Reintegration of Children Into Family-based Care in Uganda

Increase in positive parenting behaviors (supportive positive behaviors, and setting limits)

Positive parenting behaviors of parental involvement and setting limits will be measured by the Parenting Young Children Scale (PARYC; McEachern, Dishion, Weaver, Shaw, Wilson \& Gardner, 2012). The PARYC is a measure designed to address parenting behaviors relevant for the caregivers of young children in the past month. The PARYC has been used widely including in Africa such as in South Africa as part of the Sinovuyo Teen trial (Cluver et al., 2016). It has 21 items measuring the occurrence of specific parental behavior towards children during the previous month on a 7-point Likert scale (0 = never; 6 = always). We will use subscales of Supporting Positive Behavior for children aged 1-13 years (7 items), and Setting Limits for ages 1-5 (7 items). In our study, both subscales of the PARYC will be administered to the Home and the RCF caregivers; the Supporting Positive Behavior subscale will be administered to children 8 years and above, with a modified 5-point rating scale.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increase in positive parenting behaviors (positive involvement and monitoring/supervision)

Positive parenting behaviors of positive involvement and monitoring/supervision will be measured using the Alabama Parenting Questionnaire (APQ; Frick 1991). The APQ has been used widely including in studies in Africa, such as in South Africa (Casale et al., 2015) and as part of the Sinovuyo Teen parenting program (Cluver et al., 2016). The APQ has 42 items related to the etiology of child externalizing problems. Respondents are asked to select how often various actions (e.g., "Your child is home without adult supervision.") happen typically on a 5-point Likert-like scale (1 = never; 5 = always). For this study, we will be using the APQ subscales of Involvement for children aged 1-13 years (10 items), and Monitoring and Supervision subscale for ages 6-13 (10 items). In our study, the APQ child form will be administered to children 8 years and older; the APQ parent form will be administered to the home and the RCF caregiver.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increased levels of secure attachment

Attachment behaviors of children aged 1 to 6 years will be assessed by the Disturbances in Attachment Interview (Smyke \& Zeanah, 1999). This is a semi-structured interview with questions to the child's primary caregiver about the child's typical behaviors. The DAI includes 12 items - 8 questions on Disturbances of Non-attachment and 4 questions on Secure-Base distortions. Each item is explored through a series of probes. Trained interviewers rate each item as "0" = none or never, 1= somewhat or sometimes, and 2 = considerable or frequently; responses are summed with higher scores indicating greater disturbances in attachment. The DAI will be administered to the RCF caregiver at baseline, and the Home caregiver 6- and 12-months follow-up.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Decrease in Child Problem Behaviors

Child Problem Behaviors will be measured by the Child Behavior Checklist (CBCL, Achenbach 1992). The CBCL has been used widely including in studies in Africa, such as in South Africa as part of the Sinovuyo Teen parenting program (Cluver et al., 2016). CBCL is a caregiver-report questionnaire on which the child will be rated as either a 0 ("Not True"), 1 ("Somewhat or Sometimes True"), or a 2 ("Very True or Often True"), on various behavioral and emotional problems. It assesses internalizing (i.e., anxious, depressive, and overcontrolled) and externalizing (i.e., aggressive, hyperactive, noncompliant, and undercontrolled) behaviors. We will use the two versions, one for children aged 1 to 5 years, and another for children aged 6 to 13 years. CBCL will be rated by both the home caregiver as well as the RCF caregiver.

Time frame: Baseline, 6 months post- reunification and 12-month post-reunification follow-up

Better attitudes towards physical punishment in children

Attitudes towards discipline and physical punishment will be measured by using items from the International Child Abuse Screening Tool Attitudes measure, developed for the Sinovuyo study (Cluver et al., 2016). The ICAST-Attitudes has 3 items that measure attitudes towards physical punishment of children using the example of a child who is "always getting into trouble". Respondents are asked how 'good' the disciplining tactics are using a scale of 1 ("very good") to 5 ("very bad"). The measure will be administered to the home caregiver, the RCF caregiver, and the 8+ child.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Lowered report of child abuse

