Study Review

Treatment foster care

A specialist type of foster care placement for children who have more complex needs, who may be at risk of placement breakdown

Outcome Overall

This rating shows how effective the intervention is at achieving the evaluated outcome.

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Strength of

This rating shows how confident we can be about a finding, based on how the research was designed and carried out.

Child behaviour Overall effectiveness: mixed (maximum 2) Strength of evidence : 2 (maximum 3)
Placement stability Overall effectiveness: mixed (maximum 2) Strength of evidence : 1 (maximum 3)

Headline points

  • This summary comes from the original systematic review: Turner, W., & Macdonald, G. (2011). Treatment foster care for improving outcomes in children and young people: A systematic review. Research on Social Work Practice, 21(5), 501-527
  • Some evidence that treatment foster care improves outcomes but the overall picture is mixed
  • It may be more effective for boys and older children
  • Evidence was from the USA so may not be generalisable to the UK

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What is this?

Nearly 11 per cent of the children who left care in England in 2017-18 had experienced five or more separate placements and 730 of these children had experienced at least 10 placements. Treatment foster care is designed to reduce the risk of looked after children experiencing multiple placements and is targeted at those who are more vulnerable to poor outcomes (e.g. due to neglect, trauma, poor mental health, antisocial or offending behaviour or serious medical conditions). Treatment foster care involves providing foster carers with specialist training to help them manage challenging behaviour and have insight into the needs of children who have suffered abuse and neglect. Foster carers are also given routine support from staff with expertise to help them manage challenging situations. Children have direct support from other services, including therapeutic services.

How is it meant to work?

Treatment foster care is meant to work by enhancing foster carers’ caring skills, so that they are able to positively influence children’s behaviour and mental health. Children also have access to direct therapeutic input from mental health services. Foster carers are well supported to help them cope with the demands of caring for children with complex needs and thereby reduce the risk of placement breakdown associated with stress and burnout. If children are involved in offending or anti-social behaviour, action is taken to reduce the influence of negative peer networks and strengthen positive relationships.

What are the evaluated outcomes?

  • Child behaviour
  • Placement stability

How effective is it?

Child behaviour

Overall, treatment foster care had a mixed effect on child behaviour. This means that while some studies found a significant effect, others did not. This is based on moderate strength evidence.

Placement stability

Overall, treatment foster care had a mixed effect on placement stability. This means that while some studies found a significant effect, others did not. This is based on low strength evidence.

These findings are based on a review of five studies reporting on randomised controlled trials. Across all outcomes investigated in the review (including child behaviour, antisocial behaviour, foster carers’ outcomes and placement stability), there were some significant effects, but overall the picture was of mixed evidence about effect.

Where has it been studied?

The five studies reported on in this review were all carried out in the USA (four in Oregon and one in Florida). This means that the findings from these studies may not be generalisable to the UK. Since the review was published in 2011, research from Sweden and the UK has also been published. These last two studies were not included in this review, but their findings are broadly consistent.

Who does it work for?

The studies included in the review provided treatment foster care for:

  • Children and young people aged 9-18 years old, who were in psychiatric hospital with severe emotional disorders and needed care placements
  • Children who were in foster care due to experiences of abuse or neglect, who already had emotional and behavioural problems or were at risk of developing them
  • Boys aged 12-17 years old who had histories of offending behaviour
  • Girls aged 13-17 years old who had histories of offending behaviour

Sub-group analysis carried out in the review indicated that treatment foster care might be more effective for some groups than others. One study found that the intervention was more effective for boys than girls. Age had a moderating effect on placement stability. There were only significant differences between the treatment and control groups on the amount of time spent in placement for older children (aged between 11.5 years and 16 years). There are also indications that treatment foster care is a more promising intervention for children with conduct disorders and offending behaviour.

When, where and how does it work?

Details of how treatment foster care was implemented in each study are provided below. The review does not identify any variants on the intervention models that made them more or less effective. The review highlights evidence from one study showing that treatment foster care was more effective in reducing young people’s offending behaviour (and particularly violence) if foster carers provided consistent responses to challenging behaviour, supervised the young person closely and separated them from negative peer influences.

What are the costs and benefits?

The review did not include any economic analysis as none of the studies included cost-benefit data.

One study, which tested treatment foster care with young people who would otherwise have been cared for in an inpatient mental health unit, did report on costs per young person. These were $3,000 per month for young people in a treatment foster care placement and $6,000 per month young people in a psychiatric hospital (the comparison group). The researchers estimated that on average $10,280 was saved over the course of the study per young person who was in treatment foster care rather than a psychiatric hospital. These costings are not generalisable to young people who would otherwise have been in a foster care or residential placement.

How is it implemented?

The treatment foster care models described in the five reviewed studies took a variety of forms. Three of the studies tested “multidimensional” treatment foster care models and included the following elements:

  • Training foster carers who had been selectively recruited
  • Implementing a programme for managing the child’s behaviour at home and in community settings
  • Creating a tailored treatment plan for each child
  • Supporting foster carers through daily phone calls and weekly group meetings
  • Providing additional support services, with case managers available at all times to support foster carers and birth parents as needed.

Two of these models were specifically designed to help reduce offending behaviour and therefore also included the following additional elements:

  • Meetings with foster carers and children to deal with any problems arising
  • Weekly family therapy for the birth family (or alternative carers where relevant) focused on how they would provide the child with supervision, encouragement, discipline and general problem-solving
  • Enrolling the child in education and supporting the school with behaviour management
  • Weekly individual therapy for the child (and psychiatric oversight as needed)
  • Close supervision of the child’s whereabouts and prohibiting contact with negative peer groups as needed
  • A system of agreed sanctions for when the child broke rules
  • Reporting all parole violations
  • A phased approach to returning to the birth family (if this was the plan), starting with short visits.

There were also two studies that tested less intensive models, which had fewer components. These models were focused on supporting young people who had experienced abuse or neglect. The first of these two models involved providing foster carers with weekly two-hour group support meetings with a facilitator who had experience of being a foster carer and had been trained in child behaviour management and group facilitation. Foster carers also received three phone calls each week to review the child’s progress and provide support where needed.

The second model, called the Fostering Individualized Assistance Programme, enhanced standard foster care provision by employing a strengths-based approach to assessment; support with planning how to meet the needs of the child and their family; clinical case management to offer intensive, individualized support to the child in their placement; and follow-up services to help maintain changes and support further progress.

The review did not include information about the combinations of professionals who were involved in delivering the treatment foster care interventions or about how model fidelity was maintained.

In summary...

  • The five studies included in the review showed that there was some evidence that treatment foster care had improved children’s outcomes. However, overall the picture was mixed and there were no consistent effects
  • Some studies indicated that treatment foster care is a promising intervention for children and young people who have mental health problems, behavioural problems or problems with offending. It may be more effective for boys and for older children
  • Treatment foster care may be more effective in reducing children’s offending if they are closely supervised by their foster carer, receive consistent responses to challenging behaviour and are separated from negative peer groups
  • The findings from this review are based on research conducted in the USA, so they may not be generalisable to a UK context.

Further resources

This summary comes from an original systematic review called: Treatment Foster Care for Improving Outcomes in Children and Young People: A Systematic Review. (Turner, W. & Macdonald, G.). Published 2011.