Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of-Home Care The International Indigenous Policy Journal Volume 8 | Issue 3 Article 5 July 2017 Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of- Home Care Sophie Lindstedt University of Melbourne, sophie.lindstedt@gmail.com Kristen Moeller-Saxone University of Melbourne, kristen.moeller@orygen.org.au Carly Black Victorian Aboriginal Child Care Agency, carlinab@vacca.org Helen Herrman University of Melbourne, h.herrman@unimelb.edu.au Josef Szwarc Recommended Citation Lindstedt, S. , Moeller-Saxone, K. , Black, C. , Herrman, H. , Szwarc, J. (2017). Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of- Home Care. The International Indigenous Policy Journal, 8(3). DOI: 10.18584/iipj.2017.8.3.5 Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of-Home Care Abstract The child protection system in Australia includes out-of-home care (OoHC) for children and young people at risk of harm and neglect. In Australia, Aboriginal and Torres Strait Islander children and young people are 9 times more likely to be placed in care than non-Aboriginal young people (Australian Institute of Health and Welfare, 2015). Australia’s history of colonization and subsequent policies have caused trauma to individuals, families, and communities and resulted in poor physical and mental health and mistrust of services. This review was undertaken to identify programs and policies currently in place that aim to improve the mental health and well-being of this vulnerable population. It provides an analysis of both the strengths of the current system as well as what has been inadequately addressed based on literature in the area.By incorporating an Aboriginal perspective, this review focuses on social, emotional, and spiritual well-being (SESWB) and the aspects of a child’s life and community that promote this. A realist review of the academic and grey literature was conducted in 2014. It included an extensive search of government and non-government (NGO) publications. The review identified nine programs or policies that are designed to improve the SESWB of Aboriginal young people in OoHC in local and international settings. These are the Aboriginal and Torres Strait Islander Child Placement Principle, cultural support plans, Aboriginal Community Controlled Organisations (ACCOs), family group decision-making, therapeutic care, and Panyappi Mentoring Program. Given that culturally competent service provision is important to SESWB, the review concludes that an increase in monitoring and evaluation is necessary to determine the effectiveness of programs and ensure their implementation and sustainability when warranted. Policy and research work is needed to adapt and devise programs promoting the SESWB of Aboriginal young people (at both the individual and system levels), determine their effectiveness, and ensure they are sustained when warranted. Keywords Aboriginal, mental health, well-being, policy, programs Acknowledgments Mr Peter Lewis and Ms Connie Salomone at the Victorian Aboriginal Child Care Agency, and the Aboriginal Reference Group for the Ripple Study provided support for the research Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal Young People Living in Out-of-Home Care (OoHC) The child protection system in Australia includes out-of-home care (OoHC) for children and young people who are considered at-risk for harm or neglect. When children are placed in care, they can be at high risk of both mental and physical health problems as well as poor social and educational outcomes (Cummins, 2012). In Australia, the Aboriginal and Torres Strait Islander population is disproportionately represented in OoHC (Australian Institute of Health and Welfare, 2016). The mental health and well-being of this group is of paramount importance and support may be necessary for Aboriginal Australians and Torres Strait Islanders to either achieve or regain mental health following removal from their families. This article reviews and examines published evidence about a variety of programs that are designed to enhance the mental health and well-being of Aboriginal young people (aged 12-18) living in OoHC services. This age group is the focus of this review because adolescence is an important developmental stage when mental health needs can be high. Issues such as low levels of school participation, involvement with the criminal justice system, and problems with substance use during this period can be linked to mental health problems and subsequent adjustment problems as young adults (Walker, Robinson, Adermann, & Campbell, 2014). If not addressed, the impacts of trauma can be carried through into adulthood causing significant lifetime distress. Beyond the consequences felt by individuals, untreated trauma may also have negative effects on the health and well- being of families across multiple generations. As such, it is critical to understand what kinds of programs and support services are available to young Aboriginal Australians and Torres Strait Islanders and which have been shown to be effective. Background What is Out-of-Home Care? OoHC is the system that Australia has developed to care for and protect young people (i.e., up to the age of 18) who cannot live with their parents. OoHC is used in cases in which a young person is (a) considered to be at risk of harm within his or her family, or (b) his or her parents can no longer safely care for or protect him or her. The OoHC system in Australia is broadly divided into two categories: home-based care and residential care. Home-based care refers to placements with carers who are reimbursed (or who have been offered but declined reimbursement) for expenses relating to the care of a child. There are three subcategories of home-base care: relative or kinship care, foster care, and other home-based OoHC (Australian Institute of Health and Welfare, 2015). Residential care, by contrast, refers to placements in residential facilities with paid workers who are employed as either rostered staff or live-in carers (Australian Institute of Health and Welfare, 2015). Large numbers of children are in OoHC both in Australia and internationally. In Australia, the rate of children in OoHC has increased by 20% between 2010 and 2015; the 2015 figure notes that 8.1 out of every 1,000 children in Australia are in OoHC (Australian Institute of Health and Welfare, 2016). This is higher than the rates in both the United Kingdom (UK) and the United States (US). In the UK, for example, the rate of children in OoHC was 6 per 1,000 as of March 31, 2016 (U.K. Department for 1 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Education, 2016). In the United States, the number of children and young people in care on September 30, 2015 was 428,000 or 5.8 per 1,000 (U.S. Department of Health and Human Services, 2016). Aboriginal and Torres Strait Islanders in Out-of-Home Care In Australia, Aboriginal and Torres Strait Islander children and young people are greatly overrepresented in OoHC. Although Aboriginal and Torres Strait Islander children make up only 4.7% of the total population of children aged 0 to 17 years in Australia (Secretariat of National Aboriginal and Islander Child Care [SNAICC], 2013a), they make up approximately 35% of all children and young people in OoHC (Australian Institute of Health and Welfare, 2015). Data from 2014 to 2015 show that Aboriginal and Torres Strait Islander children are living in OoHC at a rate 52.5 per 1,000 children, compared to 8.1 per 1,000 children for the total population (Australian Institute of Health and Welfare, 2016). This data also shows that they are 9 times more likely than their non-Aboriginal or non-Torres Strait Islander counterparts to be placed in care. These higher odds of being placed in care range from 2.6 in Tasmania to 15.5 in Western Australia (Australian Institute of Health and Welfare, 2015). Internationally, in other colonized countries such as Canada, the US, and New Zealand, Indigenous children are overrepresented in OoHC. There are multiple and complex reasons for the overrepresentation of Aboriginal children in the child welfare system. Aboriginal communities experience higher levels of poverty, homelessness, poor health, unemployment, imprisonment, and other socio-economic disadvantages, along with lower levels of education, than