Therapeutic foster care

Impact on crime
Evidence quality 3
Effect
How it works
cog full Evidence quality 2
Mechanism
Where it works
where full Evidence quality 2
Moderator
How to do it
what full Evidence quality 3
Implementation
What it costs
cost full Evidence quality 0
Economic cost
* This is based on the strongest scores from a number of systematic reviews

What is the focus of the intervention?

Therapeutic foster care is also known as therapy foster care, multidimensional treatment foster care, specialist foster care, treatment foster family care, and family-based treatment.

It is designed for youths who cannot live at home, usually due to behavioural problems including chronic delinquency. These youths are placed in a foster home in which foster parents receive training to provide a structured environment to promote the learning of prosocial and emotional skills. Part of the care includes intensive monitoring at home, at school and during leisure activities.

Foster parents work not only with programme personnel for training, but may also collaborate with teachers, probation officers, and others in order to ensure an environment where prosocial learning and behaviour is encouraged.

This narrative is based on one review of 5 studies and a second review also based on 5 studies. The crime outcome measured was a reduction in delinquency and anti-social behaviour, using both self-reporting and officially recorded crime statistics. 

EFFECT

How effective is it?

Overall, the evidence suggests that therapeutic foster care has reduced crime.

The overall evidence comes from Review 1, based on 5 studies. All three studies with criminal outcomes saw statistically significant reductions in anti-social behaviour for the group which had therapeutic foster care.

A meta-analysis across two of the included studies found statistically significant reductions in the number of criminal referrals of youths who had completed the therapeutic foster care, at both 12 months and 24 months after the programme had ended. Criminal referrals were defined as all officially reported misdemeanour and felony offences on the youths’ records.

The meta-analysis also found significant reductions in the total number of days in locked settings for treatment groups compared to control groups, at both 12 and 24 months after the programme had ended. These locked settings included detention, correctional facilities, jail or prison. A small but non-significant reduction in self-reported delinquency was also found at 12 and 24 months.

How strong is the evidence?

Review 1 was sufficiently systematic that many forms of bias that could influence the study conclusions can be ruled out. 

Review 1 considered many elements of validity, conducted relevant statistical analyses and used quality assurance to ensure the accuracy of the information collected from primary studies. The review authors only combined studies with similar outcomes, and the review was restricted to the studies of highest design quality – randomised control trials. However, the review did not take into account possible unintentional outcomes.

MECHANISM

How does it work?

Review 1 suggested that therapeutic foster care helps to reduce delinquency and anti-social behaviour by the better management of young people by foster carers.

These foster carers provide consistent and predictable forms of discipline and close supervision, which is believed to encourage prosocial behaviour. A second possible mechanism results from separating the young person from his or her delinquent peers.

Review 2 provides further details, suggesting that therapeutic foster care separates participants from their usual peer environment, whereas placement in group homes (the usual intervention for chronically delinquent youths) often results in increased exposure to delinquent peers. This can lead to the development of shared antisocial identities amongst residents, and intensify aggressive and delinquent behaviours.

Review 2 also suggested that the interactions between youths and their foster carers are crucial to changing behaviours. Therapeutic foster care provides structured and supportive parenting for youths whose parents are unable to provide this. Foster carers play an important role in socialising youths into prosocial behaviours. Youths are taught responsible family behaviours by foster carers, and are trained to improve school attendance, relations with teachers and peers, and homework performance.

MODERATORS

In which contexts does it work best?

Review 2 separated the studies it analysed into two groups according to the age of the person in foster care: the first included two studies of younger children aged 5-13 (with programmes lasting an average of 18 months); the second group included three studies of adolescents aged 12-18 (with programmes lasting 6-7 months). Average study findings for younger children were inconsistent and suggested slight but not significant increases in undesirable behaviours. Effects on the older group were more positive, showing that the median effect on violence by juveniles with a history of chronic delinquency is a 71.9% reduction in violent crime.

Review 2 also noted that, in two studies, the results for girls and boys were similar. However, one study noted that behavioural problems in therapeutic foster care might increase for girls (which was also seen in one study in Review 1). Three studies indicated that characteristics of a youth’s background and environment may hinder the effectiveness of therapeutic foster care; in particular youths with a history of being sexually abused and those from family backgrounds where parents have a history of crime or chronic drug abuse.

IMPLEMENTATION

What can be said about implementing this initiative?

