Therapeutic Foster Care Research Articles

State Implementation of Congregate Care Reforms for Children in Foster Care.

The Family First Prevention Services Act (FFPSA) allows states to use federal Title IV-E funds to provide time-limited, clinically appropriate use of congregate care, including Qualified Residential Treatment Programs (QRTPs), for youth in foster care. October 1, 2021 marked the deadline for states to begin implementing these FFPSA congregate care reforms. From June to September 2022, we conducted a mixed-methods study to obtain a baseline understanding of implementation barriers, successes, and recommendations to inform congregate care policy and practice. We fielded a national survey with state child welfare agency directors and conducted focus groups with youth with QRTP experiences, child welfare agency administrators, and QRTP executive leaders. We integrated a descriptive analysis of survey data with focus group themes to summarize state implementation progress. A total of 47 states (90%) responded to the survey. Most states reported ongoing congregate care reforms aligned with FFPSA, reducing the use of congregate care and increasing kinship foster care. QRTPs have become the primary congregate care setting. Top implementation barriers concerned workforce resource and capacity constraints, funding, and access to therapeutic foster care models and foster families. Focus group themes converged on the lack of tailored treatment, quality staff, coordinated aftercare, and a need for QRTP outcome evidence. Early implementation lessons of FFPSA congregate care reforms call for additional funding and technical assistance, oversight of congregate care, professionalization and investment in QRTP staff, youth advisory boards to promote youth-driven treatment, and performance- and outcome-based monitoring of QRTPs.

The Context of Care: Abstraction Hierarchy Modeling of Therapeutic Foster Care Programs

Therapeutic foster care agencies provide temporary placements and a range of services to at-risk youth to help ensure their safety, permanency, and wellbeing. The practitioners that plan such care operate under heavy caseloads, limited resources, and high stakes. There is significant interest in supporting these practitioners with various technological interventions, but their work and the context around it is still poorly understood. This study aims to better understand the current assessment and treatment planning work in therapeutic foster care. We used the abstraction hierarchy modeling approach to outline the purposes, values, constraints, processes, and tools that define the workplace ecology encountered by care coordinators and clinicians from therapeutic foster care programs at Hillside, a collaborating human service organization. The resulting abstraction hierarchy was closely examined to identify areas for interventions and design implications.

Comparing Medicaid Expenditures for Standard and Enhanced Therapeutic Foster Care.

Therapeutic foster care (TFC) is a service for children with high behavioral health needs that has shown promise to prevent entry into more restrictive and expensive care settings. The purpose of this study was to compare Medicaid expenditures associated with TFC with Medicaid expenditures associated with an enhanced higher-rate service called Intensive Alternative Family Treatment (IAFT).We conducted a secondary analysis of Medicaid claims in North Carolina among children entering care in 2018-2019. Using propensity score analysis with difference-in-difference estimation, we compared monthly Medicaid expenditures before and after initiating TFC and IAFT (N = 5472 person-months).Youth entering IAFT had higher expenditures prior to treatment than those entering TFC. Both standard TFC and IAFT were associated with a downward trend in expenditures following treatment initiation.Both TFC and IAFT reverse a trend of increasing Medicaid costs prior to care among children with high behavioral health needs.

Using latent class analysis to identify clinical subgroups and pathways of youth in a therapeutic foster care program

Behavioral health assessments often focus on the average status of group members and overlook unique individual needs and attributes. Therapeutic foster care (TFC), an alternative setting to residential care that serves the highest-need population in the child welfare system, is especially vulnerable to a one-size-fits-all approach. Research to date highlights the needs to identify the target population who benefits from TFC, clarify TFC eligibility criteria, and identify the youth’s clinical pathways in TFC. Using a sample of 175 children in a therapeutic foster care program, this study examined the Child and Adolescent Needs and Strengths (CANS) assessment to test a person-centered approach for identifying subgroups of children and to examine the children’s longitudinal behavioral health changes over time. Latent class analysis identified three classes of youth: (1) Some neglect, impulsivity, and medical issues; (2) Developmental and chronic medical issues; and (3) Complex needs with low strengths. A random forest regression model identified seven CANS items most predictive of unresolved needs. Each LCA class had a different distribution on three clinical pathways associated with their overall need reduction: (1) Moderate Improvement; (2) High Improvement; and (3) Low Improvement on the needs at initial assessment, reassessment, and most recent assessment. These findings have direct implications on tailoring TFC treatment planning at the clinician-level and help measure quality improvement at the program- and system-level.

