Institutions Vs. Foster Homes the Empirical Base for a Century of Action

Institutions vs. Foster Homes The Empirical Base for a Century of Action

Richard P. Barth Jordan Institute for Families School of Social Work 301 Pittsboro Street University of North Carolina at Chapel Hill Chapel Hill, NC 27599-3550

June 17, 2002 ACKNOWLEDGEMENTS AND CITATION INFORMATION This report could not have been completed without the able assistance of C. Joy Stewart and Mercedes H. Moore. The report has been sharpened through discussions or corre- spondence with Neil Halfon, Carole Shauffer, and Joy Warren. I am grateful to the Youth Law Center and the Annie E. Casey Foundation. Points of view or opinions in this report are those of the author.

The recommended citation for this report is Barth, R.P. (2002). Institutions vs. Foster Homes: The Empirical Base for the Second Century of Debate. Chapel Hill, NC: UNC, School of Social Work, Jordan Institute for Families TABLE OF CONTENTS

Executive Summary ...... i

Section 1 Background ...... 1 Types and Uses of Institutional Care ...... 2 Background on Group Care and Placement Processes ...... 3 1.2.1 How Different are Children in Institutional Care? ...... 3 1.2.2 Children’s Perception of Types of Out of Home Care ...... 4 1.2.3 Community-based Group Homes from the Child Welfare Worker’s Perspective ...... 6 Social and Developmental Science Perspectives on Group Care ...... 6 Critique of RTC Using Research on Therapist Efficacy and Parenting . .6 The Surgeon General’s Report on Children’s Mental Health ...... 7 Perception of RTCs from the provider perspective ...... 8

Section 2 Outcomes of Out of Home Care ...... 9 Safety and Well-Being ...... 9 Abuse of Children in Institutional Care ...... 9 Exposure to Violence in Out of Home Care ...... 11 Education and Residential Treatment ...... 13 Education of Children in Group Care ...... 14 Group Care and Developmental Concerns for Young Children ...... 15 Permanence/Re-Entry ...... 16 Placement Instability ...... 16 Family Centered Residential Care ...... 16 Likelihood of Long Term Care ...... 18 Residential Mental Health Group Care for Child-Welfare-Supervised Children in California ...... 19 Re-entry Rates ...... 19 Placement Disruption Rates ...... 20 Long-Term Success/Adult Outcomes ...... 21 Long-term Effects of Foster Care and Group Care ...... 21 Treatment Foster Care vs. Group Care ...... 22 After Group Care ...... 24 2.5 Cost ...... 25 Section 3 Policy and Program Implications ...... 26 Alternatives To Group Care Should Be Pursued ...... 26 3.1.1 Foster Care and Treatment Foster Care are More Desirable and Efficient than Institutional Care ...... 26 3.1.2 Centralized Emergency Shelters are Not Necessary and are Likely to Be Inefficient ...... 26 3.1.3 An Alternative: Receiving Centers Plus Emergency Foster Care or Small Group Care ...... 29 Special Problems that Group Care Can Help Solve ...... 29 3.2.1 Youth Who Have Previously Run Away From Foster Care . .29 3.2.2 Youth Who Are Destructive ...... 30 3.2.3 Youth Who Are Stepping Down to Their Home from More Restrictive Care ...... 31 Summary ...... 31 References ...... 32 Glossary of Types of Out-of-Home Care ......

LIST OF EXHIBITS Exhibit 1. Proportion of Clinical/Borderline Scores by Type of Out-of-Home Placement ...... 3 Exhibit 2. Perceptions of Children (ages 6 and Older) in Out-of-Home Care ...... 5 Exhibit 3. Caregivers by Age and Placement Type ...... 10 Exhibit 4. Incidents Experienced by Children by Type of Out-of-Home Care (in %) ...... 12 Exhibit 5. Rate of Re-entry by Age and Placement Type ...... 20 Exhibit 6. 1989-1995 Entries: First Spell Median Length of Stay by Placement Type ...... 23 Exhibit 7. 1988 -1991 Entries: Permanence Index at 4 Years by Placement Type ...... 23 Exhibit 8. Functions and Performance of Forms of Emergency Care ...... 28 EXECUTIVE SUMMARY tive intervention. The Surgeon General’s Report on Children’s Mental Health (US he debate about the role of institu- DHHS, 2000) confirms this theoretical tional care vs. family-centered care analysis, finding little to recommend about Tis well into its second century. group care. From the perspective of Institutional (or group) care has many providers, however, residential treatment forms and purposes, including serving as a centers are quite successful at accepting chil- component of the child welfare services dren who come from, or would go to, higher system of care and as a treatment compo- levels of helping them step down to less nent of the children’s mental health sys- restrictive settings. tems system of care. Within the child welfare role, institutional care may be used as Outcomes of Out of Home Care a large or small shelter care facility, as a This review considered four components of place for children to go when family care service outcomes: safety and well-being of is not immediately available, and as a place children while in care, permanence/re-entry where children go who have not been able from care, long-term success of children in to be maintained in foster family care. The out of home care, and the costs of out of varied roles of institutional care make an home care. analysis of its efficacy difficult. This is Children in institutional care may expe- made more difficult because of the lack of rience less chance of abuse or neglect while third-party studies of institutional care and, in care, although the rates of abuse of chil- more generally, of out-of-home care. dren in all forms of care are low. Children in group care almost certainly also have Children in Group Care fewer interpersonal experiences that support One of the justifications for placing chil- their well-being, including the chance to dren in group care is that their behavior is develop close relationship with a significant substantially worse than could be managed individual who will make a lasting, legal in foster care. Recent evidence indicates commitment to them. These disadvantages that the children in group care are older of group care for developing relationship and, in general, have more problems than skills may hold for children of all ages, but children in kinship care of foster care. Yet, are most clearly demonstrated for young there are children served in foster care and children. For more than 50 years, a variety kinship care who do not have significantly of studies have shown that young children worse developmental and mental health fare better in family like settings than in conditions than children in group care. institutional care. Although educational problems are Perceptions of Group Care endemic to children in out-of-home care, Because of the scarcity of research on the these may be exacerbated for children in outcomes of different types of out of home group care because such placements limit care, perceptions of out of home care the options of children to be involved with become a useful source of data. Children and such positive aspects of the schools as youth have quite negative perceptions of extra-curricular activities. The opportunity group care (compared to foster care or kin- that group care programs have to provide ship foster care). Even child welfare workers educational instruction with greater indi- do not have uniformly positive views of the vidualized attention appears not to be con- quality of community based group care, indi- sistently realized. This is in part because cating that it is often poorly run. From the the high levels of structure make it very perspective of research on parenting and on difficult to allow children to pursue their efficacious mental health counseling, group individual development in academic and care appears to have a low likelihood of extra-curricular activities. being able to provide a powerful and posi-

