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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Effectiveness of support services for children and young people with challenging behaviours related to or secondary to disability, who are in out-of-home care: a systematic review

J Ziviani, R Feeney, M Cuskelly, P Meredith, and K Hunt.

Review published: 2012.

Link to full article: [Journal publisher]

CRD summary

The authors appeared to conclude that interventions which focused on support services lead to some positive outcomes for children and young people with emotional and/or behavioural. issues. Outcomes that related to caregivers/parents were mixed. This conclusion reflected the limited evidence presented. The generalisability of findings in relation to the review question is uncertain.

Authors' objectives

To evaluate the effects of support services for children and young people in out-of-home care who have challenging behaviour related to disabilities.


PsycINFO, ERIC, MEDLINE, CINAHL, Cochrane CENTRAL, Social Services Abstracts, PAIS International, PsycARTICLES and Sociological Abstracts were searched between January 1990 and September 2010. Search terms were reported. Reference lists and key journals were searched and papers written by known authors were retrieved. Published studies in English were sought.

Study selection

Eligible for inclusion were controlled trials (randomised, quasi-randomised or non-randomised) and cohort studies that evaluated support services delivered to children and/or young people (up to 18 years of age) with moderate to severe complex psychological and/or behavioural issues and/or a disability. Participants had to live out-of-home or with foster caregivers/parents. Studies were required to have a comparison group who received placebo, usual care or a different intervention. Excluded were studies of participants who received treatment foster care as an alternative to residential care or incarceration.

Included participants were aged between two and 17 years and had emotional and/or behavioural problems; none had a disability. Interventions included behavioural parent-training, relationship development and individually-tailored case management plans (full details of each intervention, and any theoretical base, were given in the paper). Various types of professionals were involved in administering the programmes. Intervention intensity and follow-up varied. Comparisons were made between receipt of standard practice or no intervention, or on outcomes between groups of non-relative foster parent/child dyads and biological parent/child dyads. A range of outcomes and outcome measures were included. For children and young people, outcomes included behaviour, delinquency, placement stability (home and school), and community participation. For foster caregivers/parents, these included emotional/psychological functioning, attitudes, knowledge and responses to challenging behaviour, potential for child abuse and satisfaction with the intervention.

Studies were selected by one reviewer and the decision was confirmed by a second reviewer. Disagreements were resolved by consensus. Study authors were contacted for clarification on participant characteristics, where necessary.

Assessment of study quality

The quality of randomised controlled trials (RCTs) was assessed using the PEDro scale (11 points), which covered allocation method, baseline similarity of groups, blinding, adequacy of follow-up, intention-to-treat analysis, statistical methods and reporting, and eligibility criteria. Studies that scored 5 or more points were considered to be moderate-to-high quality. Non-randomised studies were assessed using an adapted version (maximum score 28) of the Downs and Black Checklist, which covered study quality, internal and external validity, and study power.

Two independent reviewers carried out the quality assessment. Disagreements were resolved by consensus.

Data extraction

Data were extracted to enable the presentation of group means, standard deviations, mean differences and 95% confidence intervals (CI).

The authors did not state how many reviewers extracted the data.

Methods of synthesis

Data were synthesised narratively. The findings were structured according to intervention category, and for outcomes related to children/young people and to foster caregivers/parents.

Results of the review

Four studies (two randomised controlled trials, 263 participants; two non-RCTs, 382 participants) were included in the review. Overall methodological quality was considered to be moderate and adequate. The RCTs each scored five on the PEDro scale, and non-RCTs scored 14 to 17 on the Downs and Black Checklist. Expanded results on study quality were reported in the paper.

There were some positive intervention outcomes for children and young people. These included improvements in behaviour, particularly in males, (two RCTs; one non-RCT); improvements in home placement stability, reductions in placement change and runaways (two RCTs); and reduced delinquency (two RCTs). Outcomes for foster caregivers/parents were less clear. A significant post-intervention reduction in the potential for child abuse was reported, particularly for biological parents.

Authors' conclusions

Interventions that focused on support services lead to some positive outcomes for children and young people. Outcomes that related to caregivers/parents were mixed.

CRD commentary

The inclusion criteria for this review was not sufficiently robust to assess only participants with disability-related behavioural issues. No studies of participants with disabilities were included, so the review did not answer the research question. A range of relevant data sources was searched, but language and publication biases could not be ruled out, and the potential for missing studies was present (acknowledged by the authors). The processes of study selection and quality assessment were carried out with attempts to minimise error and bias; this was unclear for data extraction.

Suitable quality assessment tools were applied to the different study designs, and the results were fully-reported. The chosen method of synthesis was appropriate. The authors drew attention to the inherent difficulties in bringing together highly variable results from complex interventions, and they highlighted several limitations of the review in relation to the paucity of evidence.

The authors' conclusion reflects the limited evidence presented. However, the generalisability of findings in relation to the review question is uncertain, and the authors' recommendations for further research are appropriate.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that future research in this area should focus on children with disabilities, and in younger children and females. Outcomes for foster caregivers/parents also warrant further attention. Attempts should be made to distinguish the effective components in complex interventions. They also recommended several quality issues that needed to be addressed in relation to future study design, and that longer follow-up periods were required.


Department of Communities, Disability and Community Care Services and Multicultural Affairs Queensland (Australia).

Bibliographic details

Ziviani J, Feeney R, Cuskelly M, Meredith P, Hunt K. Effectiveness of support services for children and young people with challenging behaviours related to or secondary to disability, who are in out-of-home care: a systematic review. Children and Youth Services Review 2012; 34(4): 758-770.

Indexing Status

Subject indexing assigned by CRD


Child; Disabled Children; Humans; Social Support; Social Welfare; Adolescent; Intellectual Disability



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

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