Focus of the intervention
Therapeutic foster care is also known as therapy foster care, multi-dimensional treatment foster care, specialist foster care, treatment foster (family) care and family-based treatment.
It is designed for young people who cannot live at home, usually due to behavioural problems including chronic delinquency.
These young people are placed in a foster home in which foster parents receive training to provide a structured environment to promote the learning of prosocial and emotional skills.
Part of the care includes intensive monitoring at home, at school and during leisure activities.
Foster parents not only receive training from programme personnel, but may also collaborate with teachers, probation officers and others in order to ensure an environment where prosocial learning and behaviour is encouraged.
This narrative is based on three reviews. Review one (covering five studies) compared individualised, therapeutic, community and foster family-based intensive services to no treatment or existing foster care services. Review two (covering 13 studies) and Review three (covering five studies) compared therapeutic foster care to group care (bringing together a small number of young people in group homes).
Review one contributes to all but the moderators section. Review two contributes primarily to the effect, mechanism and moderator sections, and Review three contributes to all sections.
Across the three reviews, the crime outcome measures are changes in delinquency (unspecified including reconviction and arrest) and anti-social or undesirable behaviour, using both self-reported measures and officially recorded crime statistics.
The primary studies included in the reviews are were based on evidence from the UK, Sweden, and the USA.
Effect – how effective is it?
Overall, the evidence suggests that therapeutic foster care has reduced crime.
A meta-analysis in Review one, covering two of the five studies, found statistically significant reductions in the number of criminal referrals of young people who had completed therapeutic foster care, at both 12 months and 24 months after the programme had ended.
Criminal referrals were defined as all officially reported misdemeanour and felony offences on the young peoples’ records.
The meta-analysis also found significant reductions in the total number of days in secure settings for treatment groups compared to control groups, at both 12 and 24 months after the programme had ended.
These secure settings included detention, correctional facilities and prison.
All three primary studies that reported criminal outcomes in Review one saw statistically significant reductions in anti-social behaviour for the group that had therapeutic foster care.
Review two reports that therapeutic foster care was estimated to prevent nearly half of delinquent or criminal acts over the one- to three-year follow-up compared to group care.
However, the reduction was not found to be statistically significant. Despite the promising effect of therapeutic foster care, there are limitations across many of the individual studies that lessen the inferences that can be confidently drawn.
Review three reports that therapeutic foster care for juveniles with a history of chronic delinquency reduced violent crime by 71.9% in comparison to the control group (young people receiving other residential treatment within the community).
How strong is the evidence?
Reviews one and two were sufficiently systematic that many forms of bias that could influence the study conclusions can be ruled out.
Review three was sufficiently systematic that few forms of bias that could influence the study conclusions can be ruled out.
Review one considered many elements of validity, conducted relevant statistical analyses and used quality assurance to ensure the accuracy of the information collected from primary studies.
The review authors only combined studies with similar outcomes and the review was restricted to the studies of highest design quality – randomised control trials.
However, the review did not take into account possible unintentional outcomes.
Review two, while well designed, highlighted a number of concerns about the individual studies. Primarily, a large number of the individual studies were conducted by the same team, residences were generally poorly defined and diverse in structure (for example, ranging from two to more than 25 young people per home, sometimes within the same study), and adherence to the principles of treatment foster care varied greatly across the groups.
As such, the review authors caution that the findings should be viewed as suggestions rather than assured knowledge.
Review three is a systematic review covering five studies, which demonstrated high quality in terms of having a transparent and well-designed search strategy.
No meta-analysis was conducted and Review three did not sufficiently assess the risk of bias in the analysis, separate analysis for distinct evaluation research designs or quantify an overall effect for unanticipated outcomes, such as displacement caused by the intervention or conduct.
Mechanism – how does it work?
The reviews suggested a number of mechanisms by which therapeutic foster care might have an effect on crime.
- Review one suggested that therapeutic foster care helps troubled young people (who would otherwise find themselves in more restrictive non-family, foster care environments) by providing more organised and experienced support. It is through a network of specialists and trained caregivers, in greater numbers and skill, that therapeutic foster care can manage situations deemed too demanding in other care programs. This allows more focus and interaction with the participants on a therapeutic level, allowing for more chances to encourage greater self-esteem, personal growth and prosocial behaviours.
- Reviews two and three also suggested that the interactions between young people and their foster carers are crucial to changing behaviours. Therapeutic foster care provides structured and supportive parenting for young people whose parents are unable to provide this. Foster carers play an important role in socialising young people into prosocial behaviours. Young people are taught responsible family behaviours by foster carers and are trained to improve school attendance, relations with teachers and peers, and homework performance.
- Reviews two and three suggest that therapeutic foster care separates the young person from his or her delinquent peers, whereas placement in group homes (the usual intervention for chronically delinquent young people) often results in increased exposure to delinquent peers. This can lead to the development of shared anti-social identities amongst residents and intensify aggressive and delinquent behaviours.