Institutions vs. Foster Homes i Placement Stability and Re-Entry Policy and Program There is little solid evidence about the sta- Implications bility of placements in different types of placements. Kinship care and treatment Alternatives To Group Care Should foster care may have lower placement dis- Be Pursued ruption rates, although the evidence is dif- Evidence from a few studies indicates that ficult to interpret with confidence.Youth foster care and treatment foster care are exiting from group care and from foster more desirable and efficient than institu- care are more likely to be reunified than tional care and their development should children in kinship care. Children who be treated as the priority of policy makers leave group care to reunification have and program developers. The budgetary higher re-entry rates than children in other commitments to group care are substantial- types of settings. Family-centered residen- ly greater than they are to any other form tial care is evolving as a component of the of out of home care—a situation that mental health services system of care, and should be examined and corrected in a appears to have a positive impact on the variety of ways. likelihood of a successful reunification. Centralized emergency shelters are not a necessary or efficient way to bring children Long-Term Success/Adult Outcomes into out-of-home care. Many municipalities An important review of studies on the out- have stopped using centralized emergency comes of out-of-home care indicates that shelters and successfully provide entry into young adults who have left group care are care on an emergency basis, provide com- less successful than those who have left prehensive assessments of the children, and conventional care—a finding which is like- take care to make appropriate and safe ly to be partially attributable to the selection placements into foster family homes. of more troubled children into group care. Receiving centers are a relatively new com- Yet, recent evidence does indicate that the ponent of the child welfare services system youth in group care and other forms of out of care that can supplement the traditional of home care, at one year following place- placement process in order to provide some ment, have poorer scores on developmental of the functions of emergency shelters with- measures. Because of its structure and the out the costs or risks. Other alternatives to expectation that group care will take total shelters can be pursued. responsibility for the child (McKenzie, 1999), group care often fails to provide real Special Problems Group Care life opportunities—like doing chores or Can Help Address preparing or purchasing food—that youth Group care can provide services that may be need to prepare for independent living. more difficult to successfully provide for some special groups of youth. Youth who Cost have previously run away from foster care The costs of institutional care far exceed may be more able to be served in a more those for foster care or treatment foster remote or highly supervised setting. Youth care. The difference in monthly cost can be who are destructive or self-destructive may 6 to 10 times as high as foster care and 2 to also need a more restrictive setting, although 3 times as high as treatment foster care. some treatment foster homes can also serve Since there is virtually no evidence that this population of youth. Youth who are in these additional expenditures result in bet- process of stepping down to their home ter outcomes for children, there is no cost- from more restrictive mental health or pro- benefit justification for group care, when bation settings may benefit from a family- other placements are available. centered group setting until parental and community supports are in place. ii Institutions vs. Foster Homes Summary Placement in group care settings is not an essential component of child welfare services systems of care for the vast majority of children. There is no substantial evidence to support the necessity or value of large centralized emergency shelters or residential treatment centers for most children involved with child welfare services. The costs of these placements are so much higher than other placements, yet their efficacy appears to be no greater. Therefore, their use cannot be justified on a cost-benefit basis if any other levels of care can provide a safe place for children.

Institutions vs. Foster Homes iii iv Institutions vs. Foster Homes INSTITUTIONS VS. FOSTER HOMES THE EMPIRICAL BASE FOR A CENTURY OF ACTION

Section 1.Background care. For example, in 2001, Colorado and oncerns about the role of institu- Florida entertained legislative initiatives to tional care for children are as old as give placement in group care far greater Cthe institutions. More than a third likelihood for children who were experi- of a century ago, Wolins and Piliavin encing some foster care placement instabil- (1964) summed up a century of debate on ity. The apparent rationale for these pro- institutional care and foster care, indicating posals is that group care is more stable, at that there is a role for excellent institution- least for children who are experiencing al and foster care tailored to the needs of some placement instability, than foster care the children they serve. Since their impor- and that group care is safer than foster care tant treatise, new evidence has emerged to (because there are typically more licensing reflect on this continued debate. The regulations that govern group care). review is particularly important because of In this discussion all of institutional the continued, and possibly accelerating, care will be treated as conceptually related challenges of finding enough qualified fos- because it is primarily provided by shifts of ter parents—since labor force participation unrelated caregivers. Yet this analysis will and adoption by foster parents are pressur- be more useful by optimizing the level of ing the supply of foster parents. detail that is available, because group care The direct information on this question provided at the entry into foster care is is very limited. There are almost no studies likely to have a different form and signifi- that rigorously compare outcomes for resi- cance from group care provided much later dential care and foster care among youth in a child’s placement career. The paper (cf. Chamberlain, 1998) and there are none will endeavor to make distinctions between that make that comparison for children in “shelter care” (which is planned to be child welfare services (a very few studies short-term and transitional with primary look at this issue for children receiving goals of protection and assessment, see the mental health or juvenile justice services). glossary) and “residential care/group care” There are studies that loosely compare out- (which is intended to provide shelter and comes for children who emancipated from change behavior). Although there are likely care after spending substantial time in to be important differences in service deliv- group care vs. foster home care (reviewed ery between larger campus-based institu- by McDonald, et al., 1996) but those stud- tions and smaller (6–8 bed) community- ies fail to adequately address the selection based group homes and institutions with bias—the evidence that youth who reside and without their own nonpublic schools, in group care have more problems than there is virtually no research that makes youth in foster care. Almost nothing has these distinctions. been done to address the results of placing This analysis necessarily considers younger children in group care, although placements or services that are alternatives several states have now constrain this prac- or supplements to foster care and to group tice (e.g., California and Wisconsin), based care. These include kinship foster care, on the developmental theory that young treatment/specialized foster care and children should have the chance to develop receiving centers, which inform this debate relationships with a primary caregiver because they represent important alterna- rather than with shifts of child care work- tives to the standard approaches to place- ers (Berrick, et. al., 1997). ment. (These are also briefly described in Still, questions continue to arise about the Glossary.) For the most part, the the benefits of group home care vs. foster research on institutional care does not dis-