their non-Aboriginal counterparts. Parental issues with drug and alcohol misuse and abuse, family violence, poor mental health, and cognitive impairment can all lead to children entering OoHC —often, more than one of these are determining factors. Additionally, child protection workers’ lack of understanding of Aboriginal childcare practices can influence their assessments of parental care (SNAICC, 2013a). The differential rate of these risk factors in Aboriginal and Torres Straight Islander families is the legacy of over two centuries of devastating, violent, and intrusive legislation, policies, and practices by governments in Australia. This has been articulated by the Aboriginal and Torres Strait Islander Healing Foundation Development Team (2009), which noted: Many of the problems prevalent in Aboriginal and Torres Strait Islander communities today— alcohol abuse, mental illness and family violence . . . have their roots in the failure of Australian governments and society to acknowledge and address the legacy of unresolved trauma still inherent in Aboriginal and Torres Strait Islander communities. History of Forced Removal When discussing Aboriginal young people in OoHC, it is important to consider Australia’s history and the legacy of the Stolen Generations—the forced, systematic, and widespread permanent removal of children from their parents and communities—as well as the lifelong and intergenerational impacts of colonial policies (Human Rights and Equal Opportunity Commission, 1997). Indeed, it has been noted that colonisation and past policies continue to directly impact Aboriginal and Torres Strait Islander children and families in Australia (Cummins, 2012; Human Rights and Equal Opportunity Commission, 1997). These policies have inflicted trauma upon individuals, families, and communities, and they have often resulted in the loss of family structures and family connections, of language, of culture, and of land. As emphasised in Our Children, Our Dreaming, this multi-layered loss of 2 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 connection continues to affect the social and emotional well-being of Aboriginal and Torres Strait Islander peoples (SNAICC, 2013a). Specifically, the history of forced removal in Australia is at the core of many difficulties faced by Aboriginal and Torres Strait Islander people, particularly insofar as it continues to create barriers in terms of trust and successful cultural care (Human Rights and Equal Opportunity Commission, 1997). The intergenerational trauma resulting from forced removal has been linked to substance use, mental health difficulties, family violence, imprisonment, homelessness, and poverty among Aboriginal and Torres Strait Islander people (Atkinson, Nelson, Brooks, Atkinson, & Ryan, 2014). The programs and policies discussed in this review demonstrate the resilience of Aboriginal and Torres Strait Islander people—especially considering the broader context of colonial loss, violence, and dislocation with which they must contend. Aboriginal and Torres Strait Islander Definitions of the Family Unit, Attachment, and Parenting Considering the effect of the OoHC system on Australia’s Aboriginal and Torres Strait Islander population requires an understanding of childrearing and attachment in Australian Aboriginal and Torres Strait Islander cultures. In general, Aboriginal and Torres Strait Islander cultures are collectivist, and thus their approaches to childrearing have often been described as collectivist, too (Yeo, 2003). Traditionally, Aboriginal and Torres Strait Islander children are raised with close connections to their extended family members and to their communities; as such, they can be cared for by multiple people and might occasionally be apart from their biological parents for lengthy periods of time (Yeo, 2003). These children therefore often form multiple close attachments and have larger “secure bases,” which form an “attachment network” (McClung, 2007; Yeo, 2003). Ethnocentric approaches to understanding childrearing can lead to inappropriate decisions to place Aboriginal and Torres Strait Islander children in care because child welfare workers misunderstand how attachment networks, which include kin, actually function. Mental Health and Well-Being for Children in Out-of-Home Care Upon entering care, children and young people across racial and ethnic backgrounds have already experienced a number of adversities including neglect, trauma, abuse, and social disadvantage. Many of these children have poorer mental and physical health, poorer educational and social outcomes, as well as a higher likelihood of truancy and delinquency, drug and alcohol problems, and self-harm and suicide (Cummins, 2012; Fleming, Bamford, & McCaughley, 2005; McAuley & Davis, 2009; Pecora, Roller White, Jackson, & Wiggins, 2009; Sawyer, Carbone, Searle, & Robinson, 2007; State Government of Victoria, 2011). Turney and Wildeman (2016) have suggested that these problems may also relate to a poorer quality of life for children during their time in care. Furthermore, these problems often extend into adulthood, with care-leavers at a much higher risk of experiencing adverse outcomes. These outcomes include financial hardship, housing instability or homelessness, involvement in the criminal justice system, suicidal behaviours, and early pregnancies (Dworsky & Courtney, 2009). Unstable care placement during childhood is a major factor contributing to adverse mental health outcomes for children in OoHC (Commission for Children and Young People and Child Guardian, 2013; Tarren- Sweeney, 2008). These issues are comparable globally, with children in care in the UK and the US facing similar concerns in terms of mental health and social outcomes (McAuley & Davis, 2009; Pecora et al., 2009). 3 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Mental Health and Well-Being Among Australian Aboriginal and Torres Strait Islander People Health from an Aboriginal perspective is holistic. The most widely accepted definition of health, endorsed by the National Aboriginal Community Controlled Health Organisation (NACCHO, 2016), includes: Not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community. This is a whole of life view and includes the cyclical concept of life-death-life. (Aboriginal health section, paras. 1-2; see also National Aboriginal Health Strategy, 1989) The World Health Organization, in its definition of mental health, has noted the connection between individual and community well-being: Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. (World Health Organization, 2016, para. 2) Episodes of mental illness in the general population are initially treated in the primary health system or referred to mental health services for specialist treatment. Aboriginal and Torres Strait Islander experts stress the importance of a shared, cooperative approach to defining mental health for Aboriginal and Torres Strait Islander people (Ypinazar, Margolis, Haswell-Elkins, & Tsey, 2007). From an Aboriginal perspective, services should not just aim for an absence of the signs and symptoms of mental illness in an individual, but should “strive to achieve the state where every individual is able to achieve their full potential as a human being of their community” (NACCHO cited in Aboriginal Health and Medical Research Council of New South Wales, n.d., para. 4). A meta-synthesis of studies conducted with Aboriginal and Torres Strait Islander people found that attempts at defining mental health included elements of cultural, spiritual, social, and emotional well-being (Ypinazar et al., 2007). Ypinazar et al. (2007) also noted that there is no single Aboriginal and Torres Strait Islander culture, and thus a definitive consensus regarding the definition of mental health has not yet been reached. Well-being in an Aboriginal and Torres Strait Islander context is affected by many factors, including housing, education, financial security, cultural connection, and support, as well as Australia’s history of colonization and the grief, trauma, and loss that this caused (Bamblett, Frederico, Harrison, Jackson, & Lewis, 2012; Commission for Children and Young People and Child Guardian, 2013; Haswell, Blingnault, Fitzpatrick, & Jackson Pulver, 2013; McClung, 2007). When the harmony among these factors is disrupted, ill-health