Child abuse will be measured using an abbreviated version of the International Society for the Prevention of Child Abuse and Neglect child and caregiver version of the International Child Abuse Screening Tool (Reduced ICAST-Trial). The Reduced ICAST has questions that pertains to incidents of violence in the past months. The ICAST measures three types of abuse: physical abuse, emotional abuse, and sexual abuse. In this study, the response code was adapted to a frequency scale from 0 to more than 8 times as certain behavior occurred in the past month. The Reduced ICAST will be administered to the RCF caregiver and the 8+ child. The RCF caregiver version has 14 items. The 8+ Child version has 20 items and includes questions on whether the child has asked for help relating to the questions that are not part of the ICAST tool. The investigators will also assess frequency of overall abuse by summing all of the subscales as well as for each individual subscale.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increase in child Cognitive functioning

Cognitive functioning of younger children, aged 1 to 4 years, will be assessed by the Mullen Scales Early Learning (MSEL; Mullen, 1995). MSEL is an individually administered standardized measure of cognitive ability and motor development, which has been used in many studies in Uganda and other countries in Africa (Boivin et al., 2013). We will be administering all five scales of MSEL: Gross Motor, Fine Motor, Visual Reception, Receptive Language, and Expressive Language that are combined into an Early Learning Composite score. Raw scores will be converted to standardized score that will yield a composite of the Mental Processing Index (MPI). Cognitive functioning of older children, aged 5 to 13, will be assessed by the Kaufman Assessment Battery for Children (KABC-II; Kaufman \& Kaufman, 2004). It is an individually administered standardized measure of sequential and simultaneous processing, learning, reasoning, and crystallized knowledge ability, which has been used in many studies

Time frame: Baseline, 6-month post- reunification follow-up

Increased access to food

Household food security is measured at all 3 time points (in the Caregiver questionnaire) by the Household Hunger Scale (HHS, Ballard, Coates, Swindale, \& Deitchler, 2011). The HHS is a series of three questions regarding household food insecurity in the prior month (i.e., "was there ever no food to eat of any kind…?" \[and, if so, how often: rarely (1-2 times), sometimes (3-10 times), often (more than 10 times)\]; "did you or any member of your household go to sleep at night hungry…?" \[and how often\]; and "did you or any household member go a whole day and night without eating anything at all because there was not enough food?" \[and how often\]). The HHS will be administered only to the home Caregiver at all time points.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increased access to health care

Children's access to health care will be measured by questions on availability of shelter and clothing, general health, schedule of immunizations, and access to medical care. These questions were based on existing OVC tools and questions used in the Sinovuyo study (Cluver et al., 2016). These questions will be administered to the RCF caregiver and the 8+ child. The schedule of immunizations will be obtained from the child's vaccination card at the RCF.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increase in child and caregiver's Self-Esteem

Child and the home caregiver's self-esteem will be assessed by Rosenberg Self-Esteem Scale (Rosenberg, 1965), which is a 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self. All items are answered by the respondent using a 4-point Likert scale format ranging from "strongly agree" to "strongly disagree". The self-esteem scale will be administered to the Home Caregiver and the 8+ Child.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increase in Home Caregiver's Psychosocial Health

The home caregiver's symptoms of psychosocial health will be assessed by The Shona Symptom Questionnaire (SSQ) that was developed in sub-Saharan Africa (Patel, Simunyu, Gwanzura, Lewis, \& Mann, 1997). The SSQ consists of 14 "yes/no" questions pertaining to common symptoms of mental disorder, and idioms or distress of primary care attenders. The items are a mixture of emic and etic phenomena, and are self-rated by the respondent. The SSQ will be administered only to the Home Caregiver at all time points.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Decrease in Parenting Stress

Parenting stress of the home caregiver will be measured using the Parental Stress Scale (PSS; Berry \& Jones, 1995). The PSS has been used widely including in studies in Africa, such as in South Africa as part of the Sinovuyo Teen parenting program (Cluver et al., 2016). PSS is a self-report scale that contains 18 items representing pleasure or positive themes of parenthood (emotional benefits, self-enrichment, personal development) and negative components (demands on resources, opportunity costs and restrictions). Respondents are asked to agree or disagree with items in terms of their typical relationship with their child or children and to rate each item on a five-point scale ranging from "strongly disagree" (1) to "strongly agree" (5). The PSS will be administered only to the Home Caregiver at all time points.