Institutions vs. Foster Homes 1 tinguish between small and large institu- Group care may be used in some other tional care arrangements. One exception way—neither very therapeutic nor short- involves several program specific studies term. In such instances, group care use conducted at larger residential treatment may be for children without mental health centers (RTCs). In a very few studies, problems who are assigned to group care when there is information that the data because no foster care placement was were collected with regard to smaller com- immediately available or developed munity-based group homes, this distinction (Fisher, 2001). We do not know how often is preserved in this report. Otherwise, the this occurs, but the evidence from recent terms “Institutional Care” and “Group studies indicates that many children are in Care” are used to discuss the general phe- group care with levels of problems that are nomena of placements that have shift care not very different from children, of the provided by adults who are unrelated to same age, who are in foster care or kinship each other or the children in their resi- foster care. This suggests that the decision dence. to place a child in group care was not entirely or largely based on the youth’s 1.1 Types and Uses of Institutional Care need for treatment or a more restrictive set- The many forms and uses of institutional ting. Some of these findings are reviewed, care present substantial challenges to con- next. trasting the role and functioning of institutional care with other forms of out of home 1.2 Background on Group Care and care. In many cases, children will pass Placement Processes through a “children’s shelter” in route to This section provides background informa- another kind of more family like care. tion about the children in group care and These stays may only be a few hours or family foster care. The perspectives of four days, but may also last as much as a month key stakeholders—children, child welfare or year. A primary reason for originating workers, researchers, and residential treat- this review is concern about the use of ment providers—are also described. Each large group care facilities for emergency of these analyses stands on a very small shelter—a practice abandoned in many research platform. jurisdictions, in favor of using smaller units of care like foster homes or community- 1.2.1 How Different Are Children in Institutional based group homes. Because shelter care Care? has received the least of the little research Some of the rationale for use of group care done on group care, many of the conclu- as part of the child welfare services contin- sions from this report will have to rely on uum of care is based on the assumption that inferences from other tangential sources of children who are in group care are different evidence to the shelter care debate. than children in other settings. Although In many municipalities, group care is they are clearly older than other children, principally intended to provide intensive the evidence that they have worse behavior mental health services, replete with consis- is less clear (NSCAW, 2002). In the tent and high quality psychopharmacologi- NSCAW sample of children in out of home cal therapeutic interventions and is used as care for one year, children in group care at a placement of last resort. In other commu- the time of the assessment had significantly nities, group care is more often than not the more behavioral and cognitive scores in the first placement after entering care borderline or clinical range (see Exhibit 1). (Webster, 1999). Much of the critique of This appears, however, to be so because the group care—most notably, in the Surgeon group care setting provides care for older General’s report on children’s mental children. After controlling for age, children health (U.S. DHHS, 2000) is a critique of in group care do not appear to have higher group care’s role in mental health services. clinical scores than children of the same

2 Institutions vs. Foster Homes age who experienced the same abuse types and who now reside in kinship or non-kinship care. The NSCAW (2002) report also compares the scores of all the children in the sample (n=727) to each other by convert- ing their measures to z-scores. Z-scores duct prior to or while in group care. These Exhibit 1 have a mean of zero and a standard devia- findings are consistent with other studies Proportion of tion of 1. Z-scores were worse for youth in indicating higher levels of problems expe- Clinical/Borderline Scores group care (Mean = -.42) than for those in rienced by children who leave group home by Type of Out-of-Home foster homes (-.09) or kinship care (.19). care (Pecora, Whittaker, Maluccio, & Placement This analysis complements the one depict- Barth, 2000). ed in Exhibit 1, which is based on scores The NSCAW (2002) data also showed that compare the children to test norms. that children in group home care were sig- Using z-scores shows that children in nificantly more likely to receive mental group care are scoring substantially worse health services than children in kinship on standardized measures from other chil- care or foster care (when age, level of dren in the study. Another difference problems, and other factors were con- between children in group home care is trolled). Among the children in group home that these children are 3.5 Xs more likely care, 61% were receiving some form of to have experienced sexual abuse (27%) specialty mental health services (other than than children who reside in foster care or the group care itself) whereas the propor- kinship care. tions for children in foster care and kinship A regression analysis that controls for care were 28% and 13 %, respectively. [Of age, ethnicity, and the proportion of clinical particular note, children in group care are scores shows that children with higher pro- significantly more likely (p<.01) to have portions of clinical scores are more likely been served in a psychiatric hospital or to be in group care (p<.01). That this is unit.] A multivariate analysis that controls true even after just one-year in care sup- for age, gender, race, clinical scores, and ports Webster’s (1999) findings that many type of abuse determines that children in children do not work their way into group group home care are more than 3Xs more care after long spells in foster care. likely to receive specialty mental health Children in group care are somewhat more than children in foster care and 7Xs more troubled than other children in out-of-home likely than children in kinship care. care, although the overall level of problems shown by children in other out of home 1.2.2 Children’s Perception of Types of Out of care settings is also substantial. Many chil- Home Care dren who have a range of social, cognitive, Little effort has been made to compare the and behavioral problems are also in kinship perspectives of children about their living care and foster care. These findings do not arrangements. In the National Survey of buffer the interpretations made by others Child and Adolescent Well-Being, children (see for example, McDonald, Allen, 6 and older and in care for about one year Westerfelt, & Piliavin, 1996) that the poor- were asked for their view about out of er outcomes of children who age out of home care. Children living for one year in group care are attributable to the kind of out-of-home care are generally satisfied care that they are in rather than worse con- with their living arrangements and schools,

Institutions vs. Foster Homes 3 although children residing in group care inferred that children in group care differ appear to have different perceptions in sev- significantly from children both in kinship eral ways. First, they are almost 4 times as care arrangements and those in foster care likely as those in non-kin foster homes and with non-kin. Those in group care are less 10 times as likely as those in kinship care positive about their experience than chil- to report that they do not like the people dren in the other two arrangements. with whom they are living (p<.05 and Children in group care and foster care p<.01, respectively). They are more likely reported seeing their family members less to report never seeing their biological than children in kinship care. Children in father or mother (OR = 5.13, p<.05; OR = foster care were three times as likely to 4.19, p<.01). From these analyses it can be report seeing their biological mother less Exhibit 2: Perceptions of Children in Out of Home Care (N=320) Foster Kinship Group Care (%) Care (%) Care (%) Total (%) Family Visits Contact with Mom < twice per month e,f 69 39 73 60 Desires more contact with Mom 71 56 65 65 Contact with Dad < twice per month c 74 26 92 73 Desires more contact with Dad 68 46 73 60 Desires more contact with siblings 77 84 71 77 Family visits are frequently cancelled. c,d 28 29 60 34 Child frequently misses family b 84 66 78 78 View of current placement (% yes) Child likes who they are living with a,f 91 97 73 90 Feels like part of the family 90 95 96 92 Wants this home as a permanent home a,f 50 65 22 50 Child has tried to runaway from the home b,f* 11 10 15 11 Child wants caregiver to adopt them 39 33 30 36 Child moved to a different neighborhood 89 83 91 87 Neighborhood is better/worse than previous 55 56 47 54 Child goes to a different school 87 76 88 84 New school is better/worse than previous 61 51 62 59 Hopes for the future Believes they will live with their parents again 57 61 61 58 Believes living with parents will be different this time 72 77 76 74

*N = actual n in each cell; percentages are weighted percentages a Comparison between foster care and group care significant at .05. b Comparison between foster and kinship care significant at .05. c Comparison between kinship care and group care significant at .05. d Comparison between foster care and group care significant at .01. e Comparison between foster and kinship care significant at .01. (not used) f Comparison between kinship care and group care significant at .01.