will arise (Bamblett et al., 2012; Commission for Children and Young People and Child Guardian, 2013). In Australia, mental health funding has been directed to support the mental health of Aboriginal and Torres Strait Islander people and targeted strategies for Aboriginal people are included in the current Roadmap for National Mental Health Reform 2012-2022 (Council of Australian Governments, 2012). The government also funds specialist child and adolescent mental health services up to the age of 18 years for those living with serious mental illness. These mental health services are aimed at young people with diagnosable psychiatric disorders that seriously affect their growth and development and/or lead to 4 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 major problems in their social or family environments. Treatments range from community support to hospital-based services, and include prescription medication. One innovative initiative in Victoria, Australia sought to address the mental health needs of young people in OoHC by ensuring they would receive priority access to mental health support without needing to be diagnosed with a mental disorder (Victorian Department of Health, 2011). To our knowledge, there has been no evaluation of the utilization of the priority access initiative by Aboriginal young people in OoHC. Broadly, some of the barriers preventing Aboriginal and Torres Strait Islander people from accessing mainstream health services that are provided or funded by the government include a lack of culturally safe services, a lack of awareness of the services that are available to them, racism, shame and fear, complex administrative processes, and the costs associated with care (Victorian Auditor General's Office, 2014). Bamblett (2008) found that Aboriginal and Torres Strait Islander people are reluctant to access mainstream health services because of both racism and the history of forced removal of children from their parents’ care. In order to conceptualise what programs addressing the social and emotional well-being of Aboriginal and Torres Strait Islander youth need to include, it is important to understand and respect the worldview of Aboriginal and Torres Strait Islander people. The mental health system, designed from a Western perspective, fails to consider this worldview and the lasting impact of Australia’s colonial history on Indigenous Peoples. Aboriginal society is collective, and there is not one approach to or one model of Aboriginal healing and well-being. Indigenous Australia is, in fact, multicultural and consists of multiple complex and diverse societies. Yet, it is possible to simultaneously understand and acknowledge these differences, while also recognizing common elements, approaches, and perspectives that are shared by many Aboriginal and Torres Strait Islander communities. In general, these worldviews value kinship as the foundation of social life, and Aboriginal children develop their identities in relation to everyone in their community. Methods Given the acknowledged challenges regarding the mental health and well-being of Aboriginal young people in OoHC, this review was undertaken to (a) identify programs and policies currently in place that aim to improve the mental health and well-being of this vulnerable population, and (b) provide an analysis of both the strengths of the current system as well as what has been inadequately addressed based on relevant literature. This review is not limited to a standard, Western definition of a “mental health program”; instead, this review incorporates a broader Aboriginal and Torres Strait Islander perspective to mental health, focusing on social, emotional, and spiritual well-being (SESWB) and the aspects of a child’s life that promote these things. Programs that have been included in the review focus on maintaining and supporting connections to culture and community for young Aboriginal people in care. The scope of this review included programs for Indigenous children in other countries, and it excluded programs targeted to the wider OoHC population. This review utilized a systematic review methodology. According to guidelines for systematic reviewing, the PICOS framework was used for selecting articles (Liberati et al., 2009). This framework allows for the identification of the main components of a study design: Population, Intervention, Comparator, Outcome and Study Design. Within this framework, the components of interest for this review were: 5 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 • Population: Aboriginal young people between 12 and 18 years of age who have experienced the OoHC system. • Intervention: Any program that aims to improve the mental health or social, emotional, and spiritual well-being of the above population; this may include programs at a family, community, system, or individual level. • Comparator: A comparator was optional for this review, as the aim was to investigate all studies published that focus on programs like the ones described above. • Outcome: There were two aspects of interest relating to outcome: The first concerns the efficacy of a program’s implementation and the second concerns the improvement of social and emotional well-being. Improvement in well-being can be measured in a variety of ways, including self-rated happiness, school attendance, connectedness to community, connectedness to family, positive behavioural change, a decrease in offending behaviour, and a decrease in substance use. • Study design: All study designs were included, including grey literature. All publications meeting these criteria were included in the review. As the review of existing and relevant literature progressed, we altered our outcomes to include enhanced cultural connection, as this was discovered to be a crucial intervention for well-being. This broadened the focus of the review from only addressing programs to also include policies that impact cultural connection. At this point, we adopted the realist review methodology because it aims to address broader research questions regarding the impact of context on outcomes (Pawson, Greenhalgh, Harvey, & Walshe, 2005). We theorized legislative and policy developments as complex social interventions, and so the realist synthesis method was used to systematically review the evidence. Whereas systematic reviews seek to minimize bias, realist reviews address issues of context with the aim of providing answers that are appropriate to policymakers and other stakeholders. This review is reported in accordance with RAMESES publication guidelines (Geoff, Greenhalgh, Westhorp, Buckingham, & Pawson, 2013) Exclusion Criteria Studies and reports were excluded if they did not involve young people between the ages of 12 and18, if the participants were not Aboriginal or Torres Strait Islander, and/or if they did not include young people who had experienced OoHC. Studies were also excluded if they did not include a program or were written in language other than English. Search Terms A combination of PICO terms was searched. Terms relating to the “population” were: • Aboriginal, Aborig* • “Torres Strait Island*” 6 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 • “First nation” • “Indigenous” • “out-of-home care” • “out of home care” • “foster care” • “foster home care” • “foster-care” • “foster-home-care” • “residential care” • “kinship care” • “kinship-care” • “looked after children” • “child welfare” • “child protection” ‘Intervention’ terms were: • “program” • “intervention” • “policy” ‘Outcome’ terms were: • “mental health” • “wellbeing” • “well-being” • “well being” Information Sources The following electronic databases were searched: Cochrane Controlled Trials Register (CENTRAL); MEDLINE (1950 to May 2014); Informit, Aboriginal and Torres Strait Islander combined Informit Indexes, including 26 different online databases (up to May 2014); Discovery Search (up to May 2014). The search was conducted between January and May 2014 and results apply to publications and policies up to this date. 7 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Sample Initial database searches yielded 771 articles (see Figure 1; Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009). After the removal of duplicates, we reviewed of abstracts and full text articles based on PICO criteria and