Antipsychotic medications and admission to psychiatric residential treatment facilities among youth in foster care diagnosed with disruptive behavior disorders.

Many youth in foster care are diagnosed with disruptive behavior disorder (DBD), a diagnosis indicative of aggression and behavior problems. These youth, who are at high risk for being placed in psychiatric residential treatment facilities (PRTF), are commonly prescribed antipsychotic (AP) medications off-label. However, treating children in the community is an important goal, and although AP medications can have severe side effects, these prescriptions may help to achieve this goal. In this study, we used Medicaid data to determine whether AP medications reduce the risk of admission to PRTF among two groups of children with DBD: those with DBD only and those who were diagnosed with DBD in addition to at least one of two conditions indicated for AP prescribing (psychosis and bipolar disorder.) Event history models show that AP medications are associated with a high rate of admission, which are likely due to the higher mental and behavioral health needs of youth who are prescribed. However, youth diagnosed with both DBD and indications who are prescribed an AP medication have one-tenth the rate of admission of similar youth who are not prescribed. For youth with DBD only, the findings are inconclusive. Given these mixed results, practitioners should follow clinical guidelines; ensuring youth are treated with psychosocial interventions and other psychotropic medications prior to AP prescribing. Agencies should attempt to address systemic factors such as shortages of foster homes, increased availability of therapeutic foster care, and implementation of in-home prevention services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Four Frames for Choosing Performance Metrics for Child and Family Service Programs: Strategic Planning, Decision Points, Logic Modeling, and Implementation Science

This article provides guidance for child and family service organizations seeking to develop useful performance metrics for their programs. It describes four frames for this work, based on strategic planning, decision points, logic modeling, and implementation science. These four frameworks are applied to two cases, an afterschool program and a therapeutic foster care program. Additional considerations are provided for reducing potential metrics to a meaningful few.

A Quasi-Experimental Study of Intensive Alternative Family Treatment to Prevent Entry of Youth to Psychiatric Residential Treatment

Intensive Alternative Family Treatment (IAFT®) is an enhanced therapeutic foster care program that serves children and youth at risk for entry into a more restrictive level of care. The purpose of this study was to examine the effectiveness of IAFT in reducing first entry into psychiatric residential treatment compared to usual care. We linked IAFT program data to Medicaid claims data in order to develop a quasi-experimental study design to compare outcomes for two groups (N = 1655): (a) youth referred to IAFT who received services and (b) youth referred to IAFT who did not receive IAFT services (i.e., usual care). Propensity score analysis was used to balance treatment and comparison groups on pre-referral indicators. Cox regression analysis was used to examine group differences. Findings supported a significant reduction in risk for entry to psychiatric residential treatment favoring IAFT (hazard ratio 0.72; 95% CI 0.55, 0.93). Results of this study support IAFT’s efficacy as an intensive therapeutic foster care model for delivering mental health services and viability as an alternative to residential care.

La narrativité comme outil de recherche et d’évaluation à l’âge adulte des anciens enfants placés

Whereas the number of children and adults who know or have known a follow-up by the Child Welfare represents 2 to 3% of the French population, whereas the fate of these people is described in the literature as being of poor quality (insecure attachment, psychiatric disorders, precariousness…), this population is the subject of a small amount of scientific research.To apprehend this complex object of research, which is the Child Welfare/foster child, we have set up a study on the outcome in adulthood of children who have lived in therapeutic foster care. This study combines discourse analysis according to a narrativity research tool – Edicode – and a qualitative analysis method – grounded theory.Our results show that in situations associated with insecure attachment, narrativity is comparable to that found in people who have experienced repeated trauma. In addition, all 33 participants named the importance of a debriefing/interview after the Child Welfare follow-up. These qualitative results confirm the data in the literature on the importance of a support program between 18 and 25 years old for all minors followed up.

