. The HoNOSCA is a measure for use in mental health settings to measure general health and social functioning of a young person. It has 15 questions, answered by the clinician on a 5-point Likert scale (0 being ‘no problem’ and 4 being ‘severe to very severe problem’). It displays adequate to good psychometric properties (Child Outcomes Research Consortium, n.d).

Qualitative interviews

Young people, their carers and clinicians invited to participate in the qualitative interviews will be given a Participant Information Sheet and Consent Form. Once consented to participate, interviews will occur intermittently across the study period via phone or face-to-face. The research assistant allocated to the project (who is not an employee of NSW Health) will conduct the interviews. Interviews will be recorded and transcribed. All transcriptions will be de-identified and allocated a study ID prior to sharing with other investigators.

Analysis

Aggregate data at intake/baseline from each group (AIS and TAU) will be compared to provide a profile of the young people in OoHC accessing these services. The two groups will be compared on mean age, number of previous placements, current placement type, mental health diagnoses, school attendance, age of entry into OoHC, length of prior mental health service involvement, level of functioning (indicated by scores on HoNOSCA, CGAS and SDQ) and other risk factors (substance use, self-harm, forensic involvement, emergency department presentations). It is anticipated that at admission, the young people in the AIS group will have a more severe clinical profile as compared to those in the TAU group, as a result of the intake criteria of the different clinical streams. For this reason, data analysis will be exploratory, in order to encourage further investigation and discussions in this area of research.

Analysis of outcome data will first involve exploration of descriptive statistics of each of the treatment groups. Understanding demographic statistics will also allow identification of possible covariates (such as age, number of previous placements, current placement type, mental health diagnoses, school attendance, age of entry into OOHC, length of prior mental health service involvement, substance use). The treatment groups will then be compared using inferential statistic methods (such as t-tests and regressions) to explore the role of the different independent variables in predicting study outcomes, such as wellbeing and functioning scores (e.g. HoNOSCA, CGAS, SDQ) and service utilisation (e.g. drop out, emergency department presentations) It is anticipated that improvements (indicated by change in HoNOSCA, CGAS, SDQ scores) will be significantly larger in the AIS group compared to the TAU group. This is likely to be because the young people in the AIS group will inevitably be getting a greater intensity of service and the young people in the AIS group (by account of their grouping) will likely have lower functioning at baseline, and therefore have more room for improvement (including regression to the mean). Significantly larger change in the AIS group compared to the TAU group may also indicate that AIS is a more suitable model of care for young people in OoHC. If a significant difference between the groups is found, to look into this further, we hope to compare AIS and TAU groups on additional outcome measures, such as: the number of sessions received; number of non-attendance at sessions; and the number of placement changes during the period of intervention. If these differences exist, they are hypothesised to be driven by the increased ease of access to services in AIS due to its flexible service delivery, as well as a more effective overall intervention due to the wholistic/wraparound model of care. Exploratory findings of this nature would encourage further investigation of the mechanisms underpinning successful service engagement for young people in OoHC.

Missing data is an unavoidable complicating factor of real-world clinical research, especially research involving self-report measures collected by young people from complex psychosocial backgrounds. Data collection is likely to be poor because of the high demands on the service, as well as the fact that research is seen as a low priority in the workforce. Mental health clinicians in both AIS and TAU groups have been briefed regarding the importance of accurate questionnaire completion. Where missing values are below 30%, data will be retained through the use of multiple imputation techniques (Kang, 2013).

Audio recordings of qualitative interviews will be transcribed and coded for themes such as experiences and challenges of the OoHC context, identifying and meeting the mental health needs of young people in OoHC, and strengths and weaknesses of service design and delivery. Data analysis will take place using SPSS software for quantitative data, and NVivo for qualitative transcriptions. The qualitative data will be analysed using a thematic coding frame developed by the lead researchers. This process will involve reading the interview transcripts multiple times to ascertain the range of key issues/topics that arose and conducting team discussions to determine what they illustrated, then individually recoding the transcripts in light of these discussions, and finally reviewing coding allocations and labels as a group to determine consensus. Researchers undertaking the thematic analysis come from a mental health background, and are predisposed to a health-focused, liberal, and client-centred lens. Thematic codes will be shared with a non-mental health researcher in an attempt to counterbalance these biases.

Outcomes and significance

Currently, many young people in OoHC are missing mental health intervention opportunities due to lack of flexibility in the regular clinic-based iCAMHS services that often result in insufficient engagement, which urgently requires addressing. The study proposed here by comparing an assertive outreach programme, AIS, with current ‘usual care’ provided by iCAMHS will enrich our scant knowledge of what works for this challenging group of children with complex individual, systemic and service needs. The significance of the project is further highlighted by the fact that there is escalating economic impact both from health care and from a socio-economic perspective for young people in OoHC. Unless their mental health challenges are adequately addressed early, this can result in a cascade of negative consequences such as academic failure, school absence, social dysfunction and forensic involvement as well as adult health and mental health morbidity. If AIS is found to be beneficial in improving the engagement and mental health outcomes of young people in OoHC, this will no doubt make a positive difference to their lives and help break the transgenerational cycle of trauma, dysfunction and despair. Further, at a service delivery level, this would be of interest to be disseminated in other services and settings both locally and across the world.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author(s) received a funding grant from UNSW Medicine Neuroscience, Mental Health and Addictions Theme and SPHERE Clinical Academic Group for the SWSLHD Clinical Knowledge Exchange Seed Funding Initiative.

Ethics approval

Human Research Ethics Committee approved the Human Research Ethics Application (HREA) project reference ID: 2020/ETH00863 and 2020/STE01694.

ORCID iD

Lucy Hobby

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