excluded 767 articles. The remaining 14 articles are included in this review. Due to the limited number of articles obtained through standard database searches, a grey literature search was necessary, as was handsearching through relevant articles and reference lists, and contacting experts in the field (n = 4). Grey literature was sourced through the Informit database as outlined above, Google Scholar, and relevant government and non-government websites. Book chapters that were not discoverable using the electronic databases were not included in this review. This review seeks to identify studies wherever they were undertaken. However, the Australian-based authors had greater capacity to locate grey literature relating to Australia because of both their access to local experts and their familiarity with the context. Results Policies and Programs to Improve the Well-Being of Aboriginal and Torres Strait Islander Young People in OoHC Nine policies and programs were found that are designed to improve the SESWB of Aboriginal young people in OoHC. They are: • The Aboriginal and Torres Strait Islander Child Placement Principle (ATSICPP), • Cultural support plans (CSP), • Aboriginal self-determination through Aboriginal Community Controlled Organizations (ACCOs), • Family group decision-making (FGDM), • Four programs within a therapeutic care model, and • Mentoring through the Panyappi Program. Eight of these policies and programs are specific to Australia (FGDM is implemented in Australia and in other countries). While policies such as the ACCOs are not solely designed for young people in OoHC, they explicitly mention their impact on the SESWB of this group and are therefore included in this review. Table 1 describes the theories underpinning each policy or program and their links to mental health promotion. 8 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 F i g u r e 1 . F l o w c h a r t o f l i t e r a t u r e s e l e c t i o n p r o c e d u r e s . Records identified through database searching (n = 771) Sc re en in g In cl ud ed E li gi bi li ty Id en ti fi ca ti on Additional records identified through grey literature and handsearch (n = 4) Records after duplicates removed and records screened (n = 767) Records excluded (n = 753) Full-text articles assessed for eligibility (n = 14) Full-text articles excluded, with reasons (n = 0) Publications included in qualitative synthesis (n = 14) Programs included in review (n = 9) 9 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Table 1. Review of Programs and Policies to Improve Well-Being of Aboriginal Young People in OoHC Program or Policy Theory for Improving SESWB Indicators of Positive Mental Health for Childrena Implementation: Distribution Implementation: Barriers Evaluation ATSICPP Child Placement Principle (Tilbury, Burton, Sydenham, Boss, & Louw, 2013) ATSI people are in best position to make decisions regarding their children. It is a preference system to promote Aboriginal empowerment, recognize child, family, and community decision-making. ATSICPP promotes positive mental health at the societal level by valuing and protecting children. Placement in community and empowerment promote mental health at the individual level. Different implementation across different Australian states and territories. Lacks efficacy in distribution—increasing numbers of children in care, low socioeconomic status of carers, compounding effect of past removal leads to insufficient suitable carers. Lack of implementation of decision-making component of ATSICPP leads to ineffective implementation. Strong compliance with policy and program, but minimal compliance in practice (Commission for Children and Young People, 2016). Cultural support plans (CSPs) (Aboriginal and Torres Strait Islander Legal Services (Qld) Ltd., 2012; Libesman, 2011) Maintain young person’s connections with family and community, and engagement in culture. This leads to positive well-being and successful transition through life stages. CSPs promote positive mental health at the organizational and community levels, and individual mental health by improving social connections and self- worth. Child Protection practitioner is responsible for completion. Not implemented— Many Aboriginal children are not on guardianship orders, which means no are CSPs completed for them. None. a Indicators of positive mental health for children were developed by Maher and Waters (cited in World Health Organization, 2005). 10 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 Table 1. Review of Programs and Policies to Improve Well-Being of Aboriginal Young People in OoHC (continued) Program or Policy Theory for Improving SESWB Indicators of Positive Mental Health for Children Implementation: Distribution Implementation: Barriers Evaluation Aboriginal Community Controlled Organisation (ACCOs) (Bamblett & Lewis, 2007; Burton & Libesman, 2013; Rae, 2011) Self-determination increases self-image and confidence, improves well-being, connections and relationships, empowers Aboriginal communities, and provides adequate cultural care. ACCOs promote positive mental health at the organizational and community levels. However, final decision- making remains with government agencies. Good uptake in Canada. Many Australian states do not implement in OoHC. Victoria first to move towards self- determination. No mandatory requirement. Concerns that traditional quantitative research methods are inappropriate for evaluating ACCOs (see Therapeutic Care section for one ACCO program evaluation). Culturally appropriate evaluation methods needed to compare outcomes for young people within ACCOs versus in non- ACCOs. FGDM – Family group decision- making (Ban, 2005; Harris, 2008; Marcynyszyn et al., 2012; SNAICC, 2013b) Empower community and family as decision makers. FGDM promotes positive mental health at the community level. Trialled internationally and in all Australian jurisdictions except the Northern Territory. Removed from New South Wales and Western Australia. In Victoria it is rarely used but recent legislative changes encourage its use. Inconsistent involvement of Aboriginal families in decision making, lack of support for FGDM, and decisions made by Aboriginal families lack of authority, which can make the process tokenistic. US evaluation found that diversity of tribal communities made standardised evaluation unsuitable. 11 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Table 1. Review of Programs and Policies to Improve Well-Being of Aboriginal Young People in OoHC (continued) Program or Policy Theory for Improving SESWB Indicators of Positive Mental Health for Children Implementation: Distribution Implementation: Barriers Evaluation Therapeutic Care (TC) (Healing Foundation, 2013; Victorian Aboriginal Child Care Agency, 2009) Reparative experiences promote healing and recovery. TC promotes positive mental health at the individual level. Implemented widely throughout OoHC. Must be adapted to include culture for Aboriginal young people. Victorian Aboriginal Child Care Agency (VACCA) programs—Culture is healing—narrative evaluation appropriate for Aboriginal context. Found “improved sense of identity and belonging; importance of culture as a protective and healing factor, the role of storytelling, relationships, consistency of support and opportunities; CSPs and education in the intergenerational healing of young people in OoHC” (VACCA, 2015, p. 37). Panyappi Program (J. R. Higgins & Butler, 2007) Mentoring for young people at risk of entering or re-entering justice system that aims to reduce offending and risk-taking behaviours in Aboriginal young people. Not specifically for OoHC but a high proportion have OoHC histories. Panyappi promotes positive mental health at the individual level. One program in South Australia. Funding reduced since evaluation. Demonstrated significant reductions in 12/14 offending behaviours and increased school attendance. Also developed stronger sense of self-belief, personal and cultural identity, led to the development of other interests and strengthened relationships with family and friends. 