Violence: Therapeutic Foster Care – for Children with Severe Emotional Disturbance – Inactive

The CPSTF finding is based on evidence from a systematic review of 2 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

Two studies qualified for the systematic review of cluster therapeutic foster care for the reduction of violence by children with severe emotional disturbance.

• One study compared a cluster therapeutic foster care intervention (called a parent-therapist program) to group residence for the treatment of SED among youths aged 6-12 years.
  • Change in conduct disorders: 31.3% increase for girls and a negligible effect (a 0.2% decrease) for boys
• The other study reported effects of New York State’s version of cluster therapeutic foster care, Family-Based Treatment, on children aged 6-13 years with severe emotional disturbance.
  • Change in externalizing behavior among children: increase of 2.5%

An economic review of this intervention was not conducted because CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because CPSTF did not have enough information to determine if the intervention works.

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 Cluster Therapeutic Foster Care for Children with Severe Emotional Disturbance

Evidence on the effects of cluster therapeutic foster care for pre-adolescent children with severe emotional disturbance was insufficient to determine their effectiveness (for the reduction of violence). Only two studies of this form of therapeutic foster care assessed violent outcomes. The studies we reviewed suggest either no effect or, for girls, possible harm. Further research on the effectiveness of therapeutic foster care with this and other child and adolescent populations would clarify other possible benefits (or harms) of this intervention. Follow-up studies should determine short-term as well as long-term effects.

Applicability

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.

More research is needed to determine effectiveness among children with severe emotional disturbance and among other populations, such as mentally retarded children, children who have been sexually abused, and children with AIDS, for whom foster care may be a viable alternative to other treatment options (Eddy & Chamberlain, 2000; Aos et al., 2001; Dennis, 1992).

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 provided guidance to clusters of five foster parent families who cooperated in the care of five children (aged 5 to 13 years) with severe emotional disturbance.
• In one of the studies, children were referred by mental health, social service, and school personnel or parents. In the other study, the source of referral was unclear.
• Programs were of relatively longer duration, with an average length of 18 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

Evans ME, Armstrong MI, Kuppinger AD, Huz S, McNulty TL. Preliminary outcomes of an experimental study comparing treatment foster care and family-centered intensive case management. In: Epstein MH, Kutash K, Duchnowski A, eds. Outcomes for children and youth with emotional and behavioral disorders and their families: programs and evaluation best practices. Austin TX: Pro-Ed, 1998:543 80.

Rubinstein JS, Armentrout JA, Levin S, Herald D. The Parent Therapist Program: alternate care for emotionally disturbed children. Am J Orthopsychiatry 1978;48:654 62.

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.

CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.