Effectiveness of Intensive Alternative Family Treatment on Reducing Re-Admissions to Psychiatric Residential Treatment Facilities

Children and youth with high behavioral health needs can receive care in a psychiatric residential treatment facility (PRTF). Overutilization of PRTFs is concerning because they are highly restrictive and costly residential care settings. Intensive Alternative Family Treatment (IAFT®) is an intensive therapeutic foster care program combined with service implementation strategies that is designed to reduce risk for entry to PRTF among youth with high behavioral health needs. This article presents findings from a quasi-experimental study examining the effectiveness of IAFT services in such a population of youth. In this study, we balanced treatment and comparison groups by first sampling youth with intensive care needs as indicated by having a prior PRTF spell. We then used propensity score weighting and covariate adjustment to estimate the effectiveness of IAFT in preventing PRTF re-entry. We found that receipt of IAFT was associated with a 24% lower risk of PRTF re-entry compared with youth who exited from a PRTF in the same state but did not receive IAFT. Sensitivity tests yielded mixed results regarding the effect of IAFT. Overall, results suggest that IAFT is an effective treatment approach for reducing risk for PRTF entry among youth with high behavioral health needs.

The Attachment, Regulation, and Competency (ARC) Framework in the Treatment of Traumatized Youth

_Clara is a 16-year-old adolescent female who was removed from parental care at age 4 following extreme neglect and physical abuse by her primary caregivers. Previously, an older sibling was removed and placed into foster care. Constant psychiatric crises due to mood dysregulation and behavioral disinhibition prevented reunification or alternative family placement. As a result, and over the course of a decade, Clara transitioned through all levels of care in the child welfare and mental health system, including inpatient hospitalization, residential care, multiple group homes, therapeutic foster care, and partial hospitalization. During her journey, she continued to experience different forms of trauma, including sexual and physical abuse, neglect, unstable caregiving, and a significant number of restraints and seclusions.

Analyse quantitative et qualitative du devenir d’adultes placés lors de leur enfance puis admis en accueil familial thérapeutique

ObjectiveThis mixed research estimates the adult outcome of children who had been separated from their families and thereafter cared for in 4 French Therapeutic Foster Care Units (TFCU), parts of public child psychiatry services. MethodsThirty-three participants were included. They were 29 years old (±3.25) and had been separated from their parents at 22 months (±13.25), admitted to the TFCU at 30 months (±17.25) for 13 years (±2.10). Quantitative evaluation uses the following tools: Mini International Neuropsychiatric Interview, Functional and Socio-affective Impact, CaMir (attachment) and Edicode (narrativity). The qualitative part uses rounded Theory (TA). ResultsIn our population, the data obtained from the analysis of narrativity, attachment representations (58% with secure attachment) and social and socio-emotional impact (but not sexual functioning) are comparable to the results in the general population, unlike what is usually found in researches on the outcome of children placed in traditional (i.e. social), foster care. In addition, among the participants, those who were separated from their families before 25 months of age and thereafter cared for in TFCU before 33 months all show secure attachment and a better overall future than others of our population. The analysis according to the TA underlines the importance of planning interview a few years after the end of the placement. Conclusion, perspectiveGrown up children formerly placed and cared for in TFCU have a life course similar to that of adults in the general population. An interview planned a few years after discharge would allow all young adults who have been in care for many years to describe the evolution of their lives and, if necessary, to express their past and current difficulties. It is also important to continue the evaluation of childcare facilities and to slow down the decline of TFCU's places these last 15 years in France.

Unpacking “support”: Understanding the complex needs of therapeutic foster parents

Children in therapeutic foster care (TFC) are more likely to have complex emotional and behavioral needs that require skilled parenting, but TFC foster parents do not always receive the training and support they need to provide these children with stable, supportive and therapeutic care, resulting in high levels of placement disruptions. As the broader foster care system moves away from relying on residential programs for children with emotional and behavioral needs and in turn places more of these high-need children in home-based settings, better understanding the unique needs of TFC foster parents is critical. Drawing from focus groups with TFC foster parents, this paper explores different aspects of their experiences, identifies multiple ways in which they need support, and provides recommendations for foster care agencies looking to retain skilled foster parents and increase the quality and stability of children's experience in TFC programs.

From Adversity to Stability to Integration: how One Australian Program is Making a Difference in Therapeutic Foster Care.

This paper discusses two key strategies detailing how "relationship-focused" and "trauma-informed" intervention practices, which form the basis of an Australian therapeutic program called Treatment and Care for Kids (TrACK), made a difference in the lives of highly traumatised children. The TrACK program fosters highly traumatised children who, due to the complexity of their trauma needs, cannot be placed in traditional generalist foster care. Case files of 48 children were reviewed. Children were either current or former clients over a period of 18years since the program was initiated. In analysing the data, we noticed that children who were once highly dysregulated in the domains of foster care placement, education, arousal regulation and peer relationships were now enjoying an enhanced level of stability in their lives.