12 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 The Aboriginal and Torres Strait Islander Child Placement Principle (ATSICPP) The ATSICPP is considered an important policy to ensure the well-being of Aboriginal and Torres Strait Islander children. The ATSICPP ensures both that Aboriginal and Torres Strait Islander children are removed from their parents’ care only when they cannot safely remain at home and, when they are placed in care, that they remain connected to family, culture, and community. This is important because connection to culture helps build resilience, a sense of self-worth, and self-confidence (Dockery, 2011). Aboriginal people have connections to culture, country, and community that nurture and support their well-being, spirituality, and identity development. It is important to child and family well-being that these connections are maintained and strengthened (Tilbury et al., 2013). In addition, ATSICPP acknowledges that Aboriginal and Torres Strait Islander people are in the best position to make decisions regarding their children (Tilbury et al., 2013). Since the 1980s, the ATSICPP has been adopted into legislation and policy across Australia to varying degrees in each state and territory (see Table 2). The principle itself prioritizes placing Aboriginal and/or Torres Strait Islander children with a family member or relative (although relatives may not be Aboriginal or Torres Strait Islander). If this is not possible, then the principle notes that the child shall be placed with a member of the same community, with a third option of being placed with an Aboriginal or Torres Strait Islander family from a different community. As per the ATSICPP, Aboriginal and Torres Strait Islander children should only be placed with non-Aboriginal and Torres Strait Islander carers as a last resort. Across Australia, 69% of Aboriginal and Torres Strait Islander children in care are currently placed according to one of the first three options outlined above (Australian Institute of Health and Welfare, 2016). There are multiple reasons why such a large proportion of children are placed with non- Aboriginal and Torres Strait Islander carers. First, the principle is neither well understood nor consistently implemented and monitored. Similarly, child protection workers often do not have the resources or expertise to find and engage Aboriginal families with which to place children (D. Higgins, Bromfield, & Richardson, 2005). Second, the already large number of Aboriginal and Torres Strait Islander children in care is increasing, which poses another set of challenges to finding appropriate carers for them. As such, although Aboriginal and Torres Strait Islander people and communities are often likely to become carers, the system has become overloaded (D. Higgins et al., 2005). This trend is amplified by the demographics of the Aboriginal and Torres Strait Islander population: The majority of the population is younger than 26 years, with 36% below 15 years old (Australian Bureau of Statistics, 2012-2013). Third, Aboriginal and Torres Strait Islander families are more likely to be in a disadvantaged socioeconomic situation and hence may not be able to support children. These factors, in tandem with the compounding effect of past removal, results in too few suitable carers for the increasing number of children who need carers (Libesman, 2011). In addition to child placement, the ATSICPP also prioritizes the involvement of children, family, and community members in both decision-making and support so as to maintain connections with family, culture, and community. These elements of the principle are often not prioritized and are therefore not effectively implemented, even though they are considered as crucial for child well-being (Libesman, 2011) 13 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Table 2. The Aboriginal and Torres Strait Islander Child Placement Principle Across Australian States and Territories Year of Current Policy Child Placement Principle Aboriginal Decision- Making Recognition of Self- Determination Additional Principles New South Wales 1998 Yes ATSI families and organisations participate in decision-making regarding placement by means approved by the minister. Yes When deciding placement, take into account: child self- identifies as ATSI, child’s wishes, parents from different communities, non-ATSI parent, children with non- ATSI carer. Reunification is a fundamental objective. Western Australia 2004 Yes ATSI officer to be involved in placement decision and consult with ATSI agency. No None. Australian Capital Territory 2008 Yes Decision maker must take into account ATSI organisation submission. Yes Placed on first available principle, whether child objects, or whether it is consistent with cultural plan. Victoria 2005 Yes Decisions about an ATSI child must have consultation with a community member and ACCO. Yes When deciding placement consider: child self-identifies as ATSI, child’s wishes, parents from different communities, one non-ATSI parent, if child placed with non-ATSI person child must have continuing contact with family, community and culture. 14 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 Table 2. The Aboriginal and Torres Strait Islander Child Placement Principle Across Australian States and Territories (continued) Year of Current Policy Child Placement Principle Aboriginal Decision- Making Recognition of Self- Determination Additional Principles Queensland 1999 Yes Participation in significant decisions and consultation about other decisions, which can be done after if urgent. No Maintenance of cultural connection. South Australia 1993 Recommended placement preference system. Consultation must be sought on placement decisions. No Take into account: child’s objection to placement. Tasmania 1997 Nothing in legislation. Consultation must be sought on placement decisions. No None. Northern Territory 2007 Recommended placement preference system. Recognition of role of Aboriginal organisation, decision making when nominated. Yes None. Note. ATSI stands for Aboriginal and Torres Straight Islander. The abbreviation is used in the table for brevity reasons only. The Aboriginal Child Placement Principle is a system of preference when placing an ATSI child in care, as well as for promoting ATSI empowerment. The details vary across states and territories, but most outline preference systems in the following order: (1) extended family or relatives, (2) an ATSI person from the same community, (3) another ATSI person from a different community, and (4) a non-ATSI person. The Principle also recognises the child, family, and community in decision- making, as well as the importance of maintaining a connection to the community. 15 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 The ATSICPP has been acknowledged as a key policy to support and improve the well-being of Aboriginal and Torres Strait Islander children in care; unfortunately, however, there are now many reviews demonstrating that there is often poor implementation, compliance, and monitoring of the Principle (Arney, Iannos, Chong, McDougall, & Parkinson, 2015). A recent review of the ATSICPP in Victoria, Australia, for example, found that there is strong compliance with the policy at a program level, but not at the practice level. Program level responses typically meet the requirements of related legislation, but overall practice minimally complies—particularly, practice is not often consistent with mandatory policy and program requirements. A lack of meaningful decision-making by Aboriginal stakeholders, insofar as not all Aboriginal young people have had access to ATSICPP, together with the complex documentation required by the principle, makes it difficult for child protection staff to comply (Commission for Children and Young People, 2016). Cultural Support Plans (CSPs) The importance of culture for Aboriginal children in OoHC has been recognised through the legislative and policy requirements outlined by CSPs. A CSP should be completed in conjunction with the young person when he or she enters OoHC, and the document should then be kept as part of the young person’s care records. These plans include sections on the young person’s identity, including siblings and extended family background, supporting cultural links, plans for contact with country and kin, and connecting to community. CSPs focus on maintaining young people’s connections with their family groups and communities, and engagement with relevant cultural events and activities. It has been noted that maintaining these connections can lead to cultural strength, which can assist young people navigating the care environment—including any related “unintended detrimental experiences” related to being in care. Through encouraging cultural connectedness and positive relationships, these plans aim to promote resilience for young Aboriginal and Torres Strait Islander people and encourage their successful transition through different life stages (Aboriginal and Torres Strait Islander Legal Services (Qld) Ltd., 2012). CSPs are implemented to varying degrees across Australia (see Table 3), with all states and territories except Tasmania having some form of CSP. Each state and territory differs in its legislative or policy requirements, involved parties, and funding. 