Time frame: Baseline, 6 months post- reunification and 12-month post-reunification follow-up

Decrease in child and caregiver's loneliness

Home caregiver's and child's (8+ years) loneliness will be measured using UCLA Loneliness scale (Version 3, Russell, D. (1996)), designed to measure one's subjective feelings of loneliness as well as feelings of social isolation. We will be using the 3-item scale (Hughes, Waite, Hawkley, \& Cacioppo, 2004) that will be self-rated on a 4-point scale as either O ("I often feel this way"), S ("I sometimes feel this way"), R ("I rarely feel this way"), or N ("I never feel this way").

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Decrease in child's depressive symptoms

Children's Depression Inventory (CDI; Kovacs, 2011) will be used to assess self-rated depressive symptoms of older children (aged 8 yrs. and above). CDI measures cognitive, affective, and behavioral symptoms of depression such as depressed mood, hedonic capacity, vegetative functions self-evaluation and interpersonal behaviors in the past two weeks. It covers the consequences of depression as they relate to children and functioning in school and with peers. We will use the 2nd edition (CDI2) with 12 items. For each item the child has three possible answers; 0 indicating an absence of symptoms, 1 indicating mild symptoms, and 2, definite symptoms.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increase in Protective Factors and Resilience

The presence of a caring adult as a protective factor will be assessed using questions from the core module of The California Healthy Kids Survey (CHKS, 2014; CA Department of Education, Version H18 - Fall 2014 - Spring 2015). CHKS has been administered as a comprehensive, youth risk behavior and resilience survey . The four items pertain to child's perception of the availability of a caring adult. The items are rated on a 4-point scale: Not at all true, A little true, Pretty much true, and very much true." Of the original 6 questions, 2 questions were removed at the piloting stage. In the present study, this measure will be administered to the older children (8+ years).

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Increased levels of social support for caregiver and child

Perceived social support will be measured using the Medical Outcome Study Social Support Questionnaire (MOS-SSQ, Sherbourne \& Stewart, 1991). The MOS-SSQ has been used widely including in studies in Africa, such as in South Africa (Lachman et al., 2014) and as part of the Sinovuyo Teen parenting program (Cluver et al., 2016). The MOS-SSQ is a 19-item survey that measures emotional/informational support, tangible/instrumental support, affectionate support, and positive social interaction. Respondents report on the frequency of how often they receive support (e.g., "someone you can count on to listen to when you need to talk") on a Likert-like scale of 1 to 5 (1 = none of the time; 5 = all of the time). Total scores are calculated by averaging the scores for each item and then transformed into a 0 to 100 scale. The MOS-SSQ will be administered to the Home Caregiver and the 8+ Child.

Time frame: Baseline, post- intervention and 12-month post-intervention follow-up

Increased sense of community belonging for caregiver and child

Sense of community belonging will be measured by an adapted version of the RETRAK and ASPIRE's 3-item sense of belonging feelings of acceptance and involvement in the community. ASPIRES Family Care: Longitudinal Project Assessment Research, Child Integration Status Tool, Version 2.0, 2016. The measure will be administered to the Home caregiver and the 8+ child.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

School enrollment

School enrollment will be assessed based on self-reports. Questions on school enrollment, type of school, reasons for lack of enrollment, number of days missed, current grade, previous grade, repetition of a grade, will be asked of the RCF caregiver, home caregiver, and the 8+ child.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up

Satisfaction with school

Children's and caregiver's satisfaction with child's schooling will be measured by a 3-item questionnaire; children's feeling safe at school, having a sense of belonging at school.

Time frame: Baseline, 6-month post- reunification and 12-month post- reunification follow-up