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In the United States and England, the use of evidence-based interventions for children in foster care has the potential to decrease the widespread disparities in health and mental health outcomes, improve placement stability and increase the likelihood of children achieving permanency. Nevertheless, there have been few discussions about the systematic implementation of evidence-based practice to address different levels of need and risk in foster care. In this paper, we provide a framework for determining the types of programs needed for children with varied needs along a continuum that includes four categories of options: (1) screen and identify those who are functioning adequately in foster care versus those in need of supplemental services; (2) provide ‘enhanced foster care’ with additional resources for families and children; (3) implement interventions that target specific problems such as disruptive behavior or school functioning; and (4) implement intensive therapeutic foster-care programming. Examples of interventions in each category are provided, and implications for policy and practice are discussed.
A vast body of evidence documenting poor outcomes among children in foster care has led to numerous calls to action to document and characterize specific risk factors more effectively and to develop programming and policy to address the needs of this population (e.g. Burns et al., 2004; Landsverk, Garland, & Leslie, 2002). Since the calls for an end to ‘foster-care drift’ in the 1970s (Jones, 1978), several initiatives directed at understanding foster children's risks and programming needs have been developed. These initiatives continue to improve, and recent studies have shown that children's risks are becoming identified more systematically at the time of entry into care (Leslie, Hulburt, Landsverk, Rolls, Wood, & Kelleher, 2003). In addition, there have been some gains in the development of evidence-based programs to address the needs of foster children (Fisher, & Chamberlain, 2000). Despite this progress, there remains a lack of coherent policy regarding ways to identify and address the needs of children in care in both the United States and England. In this paper, we provide a framework of potential intervention options that are derived from the available evidence base. We frame our discussion around four sets of options that span a spectrum from low- to high-intensity programming. At the low end are approaches that focus on ongoing surveillance of children in care, especially at entry and transition points, and efforts to refer for services when problems are detected. At the high end are comprehensive interventions, including Multidimensional Treatment Foster Care (Fisher, Ellis, & Chamberlain, 1999), an evidence-based program developed and validated originally in the United States which is now being implemented and evaluated on a national scale in England.
Within each set of options, we describe examples of both evidence-based interventions and promising approaches that in are in the process of garnering evidence. We conclude with a discussion of directions for the field that will help to increase the availability of the highest quality of empirically based approaches, with the ultimate goal of improving the likelihood of success in the foster-care population.
Rarely considered in the literature is the option to leave well enough alone within the foster-care system. This approach carries with it the implicit assumption that placement in foster care is, in and of itself, an intervention that has potential to make a difference. Even in the studies that have revealed the significant higher risk levels among foster children, it is clear that many children who spend time in care emerge without significant behavioral and emotional problems (Fisher, Gunnar, Dozier, Bruce, & Pears, 2006). The concept of resilience has often been invoked to describe the positive trajectories of these children and such resilience may reflect both constitutional variables (i.e. genetic and temperamental factors) as well as environmental protective factors (e.g. adequate early nurturing from the children's biological parents in spite of the maltreatment that may have led children to enter care). Further, there are many skilled foster carers who provide an excellent quality of care to children, many of whom have had difficult and dramatic histories.
Discussions of services and policy for foster children may avoid the option of leaving well enough alone due to the potentially negative message that it carries with it for the children in foster care who are indeed in need of additional services. We argue that rather than embracing a ‘do nothing’ approach, Option 1 involves employing systematic methods to determine which children appear to be functioning adequately in regular foster care, and in the context of this evaluation to identify those who are unlikely to be successful without supplemental services.
Two examples from the recent literature suggest how this systematic evaluation might be employed. In one study, information was gathered via a series of six brief telephone interviews conducted on consecutive days with the foster carers. The interview involved asking about the number of problem behaviors exhibited by foster children on a daily basis in their home (Chamberlain, Price, Leve, Laurent, Landsverk, & Reid, 2008). Results from analyses of these data indicated that between zero and six behavior problems on a daily basis were associated with very low rates of foster placement disruption (i.e. a 9% disruption rate over the subsequent 12 months). However, beyond six problem behaviors per day, the probability of foster placement disruption increased by 17% with each additional problem behavior. This study suggests that surveillance of children in care, via a simple means such as brief telephone interviews conducted on a regular basis, might yield information regarding those most likely to need services to support placement stability.
