Violence Prevention: Therapeutic Foster Care – for Chronically Delinquent Juveniles

The CPSTF finding is based on evidence from a systematic review of 3 studies (search period through December 2001). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to violence prevention.

In both types of therapeutic foster care, participants are:

• Placed for several months in foster families who are specially trained and compensated for their work
• Provided a structured environment where they are rewarded for positive social behavior and penalized for disruptive and aggressive behavior
• Separated from their delinquent or troublesome peers and provided close supervision at school and at home

Three studies qualified for the systematic review of program intensive therapeutic foster care for reduction of violence by chronically delinquent adolescents.

• Therapeutic foster care for chronically delinquent adolescents was found to reduce violent crime by approximately 71.9%, when compared with similar youth in standard group residential treatment facilities (3 studies).

Two studies were identified for the economic review.

• One study assessed program costs incurred by the government (state and local) and included costs for personnel (i.e., case manager, program director, therapists, recruiter, and foster parent trainer), foster parent stipends, and additional health services (e.g., mental health care).
  • Average program costs were $18,837 per youth (in 1997 dollars).
• The second study was an incremental cost benefit analysis of a therapeutic foster care program compared with standard group care.
  • Incremental program costs (i.e., the additional cost per participant in one program compared with the other) were $1912 (in 1997 dollars) per youth.
  • Total net benefits (total benefits minus total costs) ranged from $20,351 to $81,664 per youth.
  • This estimated range does not include benefits to youth in the program, such as increased earnings and improved life course outcomes.

All studies of program-intensive therapeutic foster care for chronically delinquent juveniles were conducted by one research group and in one place (Eugene OR). Although similar programs are in place elsewhere, we are not aware of any other programs that have been evaluated for violent outcomes. Thus, applicability with regard to setting may be a concern.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

Effectiveness of Program-Intensive Therapeutic Foster Care for Adolescents with a History of Chronic Delinquency

The evidence we have reviewed indicates a benefit of therapeutic foster care for the reduction of violence in adolescent populations with a history of chronic delinquency. As indicated earlier, the population that might benefit is a large one. Given such a large potential need, it will be useful to conduct research, perhaps in the form of demonstration projects, to make the intervention more effective or efficient. Because the foster care programs in current use are heterogeneous (Farmer et al., 2002) and differ in content, organization, personnel, intensity, and other characteristics, questions that should be addressed regarding the effectiveness of therapeutic foster care for the prevention of violence include the following:

• Are there populations of juveniles for whom therapeutic foster care works best?
• Which program components work best with which populations?
• Which program components are essential, which dispensable?
• What is the optimal intensity and duration of the program?
• Are there circumstances in which therapeutic foster care does not work, or in which additional intervention is necessary (e.g., with abused juveniles)?
• What characteristics of foster families are associated with greater program effectiveness?
• What community factors are essential for program success?
• How would therapeutic foster care compare with programs more effective than group residential treatment with which therapeutic foster care is usually compared?
• What after-care (post-discharge) conditions and services would promote the optimal sustained program gains?

Applicability

The studies examined to determine the effectiveness of therapeutic foster care for adolescents with chronic delinquency were conducted by a single established research center in one region of the United States. The applicability of findings to similar interventions implemented by others in other geographic areas is unknown. In addition, the effectiveness of therapeutic foster care programs for the prevention of violence among juvenile populations with other problems is unclear. The body of evidence was sufficient to determine effectiveness only for the target population of adolescent youth with a history of severe, chronic delinquency.

The effectiveness of therapeutic foster care among female populations is less clear than for males. The effects of therapeutic foster care may vary by gender, indicating a need to modify programs to accommodate such differences.

Of the studies assessed in our review, most did not include information on the race or ethnicity of participants. Of those that did provide such information, the majority of participants were white. It is still unclear whether other racial or ethnic populations would benefit as did the populations studied, and whether modifications of the intervention, (e.g., employing foster parents of the same ethnicity as the youth in the program), would enhance success for these populations.

Other Positive or Negative Effects

As noted, this review did not systematically summarize evidence of the effectiveness of therapeutic foster care programs on nonviolent outcomes. Such outcomes might include school achievement; truancy; substance abuse; sexual activity; social skills; psychological adjustment; stability of home environment; and nonviolent delinquency, such as running away, theft, weapon carrying, and property crimes.

In general, the research questions for these outcomes are similar to the research questions raised above for violent outcomes. An additional question is: What are the benefits (and harms) to foster families, schools and communities?

Economic Evaluations

The available economic evidence was limited. Considerable research is warranted on the following questions:

• What is the cost-effectiveness of the various alternative therapeutic foster care programs?
• How can effectiveness in terms of health outcomes or quality-adjusted health outcomes be better measured, estimated, or modeled?
• How can the cost benefit of this program be estimated from a societal perspective?
• How do specific characteristics of this approach contribute to economic efficiency?
• How does program intensity affect the outcome and cost-effectiveness of the intervention?

Barriers

Several important barriers may adversely affect implementation and outcomes of therapeutic foster care programs. Addressing the following research questions may help to avoid or overcome these barriers:

• What design characteristics of therapeutic foster care programs improve the work satisfaction and retention of foster parents? Characteristics to assess include the selection process, training, ongoing support, respite care, and compensation.
• What features of service systems are essential for efficient implementation and sustainability of therapeutic foster care programs?
• What is the minimum level of services and communications infrastructure needed to support adequate supervision of foster families?
• What combination of community characteristics provides optimal community readiness for implementation and sustainability of therapeutic foster care programs?