4 Institutions vs. Foster Homes than once each month as children in foster ing, horrible, like a crack house” (Choice care (p<.01). Children in group care were et al., 2000, p. 23). four times as likely to report seeing their Despite group homes supposing to offer biological mother less than once each a higher level of care in comparison to month as children in kinship care (p<.01). other placements, participants saw them as Children in group care were five times as warehouses or shelters for children. One likely as children in kinship care to report participant did claim that there are some seeing their biological fathers less than very good group homes, but this point was once each month (p<.05). Finally, children not expounded. These findings have to be in group care are more likely to report vis- carefully interpreted because of the small its being cancelled frequently than are chil- number of respondents and because only dren in non-kin or kinship foster homes one county is represented. Still, they indi- (OR = 3.83, p<.01). cate that there is reason for concern about the assumption that group care provides a 1.2.3 Community-Based Group Homes from the consistent and high quality environment Child Welfare Worker’s Perspective (and that there is substantial need to collect Child welfare workers have not been given information from child welfare workers many chances to describe their experiences about group care). with group care. Informally, this author has heard that children may get placed into 1.2.4 Social and Developmental Science Perspectives group care because there is less uncertainty on Group Care about the level of supervision and caregiv- The work of understanding the effective- ing. Yet, some recent information indicates ness of group care in children’s services that child welfare workers have concerns has recently been complemented by analy- about community level group care, ses of related information from the litera- although these have rarely been probed. ture on effective therapy, effective parent- Choice et al. (2000) conducted focus ing, and effective children’s mental health groups with child welfare placement spe- services. cialists at the Alameda County Social Services Department in California. When 1.2.4.1 Critique of RTC Using Research on asked about local group homes (generally Therapist Efficacy and Parenting. six-bed homes), participants responded that Given the absence of research on the char- the quality of care for these homes was acteristics and outcomes of institutional low. Participants pointed to the lack of care, we are left to deduce the likelihood trained staff, as evidenced by this state- that institutional care will be effective from ment: “You can’t tell who are the kids and understanding the components of care and who are the staff” (p. 23). their association to other research. Shealy Participants mentioned some of the (1995) applied the findings of psychothera- homes’ neglect of children’s needs, for py literature and the parenting literature to example a situation was given in which the characteristics or residential care to homes said they had no money to buy generate hunches about the likely efficacy clothes for the children. Participants said of residential care. According to Shealy, they thought this resulted from misunder- these workers are neither “parents nor ther- standing of the use of clothing allowance apists, but appear to appear to perform both funds, in which homes thought the county of these roles as ‘therapeutic parents’” (p. should pay for clothes and the county 565). He proposed a model based upon maintained that they included the therapist efficacy and research on effective allowance in the board rate. Participants parenting. Shealy explained that the ration- complained about the physical conditions ale behind therapeutic parenting is that of the homes, for example one person children in youth facilities are often the described some group homes as “uninvit- product of disturbed parenting behavior.

Institutions vs. Foster Homes 5 Thus, youth care workers should not exhib- behavior from one child to another. The it similar harmful conduct and should report concludes that for youth who mani- exhibit healing aspects of successful thera- fest severe emotional or behavioral disor- pies. According to this analysis, factors ders, the positive evidence for home- and commonly associated with therapist effica- community-based treatments (e.g., multi- cy, including unconditional positive regard, systemic therapy, intensive case manage- empathy, interest in helping, firm, and nur- ment, treatment foster care) contrasts turing, should also be evident in the behav- sharply with the traditional forms of institu- ior of residential caregivers if their work is tional care, which can have deleterious con- to be effective. According to the therapy sequences. Even for youth in danger of literature, these are the behaviors that resi- hurting themselves (suicidal, runaways, and dential care providers should exhibit. so forth), brief hospitalization or intensive Parent behaviors associated with psy- community-based services may be a more chopathology in offspring included hostili- apt intervention than RTC. For example, ty, criticism, mixed messages, blurred Henggeler et al. (1999) have shown that boundaries, and rigidity, among others. children randomly assigned to community According to the therapeutic parenting treatment or inpatient hospitalization have model, these are the behaviors child work- better outcomes if served in the community. ers should not exhibit. Yet, some favorable findings have Can residential child care workers live emerged from residential care programs up to these therapeutic and parenting stan- that meet the best standards of care. These dards? According to Shealy’s data collec- attributes of more successful residential tion (from observations, interviews, per- care inlcude: “family involvement, supervi- sonal testimonials, and research on child sion and support by caring adults, a skill- care), there is no reason to assume that focused curriculum, service coordination, they will necessarily provide any better development of individual treatment plans, parenting than the children’s original par- positive peer influence, enforcement strict ents or will be able to consistently provide code of discipline, building self-esteem, therapeutic interventions. Whereas the family-like atmosphere, and planning and capacity exists for better care by youth support for post-program life (GAO, 1994; workers than by parents, this is made Whittaker, 2000). unlikely by their selection, inadequate The Surgeon General’s report cited compensation, and inadequate training. three controlled studies that buttress the argument that residential treatment is no 1.2.4.2 The Surgeon General’s Report on Children’s better than community-treatment. Mental Health. Weinstein (1984) conducted an evaluation An extensive review of the literature on of adolescent males in Project Re- group care as an element of mental health Education (Re-Ed), a residential program services by some of the nation’s leading with teacher-counselors (with the aid of children’s mental health researchers has mental health specialist) who provide ther- been described in the recent Surgeon apeutic services to the children and their General’s report (U.S. DHHS, 2000). (See, families. Adolescents showed improvement also, Hoagwood, Burns, Burns, Kiser, in self-esteem, impulsivity, and internal Ringeisen , & Schoenwald, 2001, for an control versus a non-treated, comparison extensive and confirming review of this lit- group. The 1988 follow-up study revealed erature.) The report indicates that residen- that the adolescents maintained the tial treatment has not shown substantial improvements at 6 months post discharge, benefit to children and youth with mental however community factors at admission health problems and hints at the possibility (family and school situation, community that residential treatment may have adverse support) were more predictive of outcomes effects because of the contagion of problem than client factors (age, IQ, school achieve-

