Violence Prevention: Therapeutic Foster Care – for Chronically Delinquent Juveniles
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends therapeutic foster care for adolescents ages 12-18 with a history of chronic delinquency based on sufficient evidence of effectiveness in preventing violence among this population.
The CPSTF has a related finding for therapeutic foster care for children with severe emotional disturbance (insufficient evidence).
The full CPSTF Finding and Rationale Statement and supporting documents for Violence Prevention: Therapeutic Foster Care — for Chronically Delinquent Juveniles are available in The Community Guide Collection on CDC Stacks.
Intervention
Therapeutic foster care describes two distinct forms of treatment:
- Program-intensive therapeutic foster care is an alternative to incarceration, hospitalization, or other forms of group and residential treatment for adolescents with a history of chronic antisocial behavior, or delinquency
- Cluster therapeutic foster care is provided to children with severe emotional disturbance (SED), most often by “clusters” of foster families that cooperatively care for a group of children
In both types, participants are placed for several months in foster families who are specially trained and compensated, provided a structured environment where they are rewarded for positive social behavior and penalized for disruptive and aggressive behavior, separated from delinquent or troublesome peers, and provided close supervision at school and at home.
About The Systematic Review
The CPSTF finding is based on evidence from a systematic review of 3 studies (search period through December 2001).
Study Characteristics
- Evaluated interventions in which 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 history of chronic delinquency
- Studies included juveniles mandated to out-of-home care but regarded as sufficiently safe to allow community treatment
- Programs lasted, on average, 6 to 7 months
Summary of Results
Three studies qualified for the review of program intensive therapeutic foster care for chronically delinquent adolescents.
- Therapeutic foster care reduced violent crime by approximately 71.9% when compared with similar youth in standard group residential treatment facilities (3 studies)
Summary of Economic Evidence
Two studies were identified.
- One study assessed program costs incurred by government (state and local) including costs for personnel, foster parent stipends, and additional health services. Average program costs were $18,837 per youth (in 1997 dollars)
- Second study was incremental cost benefit analysis comparing therapeutic foster care with standard group care. Incremental program costs were $1,912 per youth (in 1997 dollars). Total net benefits ranged from $20,351 to $81,664 per youth. This estimate does not include benefits to youth such as increased earnings and improved life course outcomes
Applicability
All studies of program-intensive therapeutic foster care for chronically delinquent juveniles were conducted by one research group in one place (Eugene OR). Although similar programs are in place elsewhere, we are not aware of other programs evaluated for violent outcomes. Thus, applicability with regard to setting may be a concern.
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 sex, 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?
Implementation Considerations and Resources
- In 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 control group.
- Researchers reported youth were taught responsible family behavior, and 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.
- Most prominent barriers include:
- Difficulty recruiting, training, and retaining suitable foster families
- On-going recruitment and training to maintain a group of well-trained foster parents, often necessitating hiring a full-time foster parent recruiter
- Research indicates providing an additional monthly stipend to normal reimbursement rate increased foster parent retention. Even greater increase in retention rates (by almost two thirds) was evident when enhanced training and support was included along with stipend.
- The rigor and fidelity required to implement the program might be difficult to maintain, considering strict monitoring and frequent contact with families required.
- Essential to establish effective systems of communication for treatment staff and foster families.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.