16 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 Table 3. Cultural Support Plans (CSPs) Across Australian States and Territories CSP Which Children? How Effective? Who Is Responsible? How Is It Funded? When Was It Developed? New South Wales Yes—policy not legislation. Every ATSI child. No data—but it is known to not be implemented for all children yet because it is still a new program. Department of Community Services None, however costs are tracked as part of the system. 2009 Western Australia Yes Every ATSI child. No data. Department for Child Protection None 2004 Australian Capital Territory Yes May be required for ATSI child on a care protection order. Known to not always be filled out promptly (due to resourcing), but no data on numbers. Care and Protection Services Office in consultation with ATSIS Unit, foster carers, and others. None—cultural needs costs are resourced by contingency funding. 2008 Victoria Yes Only legally obliged for ATSI on guardianship orders (many children in long-term care are not on a guardianship order). 2009-2010 only 34 children on guardianship orders had a CCP, which is a very small percentage of the overall number of ATSI children in care in Victoria. Child Protection has statutory responsibility, in consultation with ACCOs and Victorian Aboriginal Child Care Agency. Current shift to Aboriginal family decision-making workers gaining responsibility. None 2005 17 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Table 3. Cultural Support Plans (CSPs) Across Australian States and Territories (continued) Note. CSPs provide cultural support to Aboriginal and Torres Strait Islander (ATSI) children and young people in OoHC. They are designed to maintain connections with family groups and engagement in cultural events and activities. CSP Which Children? How Effective? Who Is Responsible? How Is It Funded? When Was It Developed? Queensland Yes— legislation encourages participation of an ATSI agency and contact with the community. No official CSP policy. Every ATSI child. No accurate data. Department of Community Services in conjunction with recognised entities (ATSI organisations). None 1999 South Australia Yes—policy not legislation: Cultural Maintenance Plans. Every ATSI child involved with Families South Australia for ≥ 6 months. No data. Department for Families and Communities $500/year 1993 Tasmania None—no policy or legislation. N/A N/A N/A N/A 1997 Northern Territory Yes—policy not legislation. All ATSI children. No data. Northern Territory Families and Children None 2007 18 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 In Victoria, Australia, these documents are the statutory responsibility of child protection practitioners, in conjunction with an Aboriginal Community Controlled Organisation (ACCO); however, increasing responsibility is being transferred to family group decision-making (discussed below). Although it has been recognised that these plans are in the best interest of all Aboriginal and Torres Strait Islander young people in care (Libesman, 2011), the policy was not implemented for all Aboriginal children until 2016. This delayed implementation is a major failing of the Victorian child protection system, as many children in long-term care are not on Guardianship Orders and thus would not have been allocated a child protection practitioner.1 A report on cultural care for Aboriginal and Torres Strait Islander children, published by the SNAICC, showed that in 2009 to 2010 only 34 children who were on Guardianship Orders—a very small number of those in care— had an active cultural care plan (Libesman, 2011). This lack of implementation of cultural care plans is a national trend, with many states and territories self-reporting both low rates of adherence and no method of quantifying these rates (Libesman, 2011). Government figures, reported in a 2012 review of the program in Queensland, suggested that 92.7% of Aboriginal and Torres Strait Islander children in OoHC had a current cultural support plan; however, further investigation found that non-government child protection agencies described these plans as incomplete and failing to meet children’s cultural needs (Libesman, 2011). In addition, an internal review was conducted within the ACCO, which showed a large proportion of cultural support plans were incomplete (Aboriginal and Torres Strait Islander Legal Services (Qld) Ltd., 2012). Figures relating to the implementation of CSPs across other states could not be reported in the SNAICC report because government agencies did not hold this data. The lack of effective implementation of CSPs suggests that many Aboriginal and Torres Strait Islander young people in OoHC are at risk of losing their connections to their cultures and thereby are at an increased risk of experiencing poor well-being outcomes. Research is necessary to assess both why CSPs have not been implemented consistently as well as their effectiveness as tools for improving the quality of care and well-being among young people. Aboriginal Self-Determination Aboriginal Community Controlled Organisation (ACCO) policies and legislation. Both nationally and internationally, there is increasing recognition that decisions surrounding Indigenous young people are best made by Indigenous organisations, resulting in legislative and policy reforms to empower Aboriginal communities (Burton & Libesman, 2013; Rae, 2011). In Canada, for example, a number of Aboriginal childcare agencies have the legal ability to provide the full range of child protection services using federal funding, thereby empowering Indigenous communities and ensuring that children receive adequate cultural care (Sinha & Kozlowski, 2013). Similarly, in Australia, the importance of ACCOs in decision making, particularly in relation to the OoHC population, has been recognised (Bamblett & Lewis, 2007). As noted in the National Framework for Protecting Australia’s Children, we must recognise the importance of Aboriginal led and managed solutions in order for Aboriginal children to be supported and safe in their families and communities (Council of Australian Governments, 2009). 1 Guardianship Orders in relation to child welfare refer to the transferral of legal parental responsibility to the State. 19 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 Despite this and other similar declarations, many states do not incorporate this principle into their child protection systems. Although the National Standards for Out-of-Home Care made it a goal for Aboriginal and Torres Strait Islander communities to participate in decisions concerning the care and placement of their children and young people (Council of Australian Governments, 2009), it has not been made a mandatory requirement to include Aboriginal and Torres Strait Islander input throughout Australia (Burton & Libesman, 2013). Victoria was the first Australian jurisdiction to introduce legislation in an attempt to create a culturally competent service system (the Children, Youth and Families Act, 2005) that actively promoted self-determination for communities (see also Burton & Libesman, 2013; Long & Sephton, 2011). However, despite this legislation, government agencies have retained final decision-making power. ACCOs are important for overseeing the appropriate placement and care of Aboriginal children in OoHC and are crucial advocates for the well-being of these children, often offering a range of programs designed to re-connect young people with their cultures. These programs are noted to be effective in terms of increasing self-image and confidence and improving