Reviews 1 and 2 each provided a list of key core components of therapeutic foster care, as summarised below:

  1. There is a clearly articulated philosophy with strong community links and individually designed treatment and education plans that include 'a stated, measurable goal, a written set of procedures for achieving the goal, and a process for regularly assessing the result’.
  2. Foster carers are selected and trained to provide therapeutic care to children and youths who have special needs that may result from emotional disturbance, developmental disabilities, behavioural difficulties, or special medical needs.
  3. Care is provided within a family setting, in homes owned or under the control of the foster carers who are responsible for the implementation of the young people's treatment plans.
  4. The number of children placed in the home is limited to no more than two. 
  5. Foster carers receive support, consultation, and supervision from professionals who carry a small caseload (5 to 15) with crisis intervention services available around the clock. 
  6. Foster carers are regarded as professional members of the service and treated as such, including intensive pre-service and in-service training, good pay, and performance evaluations. 
  7. Foster carers receive payments above those provided for regular foster care and may also receive a special stipend based on each child's treatment needs.
  8. The programme is administered by specialist agencies or, if part of a host agency, by a unit specifically identified as a treatment foster care programme, even if using a different name.


Review 1 stated that therapeutic foster care is designed for children and youths who would otherwise be in more restrictive nonfamily settings (usually institutions), or at risk of admission to those settings. This may involve children with serious emotional or behavioural problems who are at risk of multiple placements and therefore, ultimately, at risk of finding themselves in ever more restrictive settings.

Review 1 noted that implementation should centre on the support available to the foster carers and young people (with respect to regular meetings and therapeutic and clinical services being available). In addition, the young people should be closely supervised in the home (and school) setting, and contact with delinquent peers prohibited. It was made clear that any infringements of the set rules should result in a direct consequence.

Review 1 also noted that for girls in particular, the foster care needs to address emotional and psychiatric conditions that reportedly often appear alongside delinquency (and which may contribute to it, or cause impediments to treatment). Girls were taught skills to avoid social-relational aggression as this was seen as a particular problem. (Social or relational aggression is a type of bullying which damages someone’s relationships or social standing e.g. through Exclusion from social activities, spreading rumors about the victim, or  him/her in front of others).

Review 2 also mentioned some barriers to implementing therapeutic foster care, including difficulty recruiting, training, and retaining suitable foster families. Recruitment and training must be conducted year-round in order to maintain a group of well-trained foster parents. It was also noted that providing an additional monthly stipend to the normal reimbursement rate increased foster parent retention.

ECONOMIC CONSIDERATIONS

How much might it cost?

While neither review conducted a cost benefit analysis, or attempted to synthesise evidence about programme costs, both reviews provided evidence of costs from individual studies where this was available.

Review 1 reported the costs of therapeutic foster care in 1991 ($3,000 per month per participant) compared to the control group, who were in the state mental hospital ($6,000 per month per participant). This led to an average saving of $10,280 per participant in hospitalisation costs for those who were placed in therapeutic foster care. The review also noted that while therapeutic foster care was more expensive than regular foster care, it is less expensive than residential care.

Review 2 reported one study which saw average programme costs of $18,837 per youth in 1997. These costs included personnel (case manager, programme director, therapists, recruiter and foster parent trainer), foster parent stipends, and additional health services such as mental health care. A second study in Review 2 reported a cost-benefit analysis of therapeutic foster care compared to standard group care. The additional cost per participant for therapeutic foster care was $1912 in 1997, but the total net benefits for programme participants ranged from $20,351 to $81,664. 

General considerations

• All of the studies were conducted in the USA, and 4 of the 5 studies from Review 1 were from one implementation team in Oregon, USA. Findings may not be transferable to different contexts, including the UK.

Summary

Overall, the evidence suggests that therapeutic foster care has reduced crime. Significant reductions in the number of criminal referrals and the days in locked settings were seen for participants compared to control groups. Therapeutic foster care is believed to work by removing youths from delinquent peers and providing supervision and discipline by foster carers who encourage prosocial behaviours. The core components of therapeutic foster care are well documented, but the number of studies remains low and more research is needed to investigate the effectiveness of this programme in the UK context.

Ratings for Individual Reviews

Review 1

How it works
cog full Evidence quality 1
Mechanism
Where it works
where full Evidence quality 0
Moderator
How to do it
what full Evidence quality 3
Implementation
What it costs
cost full Evidence quality 0
Economic cost

Review 2

How it works
cog full Evidence quality 2
Mechanism
Where it works
where full Evidence quality 2
Moderator
How to do it
what full Evidence quality 3
Implementation
What it costs
cost full Evidence quality 0
Economic cost

Resources

Review 1: MacDonald, G.M. and Turner, W. (2007) 'Treatment foster care for improving outcomes in children and young people', Campbell Systematic Reviews 2007:9, DOI: 10.4073/csr.2007.9

Review 2: Hahn, R. A., Bilukha, O., Lowy, J., Crosby, A., Fullilove, M. T., Liberman, A., Moscicki, E., Snyder, S., Tuma, T., Corso, P. and Schofield, A. (2005) 'The Effectiveness of Therapeutic Foster Care for the Prevention of Violence: A Systematic Review', American Journal of Preventative Medicine, 28:2S1, 72-90

This narrative was prepared by UCL Jill Dando Institute and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC).  ESRC Grant title: 'University Consortium for Evidence-Based Crime Reduction'.  Grant Ref: ES/L007223/1.

Uploaded 16/12/2015

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