Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Services Interventions
Treatment Interventions
Therapeutic Foster Care
Therapeutic foster care is considered the least restrictive form of out-of-home
therapeutic placement for children with severe emotional disorders. Care is
delivered in private homes with specially trained foster parents. The
combination of family-based care with specialized treatment interventions
creates “a therapeutic environment in the context of a nurturant family home” (Stroul
& Friedman, 1988). These programs, which are often funded jointly by child
welfare and mental health agencies, are responsible for arranging for foster
parent training and oversight. Although the research base is modest compared
with other widely used interventions, some studies have reported positive
outcomes, mostly related to behavioral improvements and movement to even less
restrictive living environments, such as traditional foster care or in-home
placement.
While therapeutic foster care programs vary considerably, they have some
features in common. Children are placed with foster parents who are trained to
work with children with special needs. Usually, each foster home takes one child
at a time, and caseloads of supervisors in agencies overseeing the program
remain small. In addition, therapeutic foster parents are given a higher stipend
than that given to traditional foster parents, and they receive extensive
preservice training and in-service supervision and support. Frequent contact
between case managers or care coordinators and the treatment family is expected,
and additional resources and traditional mental health services may be provided
as needed.
Therapeutic foster care programs are inexpensive to start (few requirements for
facilities or salaried staff) and have lower costs than more restrictive
programs. In Ontario, a study found that therapeutic foster care cost half that
of residential treatment center placement for the same period of time
(Rubenstein et al., 1978).
There have been four efficacy studies, each with randomized, controlled designs.
In the first study, 20 youths who had been previously hospitalized were assigned
to either therapeutic foster care or other out-of-hospital settings, such as
residential treatment centers or homes of relatives. The youths in therapeutic
foster care showed more improvements in behavior and lower rates of
reinstitutionalization, and the costs were lower than those in other settings
(Chamberlain & Reid, 1991). In another study, which concentrated on youths with
histories of chronic delinquency, those in therapeutic foster care were
incarcerated less frequently and for fewer days per episode than youths in other
residential placements. Thus, at 2-year followup, 44 percent fewer children in
therapeutic foster care were incarcerated (Chamberlain & Weinrott, 1990). In a
third study, outcomes for children in therapeutic foster care were compared with
those of children in standard foster care. Children in therapeutic foster care
were less likely during a 2-year study to run away or to be incarcerated and
showed greater emotional and behavioral adjustment (Clark et al., 1994). In the
most recent study, therapeutic foster care was compared with group care:
children receiving the former showed significantly fewer criminal referrals,
returned to live with relatives more often, ran away less often, and were
confined to detention or training schools less often (Chamberlain & Reid, 1998).
All four studies of treatment effectiveness showed that youths in therapeutic
foster care made significant improvements in adjustment, self-esteem, sense of
identity, and aggressive behavior. In addition, gains were sustained for some
time after leaving the therapeutic foster home (Bogart, 1988; Hawkins et al.,
1989; Chamberlain & Reid, 1991).
There are also promising indications from uncontrolled studies. Looking at 18
reports from 12 therapeutic foster care programs across the country, Kutash and
Rivera (1996) concluded that between about 60 and 90 percent of youth treated in
therapeutic foster homes are discharged to less restrictive settings. Three
programs also reported followup data, indicating that about 70 percent of youth
treated in therapeutic foster homes remained in less restrictive settings for a
substantial amount of time after treatment.
It is clear from these studies that therapeutic foster care produces better
outcomes at lower costs than more restrictive types of placement. Furthermore,
with the fairly recent development of standards for therapeutic foster care, as
well as a standards review instrument (Foster Family-Based Treatment
Association, 1995), services can be monitored for quality and fidelity to the
therapeutic approach, making it easier to ascertain if the approach taken
produces the favorable outcomes.
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