well-being, connections, and relationships for Aboriginal and Torres Strait Islander young people in OoHC (Libesman, 2011; Victorian Aboriginal Child Care Agency, 2012/13). These organisations vary significantly across Australia. In Victoria, the largest ACCO is the Victorian Aboriginal Child Care Agency (VACCA, 2012/2013). VACCA runs programs designed to enhance well-being for Aboriginal and Torres Strait Islander children and families in Victoria. VACCA also aims to improve the well-being of Aboriginal young people in Victoria through a program known as the Aboriginal Children’s Healing Team. This team provides culturally attuned and therapeutic services to young people in VACCA’s care. There are currently no reviews of this program (Victorian Aboriginal Child Care Agency, 2012/2013). Family group decision-making (FGDM). The FGDM model arose from family group conferences that were developed in New Zealand to determine the best interests of Māori children placed in care. The aims of the program were to empower the community and the family as decision makers, reduce the overrepresentation of Māori children in the child welfare system, and ensure the maintenance of family group and cultural connections. Since its inclusion in the Children, Young Persons and their Families Act (NZ) in 1989, FGDM has been adopted internationally (Ban, 2005). This program has been implemented in varying degrees in the US, Canada, Australia, and in some European countries. An evaluation report of this program among tribal families in South Dakota concluded that the vast diversity of tribal communities in the US made a standard program and evaluation tool unsuitable (Marcynyszyn et al., 2012). Instead, the evaluation report stressed that each tribal group should develop their own internally driven programs and assessment tools. Furthermore, the report emphasised the importance of community empowerment and internal program development for producing the best outcomes for children in care (Marcynyszyn et al., 2012). However, it is important to note that the benefits and the disadvantages of FGDM are contested. The FGDM has been trialled in all jurisdictions of Australia except the Northern Territory. FGDM was implemented in New South Wales and Western Australia but has since been removed from legislation; currently, both states no longer practice FGDM in regards to OoHC placement. In Victoria, Aboriginal Family Led Decision-Making (AFLDM) was implemented in 1992, but was used in very few cases. However, the Child, Youth, and Families Act (2005) includes the use of AFLDM as a decision-making principle, which should increase the implementation of this program and help integrate it into mainstream decision-making for Aboriginal and Torres Strait Islander children in OoHC (Harris, 2008). 20 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 Therapeutic care. Therapeutic care refers to a type of OoHC that is designed and implemented with an acknowledgement of the background of abuse and neglect and the problems related to emotions, behaviour, and functioning that are common among young people in the system. Therapeutic care aims to provide reparative experiences that promote healing and recovery for children in OoHC (McLean, Price-Robertson, & Robinson, 2011). The standard in Australia consists of a therapeutic model based on trauma-informed care (Jackson, Frederico, Tanti, & Black, 2009; McClung, 2007; Victorian Aboriginal Child Care Agency, 2009). When implementing these programs with the Aboriginal and Torres Strait Islander population, experts have commented that the standard model should be revised in order to place emphasis on the importance of culture (Healing Foundation, 2013). Otherwise, commentators agree therapeutic care is unlikely to be effective (Victorian Aboriginal Child Care Agency, 2009). Therefore, according to VACCA, culturally appropriate therapeutic residential care should be built on a scaffolding of cultural relationships and should incorporate Aboriginal cultural practices (Victorian Aboriginal Child Care Agency, 2009). In addition, care should have a strong focus on rights, deliver knowledge of cultural responsibilities, and help children maintain their connection to family and kinship structures. Trauma-informed practice also varies in the Aboriginal context. Not only have Aboriginal children in OoHC faced abuse and neglect, which contribute to feelings of fear, terror, and/or helplessness, but they have also experienced the effects of intergenerational and pervasive trauma caused by European colonization. This trauma permeates entire families and communities as well as causing cultural trauma (Victorian Aboriginal Child Care Agency, 2009). Therefore, a healing and therapeutic approach must be holistic and take in to account the multiple aspects that impact on Aboriginal health for both individuals and communities. We found one narrative evaluation of cultural programs for young Aboriginal and Torres Strait Islander people in OoHC. Culture is Healing: Documenting Journeys to Identity and Belonging (Victorian Aboriginal Child Care Agency, 2015) uses narrative evaluation action research (NEAR) methods to document four programs and their outcomes. NEAR methods were chosen because they are congruent with VACCA’s goal of communicating evaluation findings and passing on cultural knowledge using storytelling. The cultural programs evaluated in the article were: • Return to Country, which supports children and young people in OoHC to visit and connect with their traditional countries, and their families, communities, and culture; • The Koorie Tiddas Youth Choir, in conjunction with VACCA Extended Care Program and Leaving Care Program, which provide an opportunity for young people in OoHC to connect with culture and language through music; • The Connecting to Sea Country, which uses day trips to help children learn about the Port Phillip Bay and its Aboriginal heritage from both an Aboriginal Elder and a marine scientist; • The Wrapped in Culture: Possum Skin Cloak Project, which worked with 40 children and young people to learn how to make a possum skin cloak, which were exhibited at the Melbourne Museum. The evaluation demonstrated that the participants in the programs had an improved sense of identity and belonging. Key elements of the programs were the inclusion of culture as a protective and healing factor, the role of storytelling, the importance of relationships, consistency of support 21 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 and opportunities, the use of cultural support plans, and education as part of the intergenerational healing of young people in OoHC (Victorian Aboriginal Child Care Agency, 2015). Panyappi mentoring program. The Panyappi mentoring program, developed in South Australia, was developed for Aboriginal youth aged 10 to 18 years who are at risk of entering or re-entering the justice system with the aim of reducing their offending and risk-taking behaviours. The program does not specifically target the OoHC population, but many of its clients have experience with the OoHC system. The program was evaluated after one year of operation. The evaluation found that 12 out of 14 participants had significantly reduced their offending behaviours and had increased their school attendance. Interview data also found many participants had developed a stronger sense of self-belief, and personal and cultural identity; had developed other interests, and had strengthened relationships with their family members and friends (J. R. Higgins & Butler, 2007). Through mentorship, supporting connections with family and community, and building resilience and empowerment, the program effectively enabled positive behavioural change and increased the well- being of its participants. Although the review of this program involved a small sample, its potential is noteworthy. However, the program’s funding has recently been limited and Panyappi now supports fewer participants. Discussion Main Findings Three elements are vital when reviewing the literature on programs and policies that aim to improve the mental health of young Aboriginal people in OoHC. First, it is of primary importance to use Aboriginal and Torres Strait Islander definitions and words for mental health. These definitions emphasize social, emotional, cultural, and spiritual