Current TFC knowledge base: What do we know and how can we move forward?

1. Current TFC knowledge base: What do we know and how can we move forward? Elizabeth M.Z. Farmer, Ph.D. School of Social Work Virginia Commonwealth University

2. Overview • What is the status of evidence-based treatment for TFC? • What do we know about improving treatment and outcomes in TFC? • Current possibilities and challenges

3. What is TFC? • Least restrictive treatment-focused residential placement • Conceptually appealing combination of treatment and opportunities for prosocial, ‘normal’ experiences in family- and community-based setting • Differs from regular foster care: • Training for treatment parents • Supervision of treatment parents • Treatment Parents viewed as front-line treatment providers rather than ‘just’ parent substitutes • Differs from other residential treatment options: • Provided in treatment parents’ own homes • Ideally only 1 child placed per home • Currently highly regarded • Evidence base • Less expensive than other residential options (1/3 – 1/2 daily rate of group home)

4. Current Status of Evidence-based Treatment in TFC

5. Treatment Foster Care Evidence Base • Currently 2 overall models have empirical evidence: • MTFC (Multidimensional Treatment Foster Care) • Began in late ‘70s • 2 primary RTCs (Chamberlain and colleagues; Oregon) • Outcomes compared to other more restrictive placements • Findings show decreased problem behaviors, increased prosocial behaviors, more rapid improvement than in more restrictive placements, sustainability for period after discharge • Currently disseminated to approximately 150 agencies • TFTC (Together Facing the Challenge) • Began in early 2000s • 1 RTC(Farmer and colleagues; North Carolina) • Outcomes compared to “usual care” TFC • Findings show improve practice and youth outcomes (strengths, symptoms, behaviors) • Differences between TFTC and “usual care” TFC remain significant for behaviors by 12 months • Currently disseminated to approximately 30 agencies

6. Overview of Evidence Base • Existing data show: • Youth improve while in TFC • Improvements better than in comparison setting (group homes, psychiatric hospitals, juvenile detention) • TFC is substantially less expensive than comparison settings • Training/consultation approach can improve practice to create better outcomes within TFC • Things to keep in mind: • MTFC and TFTC being used in approximately 200 agencies • There are approximately 3,500 TFC agencies in the US • Therefore, about 5% using one of 2 EBTs • Lots of challenges in implementing improved TFC into existing settings

7. What’s currently happening in TFC? • Sample of 113 TFC agencies from across the country (all from FFTA membership list) • 40% reported that they were using an “evidence-based model” • Include MTFC and TFTC • Also include wide range of other evidence-based and promising models: • Boys Town’s model, Pressley Ridge Model of Care, Re-Ed, TF-CBT, NCTSN-informed trauma model, Positive Behavioral Supports, etc.

8. Core Elements – across ALL respondents

9. What do we know about improving practice and outcomes in TFC?

10. Example from work to develop TFTC • Funding starting in 1998 to improve TFC: At that point, Chamberlain’s model was “it” – highly regarded, but little known about what other TFC providers were doing. NIMH has funded us to do a series of studies: • 1998-2002: observational -- What does usual care TFC look like? • Does it conform to MTFC model or FFTA Standards of Care? • Is “better” TFC related to better outcomes? • State-wide sample of 45 TFC agencies • 183 youth and their Treatment Parents • Longitudinal data while youth were in TFC and for up to 24 months post-discharge

11. Overview of Findings from Initial TFC Study • Tremendous variation in TFC • Few (if any) programs closely resembled Chamberlain’s model • Moderate and wide-ranging conformity to FFTA standards of care • However, when they were in place, factors from standards of care and components of Chamberlain model were associated with positive outcomes in ‘real world’ practice

12. Relationships between core components and outcomes • Improved outcomes for youth associated with: • Closer supervision of youth (p<.10) • Increased training for treatment parents (p<.05) • Increased supervision of treatment parents by supervisors (p<.05) • Quality of relationship between treatment parents and youth (p<.001)

13. Why not just implement existing “evidence-based” model? • Key differences between “usual care” TFC and existing evidence-based version • Little use of proactive behavior management strategies – and active opposition to points/levels • Length of stay in TFC • Oregon model was explicitly 6-9 months • Half of our sample remained in TFC for longer than 2 years • As length of stay increased, both focal concerns and key factors related to outcomes shifted • Emergent issues • Treatment of prior trauma and sequelea • Preparation for the future/adulthood • Key Factors affecting outcomes • Early = Supervision of treatment parent • Long-term = Parent/child relationship

14. Therefore, TFC in a System of Care (Randomized Trial) • Randomized trial to develop and test Enhanced Long-term TFC • “Together Facing the Challenge” • 2003-2009 • Worked with subset of agencies from initial study • Half of agencies implemented Enhanced TFC; other half provided ‘usual care’ • N= 14 agencies; 247 youth/families

15. Together Facing the Challenge

16. TFTC Overview • 3-day training with agency staff/TFC supervisors • 6-week training with parents • 12 hours (2 hours/once a week) • Monthly (and as-needed) consultation with TFC supervisors for 12 months • 2-day training with therapists on TF-CBT • Follow-up consultation for 6 months

17. Overview of Outcomes at 6 months Percent showing improvement

18. Moving Forward from Positive Findings….. • Continuing to examine key mechanisms: • Improved supervision of TPs, improve supervision of youth, increased consistency of behavioral approaches (praise and consequences), etc. • Examining “fit” and contextual issues: • Agency characteristics, TP and youth characteristics • For whom, under what circumstances, does MTFC seem to work best? • Working on more cost-efficient/effective ways to disseminate, implement, and support sustainability • Train-the-trainer (agency-led training for TPs) • Improving supports/infrastructure for TFC supervisors • Ongoing work with key collaborating agencies to fully implement • Figuring out organizational capacity, readiness, change factors • Incorporating more systematic use of data to support and inform service provision

19. Challenges…… • Implementing evidence-based models • Whole field of implementation science – in infancy in TFC • TFC is widely practiced – therefore, challenge of changing practice • Long process – not a “quick fix” • Learning from existing practice • Need data on effectiveness of other practices in TFC – beyond MTFC and TFTC • Studies of “real world” best practices to determine evidence • Funding • TFC is a misunderstood treatment approach • Often confused with Foster Care • Perhaps need to new name? Individualized Treatment Home? • Funding mechanisms and levels that support full range of services • Clear determination of eligibility and considerations for changes • Post-discharge follow-up/coordination/continuity • Preventing recidivism/supporting gains/achieving permanency

20. Discussion • TFC is unique in its evidence base among community-based residential options • Tremendous potential • Significant challenges to realize potential • Need active collaboration between research, practice, policy – and need it quickly • Questions and Discussion????