6 Institutions vs. Foster Homes ment, diagnosis); therefore, community perception among social scientists that resi- interventions may have been just as effec- dential care is not effective, residential care tive as the residential program. Another providers have endeavored to remedy this controlled study, Rubenstein et al. (1978), by conducting their own research. The compared RTC with a therapeutic foster Child Welfare League of America has care program. The therapeutic program launched the “Legacy Project” and a proved just as effective, but the residential national survey was recently completed by program cost twice as much. the American Association of Children’s Findings for uncontrolled studies Residential Centers (AACRC, 2000) to showed that most children (60 to 80%) track children’s services outcomes in resi- show improvement in clinical status, aca- dential treatment centers (RTCs). Ninety- demics, and peer relations, among others. six RTCs across 33 states and Canada com- Several recent studies have confirmed pleted the survey; these facilities had an these findings, indicating that the mainte- average bed capacity exceeding 75 beds. nance of improvement is linked to family Results from the survey indicated that involvement during treatment and environ- RTCs served more boys (68%) than girls mental support after discharge (Hooper, (32%). Minorities made up a disproportion- Murphy, Devaney, & Hultman, 2000; ate share of the client caseload with 30% Leichtmann, Leichtmann, Barber, & Neese, African-American and 10% Hispanic 2001; Lewis, 1988; Wells, 1991). (whites made up 52% of the caseload, with In summary, youth who are placed in the remaining children having other racial RTCs clearly constitute a difficult popula- and ethnic designations). Common reasons tion to treat effectively. The outcomes of for being placed in the facility included (in not providing residential care are generally order of frequency): severe emotional dis- unknown, although when community base turbance (clinical depression, PTSD, anxi- services are available, they provide out- ety disorders, and so forth); aggressive/vio- comes that are equivalent, at least . lent behaviors; family/school/community Transferring gains from a residential set- problems; and physical, sexual, or emo- ting back into the community is unlikely to tional maltreatment. Prior to placement in occur without clear coordination between this residential facility, 6 out of 10 children RTC staff and community services, particu- were in a congregate care setting (e.g., a larly schools, medical care, or community group home, another RTC, or juvenile clinics. Typically, this type of coordination detention). Over half of referrals to RTCs or aftercare service is not available upon come from state departments of social discharge. Given the limitations of current services and 70% of funding for RTCs research, it is premature to endorse the comes from social services. effectiveness of residential treatment— About two out of three RTCs said they even for the most troubled adolescents. provided after care services (case manage- Moreover, research is needed to identify ment, family support, and outpatient serv- those groups of children and adolescents ices), but funding was problematic for for whom the benefits of residential care these services. Most of the RTCs in the outweigh the potential risks and to better study offered a variety of medical/psychi- understand whether placing younger chil- atric, psychological, academic and health dren into residential treatment programs education service. Services not often pro- can result in untoward outcomes due to vided were detoxification (0% provided), their greater exposure to older peers. respite care (24% provided), job placement (26%), intensive in-home support (27%), 1.2.5 Perception of RTCs From the Provider and transitional aftercare group (36%), Perspective among others. Since so little is known about the outcomes The AACRC study found evidence of of residential care, and there is a general achievement of a key indicator of suc-

Institutions vs. Foster Homes 7 cess—that eight out of ten children were and not insignificant, is the cost of the dif- discharged to a lower level of care from the ferent kinds of care. Given the scarcity of RTC. Many were discharged to biological child welfare resources—services that pro- parents (34%). The next largest categories vide equivalent benefit but cost less are included: 12% to groups homes, 11% to more valuable to the public. therapeutic foster care, 7% to another RTC, 7% to a foster home, and 6% to a relative 2.1 Safety and Well Being home. No evidence is provided about the Children enter out of home care with the duration of these post-RTC placements, intent of guaranteeing their safety and pro- which is a major shortcoming of the study moting their well-being. One of the most given the legacy of previous studies of powerful indicators of safety and well-being high recidivism from RTCs (Whittaker, for children is the rate of abuse and neglect 2000). Nor do their findings disaggregate in the place they reside. Incidence data like the outcomes for children of different ages these are very difficult to gather, and tend to or referral reasons. Still, they indicate that be skewed toward higher rates of reports for children coming to larger Residential older youth who are more able to communi- Treatment Centers are subsequently mov- cate them to their child welfare worker or ing to less restrictive and more family-cen- other mandated reporter. Thus, there is a tered settings. general bias in the results toward having higher reports of abuse and neglect in group Section 2. Outcomes of care settings because they generally care for older children (Blatt, 1992). Out-of-Home Care Decisions about the optimal kind of care 2.1.1 Abuse of Children in Institutional Care must draw on a variety of data. In the Despite these challenges, several informa- remainder of this review, the focus is on tive efforts have been made to understand outcomes of care. There is no more impor- the abuse rates in different settings. tant consideration in determining which Spencer and Knudsen (1992) examined kinds of care to provide than evidence reports of maltreatment by children in out about the likely impact of the care on the of home care and found that abuse rates in child’s development and well-being. residential treatment centers were 6 times Because this is difficult to measure, under- what they were in foster homes—unfortu- standing the child’s permanency out- nately, they do not provide confidence intervals to indicate the meaning- fulness of those differences in rate nor do they control for the fact that the children in residential care are older. Blatt (1992) argued that Exhibit 3 comes—including evidence of imperma- younger (less than age 35) staff and male Caregivers by Age and nence like running away and re-entry to staff were most likely to be reported as per- Placement Type care—is, at times, the most adequate indi- petrators. He reasons that these findings are cator. Third, the child’s satisfaction with consistent with the higher reporting rates of care—if all else is equal—is an important younger parents in the general population, consideration. Fourth, promotion of suc- and that parents with a bit more experience cess in the transition to adulthood. Fifth, are more likely to find constructive, alterna-

8 Institutions vs. Foster Homes tives approaches to parenting. Group care- from 1990 to 1995 in Leeds, England. givers are much younger than caregivers in Hobbs et al. differentiated between types of foster or kinship foster homes, according to care: foster versus residential (or children’s the National Survey of Child and homes) care. They also examined the fol- Adolescent Well-being (NSCAW Research lowing characteristics of the children: rea- Team, 2002). More than three-quarters of son for placement in care, physical and the group caregivers were under 40 years of mental functioning, and other abuse char- age—39% were 18 to 29 years of age and acteristics, such as type of perpetrator. The 37% were 30 to 39 years. There were also population of foster care children included 11% who were ages 40 to 49 years, 7% 59 boys and 74 girls who ranged in age were between the ages of 50 and 59 years, from 1 to 18 years old. Eight girls (mean and 3% were 60 or older (see Exhibit 3). age 12.75 years) and 17 boys (12.36 years) The ages of caregivers in group care do, in residential care were included in the however, more closely approximate those study. of the general population, than do the ages In this study on abuse incidents in fos- of foster care givers. Although the findings ter care, 42 children suffered physical about the younger age of group care abuse, and almost twice as many children providers offers no direct evidence of high- (76) experienced sexual abuse; 15 children er risk of maltreatment of children in group suffered both types of abuse. Of those care, it does indicate that the children in abuse incidents in residential care, 12 chil- group care very often have caregivers with- dren suffered physical abuse, 6 sexual out their own parenting experiences. abuse, and 6 both types of abuse. Thus, Most recently, Garnier and Poertner abuse in group care was more likely to be (2000) used administrative data to examine physical abuse than sexual abuse, when the rate of reports of abuse and neglect for compared to foster care. As to type of per- children in various types of out of home petrator for children in foster care, 28 chil- care in Illinois. In 1988 and 1999, about 2.0 dren were physically abused and 22 sexual- reports were made for every 100 child years ly abused by foster parents. (Three families of exposure to care. The lowest rates were were identified in multiple allegations of for adoptive families (0.0), then for institu- abuse.) Twenty-two children were sexually tional care (1.6), group care (1.6), kinship abused by biological parents, during visits. care (1.7), specialized [treatment] foster In 24 cases, children were the perpetrators care (1.9), and family foster care (2.7). The of sexual abuse. As to type of perpetrator higher rate for family foster care is partially for children in residential care, 8 children explained because abuse by parents (during were abused by a staff member (all physi- home visits and trial visits) and retrospec- cal abuse). In 17 cases, children were tive reports (for example after finding out abused by another child, 4 by a child with- that a child had been molested) are also in the residential care home (2 sexual and 2 included in the rate calculations. These physical abuse) and 13 by a child outside events might be more likely to be made by the home (9 sexual and 4 physical). foster families than other providers. When compared to the general popula- There have been numerous studies of tion in Leeds, foster children were 7 to 8 the abuse of children in residential care in times more likely to be assessed by a pedi- other countries. Hobbs, Hobbs, & Wynne atrician for abuse. Children in residential (1999) examined the incidence of abuse of care were 6 times more likely (the differ- children in foster and residential care in the ences between foster children and group United Kingdom. In a retrospective study care children are not significant). Hobbs et of 158 children, Hobbs et al. found that al. (1999) noted that children in foster and there 191 incidents of alleged physical residential care are obviously easier to and/or sexual abuse as assessed and report- monitor by professionals than children in ed by pediatricians over a 6 year period the general population, so this accounts for