well-being. Second, it is necessary to understand Aboriginal and Torres Strait Islander family structures, attachment networks, and parenting methods that emphasize collectivist approaches to childrearing. Third, it is crucial to recognize and respect how Australia’s history of colonization and forced removal has broken down trust between Aboriginal people and the government, and damaged some Aboriginal and Torres Strait Islander kinship groups and communities. Other communities have survived and thrive and are sources of traditional knowledge. These elements reoriented this review to search for all policies and programs that promote any aspect of an Aboriginal young person’s life that influences his or her social, emotional, and spiritual well-being. This review linked the theory for improving SESWB to indicators of positive mental health for children (World Health Organization, 2005), and nine programs and/or policies that sought to do this were found. Despite the disproportionately high number of young Aboriginal and Torres Strait Islander people in OoHC and their need for support, the most striking aspect of this review was the absence of studies evaluating programs designed to improve the well-being of Indigenous young people, and particularly those in OoHC. The Panyappi mentoring program and the VACCA programs demonstrated that connecting young people to their cultures and communities has positive outcomes for Aboriginal young people in OoHC. The current system, designed from a Western perspective, does not adequately address the need to feel a sense of belonging among young people in OoHC (Corrales et al., 2016). The lessons from these programs could lead to improved mental health for both Indigenous and Western young people in OoHC. International programs, such as the FGDM, support the principle of community empowerment, which in turn supports the SESWB of young people in OoHC. 22 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 What This Study Adds This study recognizes that the importance of cultural care and support for Aboriginal and Torres Strait Islander young people in OoHC needs to be acknowledged and documented. It describes the inconsistent implementation of policies and programs that are intended to assist Aboriginal and Torres Strait Islander young people in OoHC, and the findings suggest that this inconsistency risks not providing effective support to promote the SESWB of young people in OoHC. This review describes the pathways from policy and program theory to the improvement of mental health outcomes for young Aboriginal and Torres Straight Islander people. Although most of the programs and policies evaluated in this review emphasize the cultural and social components of SESWB, it is still necessary to assist individual young people who are struggling with problems related to their SESWB. The Panyappi mentoring program and VACCA program are the only programs aimed at individuals that have documented preliminary success. While the policies and programs discussed in this review are seen to be important for Aboriginal well-being, it is important that each individual child’s needs are also met. Further culturally appropriate evaluation of programs meant for individuals is necessary. Available research supports the empowerment of communities as a culturally appropriate method for improving SESWB among Aboriginal and Torres Strait Islander young people in OoHC; fittingly, the promising practices highlighted in this review are those that are driven by communities and cultural knowledge. Limitations Despite our efforts to identify a comprehensive range of programs and policies, it is possible that other programs have either not been documented or program reports have not been published in a locatable form—at least in terms of the search methods of this review. While the focus of this review was evaluating published accounts of relevant programs and policies, key informants in the fields of OoHC and Aboriginal childcare were contacted to gather information on any programs that exist but have not been written about. The review covers the period up until May of 2014; as such, policies and programs that originated or were written about after this date may alter some of this review’s conclusions. For example, in 2016, changes to permanency laws passed in Victoria, Australia, which made the reunification of children and their families dependent on families meeting court and government-set goals. If permanency laws are not properly enacted, then Aboriginal and Torres Strait Islander young people are at risk of being placed in circumstances that disconnect them from their identities, exacerbate existing trauma, and damage health (SNAICC, 2016). Some Aboriginal and Torres Straight Islander people and groups are reluctant to participate in research, as described in the report, We Don’t Like Research, But in Koori Hands It Could Make a Difference (VicHealth Koori Health Research and Community Development Unit, 2000). This reticence to participate in research may have contributed to the lack of published evaluation of and research about successful programs for young people. Conclusions and Recommendations There is a pressing need for early intervention, prevention, and intensive family support to reduce the numbers of Aboriginal and Torres Strait Islander young people entering care. For young people 23 Lindstedt et al.: Review of Programs to Support Young People in Out-of-Home Care Published by Scholarship@Western, 2017 who cannot be properly cared for by their own families, this review notes the need for improved programs and policies promoting the SESWB of Aboriginal and Torres Strait Islander young people in OoHC. Importantly, this improvement needs to occur at both an individual and system-wide levels. Specifically, there is a need for culturally competent service provision and attention to the monitoring and evaluation of all relevant policies and programs. International examples provide guidance and may be suitable for adaptation to local contexts, although this review focuses on several Australian programs and policies that appear promising. Programs and policies that enhance cultural and community connection and empower communities could potentially provide necessary support to a small and overburdened group of carers. Information from implementation research is needed to evaluate their effectiveness and to support the case for continuing to fund programs that are working demonstrably well. The personal, communal, and social costs of ineffective programs are profound, and scarce social welfare funds are being expended so there is strong interest in ensuring they are used well. There are clearly compelling grounds for governments and others to commission and sponsor policy and research work to adapt and devise programs promoting the SESWB of Aboriginal and Torres Straight Islander young people (at both the individual and system levels), determine their effectiveness, and ensure they are sustained when warranted. The increasing numbers of young people in OoHC drives a need for evaluations that specifically report SESWB outcomes for young people in OoHC. Finally, programs that support reunification as well as early intervention and prevention and intensive family support need to be funded, so as to reduce the numbers of Indigenous young people entering care. 24 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 References Aboriginal and Torres Strait Islander Healing Foundation Development Team. 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Australian and New Zealand Journal of Psychiatry, 41, 467-478. doi: https://doi.org/10.1080/00048670701332953 30 The International Indigenous Policy Journal, Vol. 8, Iss. 3 [2017], Art. 5 http://ir.lib.uwo.ca/iipj/vol8/iss3/5 DOI: 10.18584/iipj.2017.8.3.5 The International Indigenous Policy Journal July 2017 Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of-Home Care Sophie Lindstedt Kristen Moeller-Saxone Carly Black Helen Herrman Josef Szwarc Recommended Citation Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of-Home Care Abstract Keywords Acknowledgments Creative Commons License Realist Review of Programs, Policies, and Interventions to Enhance the Social, Emotional, and Spiritual Well-Being of Aboriginal and Torres Strait Islander Young People Living in Out-of-Home Care