Can we deepen the pool of Australian foster carers through enhanced training and support?

Event Abstract Back to Event Can we deepen the pool of Australian foster carers through enhanced training and support? Danielle J. Brooke1* and James F. Donnelly1 1 Department of Psychological Science, School of Health and Human Sciences, Southern Cross University, Australia Aim: One of the biggest problems in Australian foster care is that the pool of foster carers is decreasing while the number of children in out of home care is increasing. Foster carers also report that they are not supported enough in their role, leading to role dissatisfaction. The effects of a therapeutic foster care pilot program (Circle Care) showed significantly higher foster carer retention rates and role satisfaction than traditional foster care. We explored further to what extent the likelihood of remaining or becoming a foster carer would increase if each of the following, enhanced system components were provided: A specialized support system, extensive information regarding the individual child’s family and behavioural history, enhanced training, and increased funding. Method: 216 current foster carers, 48 past foster carers, and 99 prospective foster carers responded to an online survey. They rated their likelihood to remain, serve again as, or become a foster carer both before and after enhanced system components were implemented. Results: Perceived support in the role at the time of serving was identified as key covariate. A repeated measures MANCOVA revealed that for current and past carers there was a main effect of the program enhancements on likelihood ratings but no carer type by enhancement effects. A second repeated measures analysis conducted for the prospective foster carers only, also revealed a significant difference from baseline if each of the suggested Circle Care components were implemented. Conclusion: Results indicate that if agency support systems could be enhanced as described, foster carers are more likely to be retained or recruited. Keywords: Australian foster care, Out of Home Care, Role dissatisfaction, Therapeutic foster care, Retention and recruitment Conference: 15th Annual Psychology Honours Research Conference , Coffs Harbour, Australia, 4 Oct - 5 Oct, 2018. Presentation Type: Research Topic: Abstract for 15th Annual Psychology Honours Research Conference Citation: Brooke DJ and Donnelly JF (2019). Can we deepen the pool of Australian foster carers through enhanced training and support?. Front. Psychol. Conference Abstract: 15th Annual Psychology Honours Research Conference . doi: 10.3389/conf.fpsyg.2018.74.00002 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 18 Sep 2018; Published Online: 27 Sep 2019. * Correspondence: Miss. Danielle J Brooke, Department of Psychological Science, School of Health and Human Sciences, Southern Cross University, Coffs Harbour, Australia, danielle.brookey@hotmail.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Danielle J Brooke James F Donnelly Google Danielle J Brooke James F Donnelly Google Scholar Danielle J Brooke James F Donnelly PubMed Danielle J Brooke James F Donnelly Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Placement Instability Among Young People Removed from Their Original Family and the Likely Mental Health Implications.

BackgroundYoung people in out-of-home care are more likely to experience poorer mental and physical health outcomes related to their peers. Stable care environments are essential for ameliorating impacts of disruptive early childhood experiences, including exposure to psychological trauma, abuse and neglect. At present there are very few high quality data regarding the placement stability history of young people in out-of-home care in Australia or other countries.ObjectivesTo undertake the first systematic census of background, care type and placement stability characteristics of young people living in the out-of-home care sector in Australia.MethodsData was collected from four non-government child and adolescent community service organisations located across metropolitan Melbourne in 2014. The sample comprised 322 young people (females 52.8%), aged between 12 – 17 years (mean age=14.86 [SD=1.63] years).ResultsMost young people (64.3%) were in home-based care settings (i.e., foster care, therapeutic foster care, adolescent care program, kinship care, and lead tenant care), relative to residential care (35.7%). However, the proportion in residential care is very high in this age group when compared with all children in out-of-home care (5%). Mean age of first removal was 9 years (SD=4.54). No gender differences were observed for care type characteristics. Three quarters of the sample (76.9%) had a lifetime history of more than one placement in the out-of-home care system, with more than a third (36.5%) having experienced ≥5 lifetime placements. Relative to home-based care, young people in residential care experienced significantly greater placement instability (χ2=63.018, p<0.001).ConclusionsPlacement instability is common in the out-of-home care sector. Given stable care environments are required to ameliorate psychological trauma and health impacts associated with childhood maltreatment, well-designed intervention-based research is required to enable greater placement stability, including strengthening the therapeutic capacities of out-of-home carers of young people.