A second study of preschool-aged foster children (Fisher, Burraston, & Pears, 2005) examined the association between the number of prior placements and the likelihood of achieving permanent placement (i.e. reunification of biological parents or adoption by relatives or non-relatives). That study showed that for children who had four or more prior placements, the likelihood of achieving permanency was quite poor. However, for children who had only one or two prior placements, there was an excellent chance (greater than 80%) that they would achieve permanency. This suggests that only those children who are experiencing considerable placement instability may require additional services to achieve permanency in the long term.
Leslie and colleagues have called for systematic screening to address the physical, mental and developmental wellbeing of children in care (Leslie et al., 2003). Such systems, in connection with ongoing efforts such as those employed by Chamberlain et al. (2008) to monitor the progress of children in foster homes, may be cost-effective and highly productive ways to identify children who are unlikely to benefit from conventional foster care and may need additional services. Further, if delivered in a preventive manner, such identification may prove ultimately to be highly cost-effective in reducing extremely expensive events, such as foster placement disruption and the loss of available foster parents (as a result of them no longer wanting to take in foster children), and may also yield significantly better outcomes for the children.
Beyond systematic screening and ongoing identification of those in need of additional services, the next of level of intervention involves providing additional resources to the regular foster care system without necessarily introducing systematic interventions. This approach was examined in a recently published study by Kessler et al. (2008). Within the context of enhanced foster care, caseworkers had lower caseloads and were paid higher salaries. In addition, there was enhanced support and behavioral consultation available to foster carers. Finally, additional services to children, such as after-school and recreational activities, were also provided. Compared to individuals who had participated in regular foster care, children who were placed in this enhanced programming showed improved health and mental health outcomes when followed-up as adults.
The idea of enhanced foster care is appealing because, although it requires additional economic resources, it is a readily implemented change in the social policy system that appears to produce significant effects. This approach embraces the concept that foster care in general is an under-resourced system and that many of the negative outcomes are due in part to the unfavorable circumstances within which foster carers, children and social workers exist. As in any under-resourced system, providing additional resources would be expected to produce many of the observed changes.
Although enhanced foster care may be an effective universal intervention for foster children overall, clearly there are instances in which specific problems are of sufficient magnitude to require targeted attention. A number of programs have been developed to address these specific needs; the programs either have an established evidence base or are in the process of developing such a base. Here, we address two of these targeted interventions. Chamberlain et al. (2008) developed a program called Project KEEP (Keeping Foster and Kin Parents Skilled and Supported). In this program, foster parents attend support groups to learn how to address specific behavioral problems through intervention techniques that prior research has found to be effective. This program has been evaluated by a randomized trial and has been found to have a number of positive effects. Children whose carers participated in the 16-week KEEP curriculum had lower rates of behavior problems, carers used relatively more positive parenting methods and reunification rates were higher and disruption rates lower for children whose carers participated in KEEP relative to those in the study control condition (Chamberlain et al., 2008; Price, Chamberlain, Landverk, Reid, Leve, & Laurent, 2008). Further, the study showed that the increase in positive parenting methods specifically caused (or drove) the reductions in child behavioral problems (Chamberlain et al., 2008). It is important to acknowledge that the data gathered in this study to date examines only outcomes from baseline to the termination of treatment. Long-term follow-up data examining intervention effects over time are being gathered, but were not available at the time of publication of this paper.
Similarly, with regard to young children in foster care, concerns have been expressed about a frequent lack of readiness to enter the education system successfully. To address this, Pears et al. have developed a program called Kids in Transition to School (KITS; Pears, Fisher, Heywood, & Bronz, 2007). The KITS program targets three domains that have been identified in the literature as most critical to success in school: early literacy, self-regulation and social–emotional competence. The KITS program intervention consists of child playgroups that occur twice weekly in the summer before children enter kindergarten and continue less frequently in the autumn of kindergarten. In addition, foster parents attend twice-monthly support groups that emphasize ways to support literacy, the benefits of parental involvement in school and ways to manage children's problem behaviors. A randomized trial of the KITS program is currently under way. Preliminary evidence reveals positive effects in a number of domains, including self-regulation and peer relations (Pears, Fisher, & Bronz, 2007).