Institutions vs. Foster Homes 9 some of these differences. Hobbs et al. in the past 3 months. The question—“Did (1999) argue that a comparison between this happen in the last 3 months?—was not children in care and the general population completely clear as to whether this was by can be assumed to be valid given that all the parent or other adult caregiver, or if it pediatric assessments have the same doc- had happen in the community. The percent- tors, referral pathways, and diagnostic cri- ages of children who reported such expo- teria. Yet, they fail to account for the fact sure were low in all settings and no signifi- that the children in group care do not come cant differences using chi square analysis from the general population, they come were found between the three types of out from a small subset that may be quite dif- of home care. Thus the earlier cited evi- ferent. dence of the disaffection of children for Hobbs et al. (1999) argue that although group care occurs even though the propor- children in care are more likely to be tions of children who report that they are assessed for abuse, they are also at a higher experiencing or witnessing being yelled at risk of abuse, given their prior histories of or spanked in group care are no higher than abuse. Prior abuse history increases the like- in other settings. lihood of re-victimization and of becoming a perpetrator. Findings of Hobbs et al. (1999) 2.2.1 Education and Residential Treatment suggested that a factor in re-victimization Lewis (1988) investigated personal and might be the behavioral problems of the chil- ecological outcomes for children in a resi- dren themselves, especially in cases of phys- dential treatment program 6 months after ical abuse by caregivers. Thus excellent discharge. The treatment program, preparation is needed for caregivers in deal- Cumberland House, employs cognitive- ing with behavioral issues of abused chil- behavioral, educational and ecological dren. interventions with the children and their families. Students of the program tend to 2.2 Exposure to Violence in have serious behavioral problems, are Out-of-Home Care behind in school, and usually have been Although children may receive many serv- referred by mental health or by order of the ices while in out-of-home care, the contact juvenile court. Given the centrality of edu- they have with their caregivers is likely to cation to the Cumberland program, educa- be the most extensive and influential. Few tors are primary treatment providers versus studies have endeavored to directly assess mental health or child-care staff. the differences between foster home and The ecological intervention is a unique group care environments. New information part of the program and thus deserving of is emerging from the National Survey on further explanation. Treatment involves Child and Adolescent Well-Being defining a child’s ecosystem (home, (NSCAW) from children and youth about school, community, etc.) and behavioral their safety-related experiences with their expectations for those settings. If a child is caregivers (see Exhibit 4). not meeting those expectations, then an To gain additional clarification about intervention is performed by either increas- the experiences that children had in their ing the child’s competence with the desired current setting, the Conflict Tactic Scale behavior (for example less temper Parent Child version (CTS-PC) was used to tantrums) or expectations (of parents, assess the frequency and extent of nonvio- teachers) for the child’s behavior may be lent discipline and child maltreatment inci- changed to create a better match with the dents as reported by children ages 11 and child’s actual behavior. older (Strauss et al., 1998). If the children Lewis’s (1988) study sample included indicated an incident had occurred on the 106 consecutive voluntary admissions, 82 CTS-PC, they were then asked to indicate which complete data was obtained. on six of the severe items if it had occurred Personal characteristics of the sample

10 Institutions vs. Foster Homes Exhibit 4 Incidents Experienced by Children by Type of Out-of-Home Care (in %)

Foster Kinship Group Foster Kinship Group Care Foster Care Care Care Foster Care Care Incident within Last Month Saw yelling at someone else Saw adult point knife or gun at someone else Current (n=198) 14 11 4 Current (n=52) 2 0 <0.50 Month (n=199) 15 11 4 Month (n=53) 3 1 <0.50

Yelled at by current resident Adult pointed knife or gun at child Current (n=193) 15 10 4 Current (n=27) <0.50 0 <0.50 Month (n=193) 10 12 4 Month (n=27) 2 <0.50 <0.50

Saw something thrown at someone else Saw Adult stab someone else Current (n=97) 3 2 <0.50 Current (n=24) <0.50 <0.50 0 Month (n=96) 4 2 <0.50 Month (n=23) 0 1 0

Adult threw something at child Saw adult shoot someone else Current (n=67) 4 <0.50 <0.50 Current (n=19) 2 1 <0.50 Month (n=67) 4 <0.50 <0.50 Month (n=19) 2 <0.50 1

Saw Adult shove someone else Saw person arrested Current (n=92) 1 1 1 Current (n=123) 3 2 2 Month (n=96) 6 1 1 Month (n=121) 2 2 1

Adult shoved child Saw person deal drugs Current (n=80) 1 3 3 Current (n=63) <0.50 1 <0.50 Month (n=80) 4 2 2 Month (n=63) <0.50 <0.50 1

Saw adult slap someone else Saw other kid getting spanked Current (n=82) 1 <0.50 1 Current (n=184) 11 6 1 Month (n=82) 4 <0.50 1 Month (n=182) 12 5 <0.50

Adult slap[slapped ok? CO] child Child was spanked Current (n=64) 2 <0.50 1 Current (n=145) 8 6 1 Month (n=66) 2 3 1 Month (n=144) 4 3 <0.50

Saw adult beat up someone else Current (n=81) 5 <0.50 1 Month (n=78) 2 1 1

Adult beat up child Current (n=47) 2 2 1 Month (n=47) 6 3 3

Saw person steal from another in the home Current (n=108) 4 1 3 Month (n=109) 4 2 3