Moderators – in which contexts does it work best?
The reviews note that the effect of the intervention might differ by age, sex and background.
- Age – Review three reported that effects on younger children (5 to 13 years old) were inconsistent and suggested slight but no statistically significant increases in undesirable behaviours. Effects on the older group (12 to 18 years old) were more positive, showing that the median effect on violence by juveniles with a history of chronic delinquency is a 71.9% reduction in violent crime in comparison to a control group (young people receiving other residential treatment within the community).
- Sex – Review three also noted that, in two studies, the results for girls and boys were similar. However, one study noted that behavioural problems in therapeutic foster care might increase for girls (which was also seen in one study in Review one).
- Background – three studies in Review three indicated that characteristics of a young person’s background and prior environment may hinder the effectiveness of therapeutic foster care, in particular young people with a history of being sexually abused and those from family backgrounds where parents have a history of crime or chronic drug abuse.
However, the reviews did not analyse or test these moderating variables.
Implementation – what can be said about implementing this initiative?
Review one noted that implementation should centre on the support available to the foster carers and young people (with respect to regular meetings and therapeutic and clinical services being available).
In addition, the young people should be closely supervised in the home and school setting, and contact with delinquent peers prohibited. It was made clear that any infringements of the rules should result in a direct consequence.
Review one also noted that for girls in particular, the foster care needs to address emotional and psychiatric conditions that reportedly often appear alongside delinquency (and which may contribute to it, or cause impediments to treatment).
Girls were taught skills to avoid social-relational aggression as this was seen as a particular problem. Social or relational aggression is a type of bullying that damages someone’s relationships or social standing, for example, through exclusion from social activities or spreading rumours about the victim in front of others.
Review three also mentioned some barriers to implementing therapeutic foster care, including difficulty recruiting, training, and retaining suitable foster families.
It was reported that recruitment and training must be conducted year-round in order to maintain a group of well-trained foster parents.
It was also noted that providing an additional monthly stipend to the normal reimbursement rate increased foster parent retention.
Economic considerations – how much might it cost?
While none of the reviews conducted a cost-benefit analysis, or attempted to synthesise evidence about programme costs, Reviews one and three provided evidence of costs from individual studies where this was available.
Review one reported the costs of therapeutic foster care in 1991 ($3,000 per month per participant) compared to the control group, who were in the state mental hospital ($6,000 per month per participant).
This led to an average saving of $10,280 per participant in hospitalisation costs for those who were placed in therapeutic foster care.
The review also noted that while therapeutic foster care was more expensive than regular foster care, it is less expensive than residential care.
Review three reported one study that saw average programme costs of $18,837 per young person in 1997.
These costs included personnel (case manager, programme director, therapists, recruiter and foster parent trainer), foster parent stipends and additional health services such as mental health care.
A second study in Review two reported a cost-benefit analysis of therapeutic foster care compared to standard group care.
The additional cost per participant for therapeutic foster care was $1912 in 1997, but the total net benefits for programme participants ranged from $20,351 to $81,664.
All of the studies were conducted in the USA, and four of the five studies from Review one were from one implementation team in Oregon, USA. Findings may not be transferable to different contexts, including the UK.
Overall, the evidence suggests that therapeutic foster care has reduced crime.
Significant reductions in the number of criminal referrals and the days in secure settings were seen for participants compared to control groups.
Therapeutic foster care is believed to work by removing young people from delinquent peers and providing supervision and structure by foster carers who encourage prosocial behaviours.
Placement of seriously at-risk young people in less restrictive environments such as therapeutic foster care (as opposed to secure facilities) is preferable.
The core components of therapeutic foster care are well documented, but the number of studies remains low and more research is needed to investigate the effectiveness of this programme in the UK context.
MacDonald, G.M. and Turner, W. (2007) 'Treatment foster care for improving outcomes in children and young people', Campbell Systematic Reviews 2007:9, DOI: 10.4073/csr.2007.9
Osei, G.K., Gorey, K.M. and Hernandes Jozefowicz, D.M. (2016) ‘Delinquency and Crime Prevention: Overview of Research Comparing Treatment Foster Care and Group Care’, Child Youth Care Forum 45: 33-46 DOI: 10.1007/S10566-015-9315-0
Hahn, R. A., Bilukha, O., Lowy, J., Crosby, A., Fullilove, M. T., Liberman, A., Moscicki, E., Snyder, S., Tuma, T., Corso, P. and Schofield, A. (2005) 'The Effectiveness of Therapeutic Foster Care for the Prevention of Violence: A Systematic Review', American Journal of Preventative Medicine, 28:2S1, 72-90
Summary prepared by
This narrative was prepared by UCL Jill Dando Institute and was co-funded by the College of Policing and the Economic and Social Research Council (ESRC). ESRC grant title: 'University Consortium for Evidence-Based Crime Reduction'. Grant reference: ES/L007223/1.