The highest intensity of services within the continuum of options described here involves a program called MTFC, which is designed to meet the needs of children with severe behavioral and emotional problems (Chamberlain, 1994). This intervention includes intensive training and ongoing support to foster carers through daily telephone contact and weekly support group meetings. Youth receive individual services to facilitate skill development and self-regulation. Consultation is provided to schools and other community settings in which the child is engaged in order to facilitate consistency across the child's environments. Versions of the MTFC program have been developed for both older children and preschoolers, and a number of randomized clinical trials have been conducted in the United States to evaluate the effectiveness of this approach. (Although randomized evaluations of MTFC are under way in England, no data are available as yet.) The results from studies to date consistently reveal positive outcomes, including the likelihood of achieving permanency (this effect is particularly marked for children who have had multiple prior foster placement failures), children's attachment to caregivers, foster-parent stress levels, older children's delinquency and antisocial behavior, participation in school and subsequent time incarcerated (Leve, Fisher, & Chamberlain, in press).
In addition, for the past 10 years we have been investigating the extent to which underlying neurobiological systems known to be affected by the types of early stress experienced by foster children can be impacted positively and function normally, as a result of participation in these more intensive types of interventions. A growing evidence base suggests that it is indeed possible to impact functioning in these areas. For example, one study found that cortisol levels of children who received the intervention normalized over time relative to regular foster children, who showed greater dysregulation in cortisol over time (Fisher, Stoolmiller, Gunnar, & Burraston, 2007). Notably, children's cortisol levels were associated with foster parents' stress responding to child problem behavior. In the context of the MTFC intervention, foster parents reported significantly lower stress levels managing the child over time, and this was associated with greater regulation in cortisol. In contrast, regular foster parents showed high levels of stress across time, and this was associated with dysregulation in cortisol levels (Fisher, & Stoolmiller, 2008).
Although the various approaches described in the preceding discussion show considerable promise for improving outcomes, one of the greatest areas of need is a systematic approach for implementing these interventions on a wide-scale basis in the context of foster care. There have been some positive developments along these lines in recent years. For instance, in England government funding has provided for national level implementations of the MTFC program for the most challenging foster children in both the adolescent and preschool age groups. This implementation is ongoing and data are beginning to be gathered regarding the impact of this implementation. Large-scale efforts such as this, in addition to more concentrated local efforts, have the potential to begin to tip the balance towards greater availability of evidence-based programs on a wide-scale basis. Similarly, in the state of California in the United States, Chamberlain and colleagues are conducting a randomized trial testing two methods of MTFC implementation in 40 counties throughout the state. The study examines what factors facilitate or impede implementation, ‘what it takes’ to engage decision makers and leaders to consider adoption of evidence-based approaches, and how to support and train practitioners to implement model-adherent, effective and sustainable programs.
In conclusion, we believe that although considerable positive movement has occurred to address the needs of children in foster care, efforts will need to continue in order to ensure that all children in care receive the services to which they are entitled. Options 1–4 described in this paper all represent viable and necessary ways to improve outcomes for children in foster care. The studies reviewed here provide many reasons to be optimistic regarding the likelihood of positive outcomes within this continuum of intervention services. As this work continues to develop, the need for research on what leads to successful large-scale implementations will be considerable. In addition, there will need to be attention given to how programs must be adapted in such ways that address both the cultural differences in specific countries (particularly in implementations of these approaches in developing countries), while still maintaining the core components that were responsible for intervention effectiveness. Finally, there is a strong need for practitioners, researchers and policy makers to work collaboratively on efforts toward change. It is only through these multidisciplinary and multicontextual efforts that children and families will receive these services. They require that foster care will live up to its promise to provide a better life for children who have experienced early difficulties.
Support for this research was provided by the following grants: MH059780, NIMH, U.S. PHS; MH065046, NIMH, U.S. PHS; and MH052135, NIMH, U.S. PHS.