Institutions vs. Foster Homes 11 included: 42% repeated at least one grade; dren in California group homes or 27% had been in residential treatment Licensed Children’s Institutions (LCIs). before; and 26% were involved with the AIR obtained data via state data analysis, juvenile court. The average length of stay agency surveys (social services, education- was 7 months. After discharge, children al, group homes, and so forth), site visits returned to the following settings: 71% to and interviews with key stakeholders (stu- their own homes, 15% to relatives, 8% fos- dents, policymakers, among others). The ter families, 3% group homes, and 2% to AIR study found that 18,416 children were some other residential treatment program. in LCIs and that 47% of those children A teacher-counselor who worked with the were in special education. Forty-six percent students and their families obtained data at of the students in special education were admission, discharge and 6 months after being educated in nonpublic schools discharge. Ecological measures included (which are often affiliated with LCIs) as assessment of family problems, school cli- opposed to 1% of non-foster care, non- mate, community resources, parenting group home children and 4% of foster care, measures and student adjustment post dis- non-group home children in special educa- charge. Inter-rater reliability was deter- tion. In addition, residing in an LCI mined for each measure except for the increased the probability that children in a school climate rating scale. disability group (e.g., emotionally dis- Other interesting findings included that turbed) would attend a nonpublic school students with higher SES backgrounds versus those emotionally-disturbed children tended to have better post discharge func- who did not reside in LCIs. tioning. Lewis also found a relationship Interview data revealed that a shortage between higher scores on father’s behavior of group homes forced placements of chil- management practices and improved home dren into LCIs that were not appropriate to adjustment, while higher scores on moth- their educational needs. For example, chil- er’s behavior management was related to dren in LCIs might end up unnecessarily better adjustment in school. In addition, receiving schooling by a nonpublic school raters expectations at discharge for home and thus might violate the federal special and school adjustment, progress in present- educational requirement of least restrictive ing problem, and the development of new environment. Agency survey information problems was found to be predictive of showed that one-half to three-quarters of actual outcomes in these measures. Lewis respondents said that funding considera- concluded that the results from this study tions often affected educational placement suggest increasing both the ecological sup- decisions. Non-group home respondents port and the student’s ability to meet the also said that they often relied on funding demands of his or her ecology result in bet- from affiliated nonpublic school programs ter adjustment to home and community. to help cover the costs of residential or other non-educational services. 2.2.2 Education of Children in Group Care Site visits to group homes revealed that Residential settings have long been the staff reported getting little or no education- locus of educational opportunity and al information from caseworkers and hav- achievement in America, as witness the ing great difficulty in getting transcripts high status of our private boarding schools, from schools. Many group homes said they the military academies, and public and pri- had to hire staff to track down educational vate universities (Wolins, 1974). Yet, the information. Students had several com- assumption that group home care also rep- plaints: being placed far away from neigh- resents a powerful educational environment borhood schools; subpar teaching; discom- has not been well tested. The American fort with teacher in discussing educational Institutes for Research (AIR, 2001) investi- needs or goals; and missing and/or lost gated the educational outcomes for chil- transcripts’ effect on the quality of educa-

12 Institutions vs. Foster Homes tion and likelihood of timing and gradua- babies to American children requires a sig- tion from high school. The study’s review nificant leap, some of the mechanisms for of educational records at the group homes the lower developmental performance of revealed that only 27% had transcripts and institutionalized children posited by Nelson only 25% had educational assessments. & Budd (2001) are consistent with group The AIR (2001) study concluded, that care practices—for example, in shelter changes to the educational system must be care—in the U.S. They proposed that the made in order to assure that group home lack of: physical contact, one-on-one rela- children receive appropriate educational tionships, and extended interactions are services. For example, the study noted that iatrogenic contributors. Group care and education by nonpublic schools might pro- shelter care policies and practices often vide the services needed by some students prohibit or preclude physical contact with to achieve school success, such as those children, being along with a child for with emotional disturbances. The authors extended times, and significant prolonged also suggest, however, that even for chil- interactions with staff that promote the dren who momentarily need them, nonpub- development of relationships. lic schools should be seen as transitional services that prepare children for public 2.3 Permanence/Re-entry school settings. In addition, interagency coordination between educational, social 2.3.1 Placement Instability services, and mental health agencies should Placement instability is widely viewed as be established to ensure the timely provi- harmful to children, yet research about it is sion of appropriate education services to very limited. Webster et al. (2000) studied group home children. the number of placement moves of a cohort Foster and kinship homes also have had of 5,557 children over an eight-year period limited success in helping children to make of time using data from the California normative academic progress (Ferguson, Children’s Services Archive at the 2001). There is no scientific basis on which University of California at Berkeley. The to conclude that children in foster care cohort consisted of children age 0 to 6 first make greater academic gains than children entering out-of-home care between January in group home care. 1988 and December 1989 and who remained in care for the entire eight year 2.2.3 Group Care and Developmental Concerns for period studied. Thus, it is important to note Young Children that the children studied comprised 28% of Young children reared in families appear to the total number of children who entered have better developmental outcomes. This care during the same time span and repre- finding has been shown by researchers to sent all children who remain in long-term be consistent and longstanding (see review foster care. by Berrick, Barth, & Jonson-Reid, 1997). The study did not include placement Following on a long series of studies that moves required to achieve reunification, have shown that children in institutions guardianship, or adoption. The predomi- have poor developmental outcomes (e.g. nant placement setting was coded as either Hunt, Mohandessi, Ghodessi, & Akiyama, kinship or non-kinship care. Non-kinship 1976), Nelson & Budd (2001) recently care included foster homes, specialized fos- found corroborating evidence in follow-up ter care homes, and group care. Webster et assessments of children adopted from al. (2000) employed a multivariate analysis China. Children reared in “foster/private to determine the likelihood of placement homes” had significantly better develop- instability. The study defined “placement mental (motor and mental) outcomes at one stability” as the children having “three or year than children raised in orphanages. more moves in care following placements Although generalizing from Chinese experienced during their first year in care”

Institutions vs. Foster Homes 13 (p. 10). The multivariate analysis tested for aged 13 to 16 at the time of admission who the effects of age, placement setting, and were mostly male, 67%, and white, 60%. number of placements during the first year The average length of stay was 9 to 10 in care on placement stability. months. Most of the adolescents had major Children in kinship care experienced psychiatric diagnoses: most frequently, fewer moves than children in non-kinship conduct disorder, attention deficit/hyperac- care—a disparity which held across time. A tivity disorder, major depression, and post- year into care, 64% of children in kinship traumatic stress disorder (85% of the sam- care versus 49% of those in non-kinship ple were being pharmacologically man- care were still in their first placement. aged). The majority had some type of doc- After two years in care, the percentage still umented abuse (80%) and 85% had been in in their first placement was 55% (kinship) an out-of-home placement prior to admis- to 38% (non-kinship). After eight years in sion.Hooper et al. (2000) collected out- care, those still in their first placement come data at 6, 12, 18 and 24 months after were 37% (kinship) and 22% (non-kin- discharge in a cross-sectional manner (one ship). As far as placement instability, gen- follow-up interview per adolescent). The der, age, and being African-American were data was collected via telephone interviews strongly related to instability. Males were with the individual’s case managers. The 35% more likely to experience instability information collected was across the than females and children entering care as domains of legal, school, and level of care. toddlers were one and three quarters more The case managers rated students’ func- likely to have instability versus infants. tioning as unsatisfactory or satisfactory African-American children were 25% less from the time of discharge. A satisfactory likely to experience placement instability rating was defined as the individual “con- as Caucasian children. tinuing to function on a modestly adaptive level” (p. 494). For the legal domain, a sat- 2.3.2 Family-Centered Residential Care isfactory rating was given to a student if Family focused, community-oriented resi- s/he had no new illegal activity since dis- dential programs have shown considerable charge. For the school domain, satisfactory success. Hooper, Murphy, Devaney, & meant ongoing educational participation Hultman (2000) conducted a single sample and for the level of care domain—satisfac- design study of ecological outcomes for tory meant that the student had not been 111 adolescents who completed a re-educa- hospitalized unexpectedly or moved to a tion residential program, the Whitaker more restrictive treatment level. School, in North Carolina. The Whitaker Hooper et al. (2000) found that about School is a publicly funded program that 58% of the students were rated as satisfacto- operates under the Re-Education model ry in all three domains. When only the legal (Hobbs, 1982). This model is based on sys- plus one other domain was included, the sat- tems theory in that emotional conflict is isfactory rating increased to around 78% derived from interpersonal and system and then to 90% when any two of the three level problems, such as service provision domains was rated. They also found that the problems in the mental health system. The students’ overall success rate did decrease Whitaker School is particularly intended over time, but Hooper et al. also noted that for students who have not been treated suc- these results are better than the outcomes of cessfully in more traditional programs. more punitive types of residential programs Unique to the program is its emphasis on (Peters, Thomas, & Zamberlan, 1998). community involvement for the students More successful students tended to have before, during and after the program. Thus, the following qualities, they were: female, it offers community/family-oriented wrap- slightly younger, have higher IQs, better around services. reading and writing skills, less psychiatric The sample consisted of adolescents diagnoses, and have internalizing types of