• In the evaluated interventions program personnel collaborated closely and daily with foster families in a therapeutic foster care program directed toward older juveniles (aged 12 to 18 years) with a history of chronic delinquency.
• The studies included juveniles who were mandated to out-of-home care, but were regarded as sufficiently safe to allow community treatment.
• Programs lasted, on average, 6 to 7 months.

Hahn RA, Bilukha O, Lowy J, et al. The effectiveness of therapeutic foster care for the prevention of violence: a systematic review. American Journal of Preventive Medicine 2005;28(2S1):72-90.

Task Force on Community Services. Recommendations to reduce violence through early childhood home visitation, therapeutic foster care, and firearms laws. American Journal of Preventive Medicine 2005;28(2S1):6-10.

Centers for Disease Control and Prevention. Therapeutic foster care for the prevention of violence. a report on recommendations of the Task Force on Community Preventive Services. MMWR 2004;53(RR-10):1-8. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5310a1.htm.

Lipsey MW. The challenges of interpreting research for use by practitioners: comments on the latest products from the Task Force on Community Preventive Services. American Journal of Preventive Medicine 2005;28(2 Suppl 1):6-10.

Calonge N. Community interventions to prevent violence: translation into public health practice. American Journal of Preventive Medicine 2005;28(2 Suppl 1):4-5.

Task Force on Community Services, Zaza S, Briss PA, Harris KW. Violence. In: The Guide to Community Preventive Services: What Works to Promote Health? Atlanta (GA): Oxford University Press; 2005:329-84.

Effectiveness Review

Analytic Framework – See Figure 1 on page 76

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of therapeutic foster care for chronically delinquent juveniles and children with severe emotional disturbance

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Chamberlain P. Comparative evaluation of specialized foster care for seriously delinquent youth: a first step. Community Alternatives Int J Fam Care 1990;2:21 36.

Chamberlain P, Reid JB. Differences in risk factors and adjustment for male and female delinquents in treatment foster care. J Child Fam Stud 1994;3:23 39.

Chamberlain P, Reid JB. Comparison of two community alternatives to incarceration for chronic juvenile offenders. J Consult Clin Psychol 1998;66:624 33.

Economic Review

Chamberlain P, Mihalic SF. Blueprints for violence prevention. Book 8. Multidimensional treatment foster care. Boulder CO: Center for the Study and Prevention of Violence, 1998.

Chamberlain P, Moreland S, Reid K. Enhanced services and stipends for foster parents: effects on retention rates and outcomes for children. Child Welfare 1992;71:387 401.

Electronic searches for literature were conducted in Medline, EMBASE, Applied Social Sciences Index and Abstracts, NTIS (National Technical Information Service), PsycInfo, Sociological Abstracts, NCJRS (National Criminal Justice Reference Service), and CINAHL (Cumulative Index to Nursing & Allied Health Literature) in November and December 2001. We also reviewed the references listed in all retrieved articles, and consulted with experts on the systematic review development team and elsewhere. We used journal papers, governmental reports, books, and book chapters. The initial literature search on the topic was conducted in August 2000, and a second (update) search was conducted in July 2001.

In searching the literature, our inclusion criteria included:

• Evaluation of the specified intervention
• Assessment of at least one of the violent outcomes specified
• Conducted in an established market economy*
• Primary study rather than, for example, guideline or review
• Comparison of a group of people who had been exposed to the intervention with a group of people who had not been exposed or who had been less exposed. (The comparisons could be concurrent or in the same group over time before and after the intervention.)

We included any applicable study published or in press through December 2001, using all studies available.

*Established market economies as defined by the World Bank include Andorra, Australia, Austria, Belgium, Bermuda, Canada, Channel Islands, Denmark, Faeroe Islands, Finland, France, Germany, Gibraltar, Greece, Greenland, Holy See, Iceland, Ireland, Isle of Man, Italy, Japan, Liechtenstein, Luxembourg, Monaco, the Netherlands, New Zealand, Norway, Portugal, San Marino, Spain, St. Pierre and Miquelon, Sweden, Switzerland, the United Kingdom, and the United States.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• In the randomized trial of therapeutic foster care for chronic male offenders, self-reported rates of general delinquency and “index” offenses were lower among therapeutic foster care participants than among those in the control group.
• Researchers reported that youth in the therapeutic foster care program were taught responsible family behavior, and were trained to improve school attendance, relations with teachers and peers, and homework performance.
• Foster care participants spent, on average, almost twice as many days living at home following the program as did group care participants.
• The most prominent barriers to implementing therapeutic foster care discussed in the literature include the following:
  • Difficulty recruiting, training, and retaining suitable foster families
  • On-going recruitment and training to maintain a group of well-trained foster parents. This often necessitates hiring a full-time foster parent recruiter.
• Research indicates that providing an additional monthly stipend to the normal reimbursement rate increased foster parent retention. An even greater increase in retention rates (by almost two thirds) was evident when enhanced training and support was included along with the stipend.
• The rigor and fidelity required to implement the program might be difficult to maintain, considering the strict monitoring and frequent contact with families required in therapeutic foster care interventions.
• It is essential to establish effective systems of communication for treatment staff and foster families.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the rate of minors and young adults committing violent crimes — AH‑10