In my last blog post, I suggested that the District needs to get rid of its poorly performing foster homes and that it should consider placing some of its older and more troubled teens in family-style group homes instead of foster homes. Many people will respond negatively to this suggestion. The prevailing wisdom today is that foster homes are better than group homes for almost all children. However, this common wisdom is based on a misinterpretation of available research, which is quite limited.
While it is commonly argued that evidence shows foster care to have better outcomes than group care, this conclusion is based on a few studies comparing group homes with a specialized model of foster care called Multidimensional Treatment Foster Care (MTFC). In the foster homes studied, parents were expected to implement an individualized behavior management system to reinforce clients’ strengths and provide consequences for problem behaviors. Foster parents were supervised during weekly group meetings and daily telephone calls. School performance was monitored daily with a daily school card signed by the teachers. Clients participated in therapy weekly with therapists who were employed by the program and had training and supervision in the same behavioral techniques used by the foster parents. Children’s behavior was tracked daily and used to adjust treatment in the foster home..1 The District of Columbia does not have MTFC or any other similarly intense Treatment Foster Care model. The District has two types of foster care, “traditional” and “therapeutic.” “Therapeutic foster care,” designed to serve more difficult clients, provides a higher reimbursement rate to foster parents but does not require anything of beyond additional training. The therapeutic homes that I have seen in my five years of practice are indistinguishable from traditional homes except in the nature of the children. Many of the non-nurturing foster homes that I described in my last post are so-called “therapeutic foster homes.”
Even the conclusion that MTFC is more effective than group care is open to question. Dr. Bethany Lee of the University of Maryland School of Social Work is one of the nation's leading experts on group care. She points out that there are several methodological problems with the existing comparative studies between group care and foster care, including poor response rates, small sample sizes, and the lumping together of different types of group homes. In her own study, she and her co-author, Dr. Ronald Thompson, attempted to minimize these limitations. Comparing youth who received treatment foster care through BoysTown with youth who participated in Boys Town family-style group homes, they found that the youth in group care were more likely to be favorably discharged, more likely to return home, and less likely to experience a subsequent formal placement than the foster care youth. No differences were found in subsequent legal involvement or the likelihood of living in a homelike setting six months after discharge.2
It is important to note that Boys Town group homes differ from the traditional group home, which is staffed by shift workers. In the Boys Town Family Home Program, six to eight boys or girls live with a married couple in a single-family home. The home functions like a family, where every child attends school, participates in extracurricular activities, and take part in daily chores and family activities. This type of family-style group home looks more like a foster home than like a shift-style group home, as I learned when I visited a Boys Town group home in Washington, DC. The “Teaching Parents” who run the home with the help of two Assistant Teaching Parents who work in the afternoon and evening, have a wall full of pictures of young men who have graduated from the home and who often come back for visits. All of their children have grown up in the home, which is bright, sparkling and immaculate—especially compared to some of the dark, dingy foster homes where some of our children are placed. Based on extensive research documenting positive impacts, the Family Home Model was found to be a promising practice in an exhaustive review of the research by the California Evidence-based Clearinghouse for Child Welfare (www.cebc4cw.org/).
As Boys Town researchers point out in an excellent publication available on their website, “Many organizations like Boys Town acknowledge and agree that at-risk youth should be served in their own homes or in foster care whenever possible, and have already made a shift to that approach....But even with that shift, we still known that these less-restrictive approaches cannot meet the needs of all youth, particularly those with serious behavioral and emotional problems.” Anyone who has worked with these youth, as I have, and seen them expelled from home after home, knows how true that statement is. It is not without cost to let children bounce from home to home. Placement disruptions cause trauma, may require a change of school, and lead to further emotional and behavioral problems. Eventually these youth may end up in a residential treatment center or in the criminal justice system--or even homeless. (See www.boystown.org/quality-care for more information about the reasons why group care is the best option for some youth.)
Incredibly, Boys Town operates only one Family Home under contract with CFSA. The other three homes on Boys Town's DC campus serve clients of the Department of Youth Rehabilitation Services (DYRS). CFSA reported to the DC Council on February that only 4% of its youth, or 42 in total, are in a group care setting. This compares to 57 in 2013, and more in prior years. CFSA terminated two group home contracts last year. Of course every child should be in the least restrictive setting capable of meeting his/her needs, but I think CFSA and other agencies around the country are hurting children by denying them the higher level of care that they need. And I can't help feeling that saving money is part of the motivation behind this misguided policy.
Yes, quality residential care costs money. But not providing the level of services needed by our most troubled youth costs even more. A study published in 2008 found that saving a 14-year-old high risk juvenile from a life of crime will save taxpayers between $2.6 and $5.3 million in costs due to crime, drug abuse, and lost productivity.
What about treatment foster care programs like MTFC? Some advocates might argue for investing in that approach rather than in group homes. I think that some of the children who are now struggling in so-called therapeutic foster homes could benefit from true therapeutic or treatment foster care, which provides the same type of structure and supervision that is provided by Boys Town group homes. However, it is not reasonable to expect that many of our current foster parents, most of whom work full-time, would be able to take on this demanding job, or that many new foster parents could be recruited. Although there is no national data on the number of children in intensive treatment foster care programs such is MTFC, most programs seem to be small. One of the best-known programs is operated by Anu Family Services in Wisconsin and Minnesota. Anu states on its website that it received 800 referrals last year and were able to find homes for less than 60 children. Probably the only way to expand treatment foster care to all the children who need it would be to pay the foster parents for full-time work. That would make treatment foster care more expensive than family-style group care, since we would be paying people full-time to care for only one or two children. In my view, a family-style group home such as those operated by Boys Town provides all the benefits of treatment foster care in a more efficient manner. And it is more amenable to expansion since being a Teaching Parent is a full-time job that appeals to people who love and care about children but want to do it as a full-time job.
1. Chamberlain, Patricia and Reid, John, Comparison of Two Community Alternatives to Incarceration for Chronic Juvenile Offenders. Journal of Consulting and Clinical Psychology 1998. Vol. 66, NO. 4, 624-633.
2. Lee, Bethany R. and Thompson, Ron, Comparing Outcomes for Youth in Treatment Foster Care and Family-Style Group Care. Child Youth Services Review, 2008: 30(7): 746-757.
3. Thompson, Ronald, Huefner, Johnathan, Daly, Daniel, and Davis, Jerry, Why Quality Residential Care is Good for America’s At-Risk Kids: A Boys Town Initiative, available from http://www.boystown.org/documents/quality-care/why-quality-care.pdf.
4. Cohen, Mark A. and Piquero, Alex R, New Evidence on the Monetary Value of Saving a High Risk Youth. Journal of Quantitative Criminology (2009) 25: 25-49.