Improving outcomes for children in out‐of‐home care: the role of therapeutic foster care

AbstractHow best to support children and young people in foster care remains a challenge for child welfare. There has been little Australian research on the outcomes for children and young people placed in therapeutic foster care (TFC). This article aims to address this knowledge gap, presenting the evaluation of a state‐wide model of TFC known as the Circle Program operating in Victoria, Australia. Data sources for the study were case assessment analysis; surveys of foster carers, program workers and other stakeholders in the sector; and both focus groups and individual interviews with foster care workers. The evaluation found that the Circle Program lessened the number of unplanned exits of children from foster placements compared with generalist foster care. Another important finding was that the Circle Program positively influenced foster carers' decisions to stay in the carer role. Key components perceived as contributing to outcomes of the Circle Program included enhanced training of foster carers, intensive carer support, specialist therapeutic support to the child and carer, therapeutic service to family members and a network of services to provide support to the child.

Placement Stability in Therapeutic and Non-Therapeutic Foster Care Placements in South Carolina

Placement Stability in Therapeutic and Non-Therapeutic Foster Care Placements in South Carolina

Research, Data, and Evidence-Based Treatment Use in State Behavioral Health Systems, 2001-2012.

Empirical study of public behavioral health systems' use of data and their investment in evidence-based treatments (EBTs) is limited. This study describes trends in state-level EBT investment and research supports from 2001 to 2012. Data were from National Association for State Mental Health Program Directors Research Institute (NRI) surveys, which were completed by representatives of state mental health authorities (SMHAs). Multilevel models examined change over time related to state adoption of EBTs, numbers of clients served, and penetration rates for six behavioral health EBTs for adults and children: supported housing, supported employment, assertive community treatment, therapeutic foster care, multisystemic therapy, and functional family therapy. State supports related to research, evaluation, and information management were also examined. Increasing percentages of states reported funding an external research center, promoting the adoption of EBTs through provider contracts, and providing financial incentives for EBTs. Decreasing percentages of states reported promoting EBT adoption through stakeholder mobilization, monitoring fidelity, and specific budget requests. There was greater reported use of adult-focused EBTs (65%-80%) compared with youth-focused EBTs (25%-50%). Overall penetration rates of EBTs were low (1%-3%) and EBT adoption by states showed flat or declining trends. SMHAs' investment in data systems and use of research showed little change. SMHA investment in EBTs, implementation infrastructure, and use of research has declined. More systematic measurement and examination of these metrics may provide a useful approach for setting priorities, evaluating success of health reform efforts, and making future investments.

“The Way All Foster Care Should Be”: The Experience of Therapeutic Foster Carers in the Victorian Circle Program

Central to the success of therapeutic foster care (TFC) is the quality and stability of the relationship between the child and carer. This key relationship may, from a therapeutic perspective, facilitate healing by addressing the impact of complex developmental trauma experienced by the child who has been placed in care. Stability of the carer–child relationship is critical in this context. Therapeutic carers have been shown to be significantly more likely to remain in the role of carer than their counterparts in mainstream foster care. The research reported on in this paper draws upon findings from an evaluation of a TFC programme and gives voice to the Circle Carers, presenting the components of TFC which are important to them. The paper commences with the story of Ruby in TFC as told by a carer. The focus then becomes a detailed exploration of the experience of carers and their capacity to care. Implications for practice are identified.

Therapeutic Kinship Care: A Carer's Perspective

Kinship-care placements in Australia are now more prevalent than foster care and are the fastest growing form of out-of-home care in this country (AIHW, 2014). On 30 June 2013, 93% of Australian children in out-of-home care were in home-based care, with 43% of these in foster care and 48% in relative/kinship care (AIHW, 2014). The past decade has seen a greater understanding of children's needs in out-of-home care, with models of therapeutic care showing promise in Australia and internationally. These models, however, are designed almost exclusively for children placed in foster care or residential care, and as such do not consider the unique features of kinship care. This paper will identify the needs of children in out-of-home care, before briefly examining the concepts of therapeutic foster care as a response to children who have experienced trauma. Key distinctions between foster care and kinship care will be highlighted and implications for a conceptual model of therapeutic kinship care discussed.