14 Institutions vs. Foster Homes behavior as rated by caregivers on the ilies (40%) in both groups had already Child Behavior Check List (CBCL). Little received family-centered services and variance was due to ecological variables, about one-third had intensive family such as history of abuse and living with preservation services. Family reunification biological parents. Hooper et al. suggest was the most frequent goal for families in that this effect was due to the fact that both groups, however the REPARE group these variables are more static and other had a higher percentage of reunification variables (literacy skills, affective symp- goals (86% to 59% for the comparison toms, and SES) are more malleable and group). thus provide the opportunity for treatment REPARE children had shorter lengths to produce positive changes. of stay (242 average number of days versus Hooper et al. (2000) acknowledge that 444 for the comparison group, for children their methodology does not allow for a true admitted after January 1993, n = 59 to n = comparison between the re-education model 33). REPARE children were more likely to of residential treatment and other types of go home after treatment (49% to 19%) and more punitive models. However, their find- comparison children were more likely to ings do suggest that the psychoeducational go to group care or long-term family foster approach does appear to offer long-term care. benefits to youth and the community. In terms of stability, defined as “contin- In a more rigorous third-party evalua- uous (uninterrupted) placement with a par- tion effort, Landsman, Groza, Tyler, & ent, relative, or legal guardian, or in a Malone (2001) conducted a quasi experi- planned long-term family foster home” (p. mental study which examined the effective- 367), REPARE children also fared better. ness of a family-centered residential treat- Six months after discharge, 59% of ment model (the Reasonable Efforts to REPARE children were in stable situations Permanency through Adoption and as compared to 38% of comparison chil- Reunification [REPARE] program) in Iowa dren. Eighteen months after admission to in a comparison to a traditional program. residential care, 75% of REPARE children The REPARE program integrated success- had stability versus 38% of comparison ful aspects of family preservation into children. In the multivariate analysis of sta- more traditional residential treatment. The bility, increased length of stay had a nega- program sought to reduce children’s length tive effect on stability at both time intervals of stay and severity of emotional/behav- of 6 months after discharge and 18 months ioral systems, improve family functioning after admission. Also at 18 months after as well as achieve permanency for chil- admission, assignment to the REPARE dren. The program was family-centered group had a positive effect on ability. No and engaged families as partners in deci- other variables studied (number of place- sion-making and in teaching skills to par- ments, goal of reunification, number of ents and integrating staff into the home and family visits) were found to affect stability. parents into residential placement. Landsman et al. (2001) included 82 2.3.3 Likelihood of Long-Term Care children in the experimental REPARE Understanding the impact of group care on group and 57 in the comparison traditional the likelihood of achieving permanency program group. County of residence deter- goals is difficult, because the ages of chil- mined assignment of children to the facili- dren who enter group care are so much dif- ties. The study sample of 139 children ferent than those of the typical child enter- (both groups) was mostly male, white and ing foster or kinship care. Some efforts ranged in age from 4.7 to 14 years with an have been made to look at older children average age of 10. Most children had expe- and to understand their paths through child rienced at least one out-of-home placement welfare services. Wulczyn & Hislop (2001) prior to their current placement. Many fam- used data from the Multistate Foster Care

Institutions vs. Foster Homes 15 Data Arrive to determine the characteristics children can be effective. In California, of 119,000 youth in out-of-home care at group homes that have higher payment age 16 and likely to be there at age 21. rates (provided to them because children Specifically, they looked at the youth’s are receiving special education, child wel- type of placement, whether placements var- fare and mental health services), have a ied by state, whether 16 year-olds were less higher proportion of teenagers than other likely to be in family placements and group home or out of home care placement whether they were more likely to be in res- types (Webster, 1999). As is also found in idential placements. The sample consisted the NSCAW (2002) data, there is a higher of youth placed in foster care for the first proportion of Caucasians than African- time between 1990 and 1998. Americans in group homes in California— About 50% of the youth were in foster especially in mental health group homes. A or kinship care while 42% were in congre- little less than half of children first placed gate care. The remaining 8% experienced a in mental health group homes are in their mixed type of care. This result varied some 3rd or higher foster care placement. by state. Alabama, New Jersey and New Children who enter group home care for York were more likely to have youth in con- the first time, have a median stay of about gregate care than other states (about 60% of one year. Children who entered care at 6 or youth were in congregate care). Youth in older with a first or second placement in a California (14%) were less likely to be in standard or mental health group home were congregate care. Youth who were already 16 more likely to runaway 2 than children in years old at the time they entered care were foster homes. more likely to be in congregate care versus those who came into care at an earlier age 2.3.5 Re-entry Rates and turned 16 while in care. Children and youth who leave group care The majority of the sample, 41%, exited have the highest likelihood of returning. In to reunification with their families. The a comparison of re-entry rates by age group next most common type of exit, about 1 in and placement type, children aged 6 to 12 5, was to some other destination, such as in congregate care tended to have the high- being transferred to a program outside of est rate of re-entry at 34% (Wulczyn, the foster care system (mental health, Hilsop, & Goerge, 2001; see Exhibit 5). detention). 19% of the sample ran away The next highest rate of re-entry was chil- while 12% reached the age of majority (21 dren in congregate care aged 13 to 18 at years old) and a very small percentage 25%. The re-entry rate for children in con- (1%) were adopted. In regard to type of gregate care aged 3 to 5 was 23% and 0 to placement and type of exit, youth exiting 2 was 22%. All age groups in mixed type of from foster care and youth exiting from care experienced similar re-entry rates from congregate care were equally likely to be 20 to 22%. Children in foster care aged 6 to reunified. Youth exiting from kinship care 12 (23%) and 13 to 18 (22%) experienced were more likely to run away than those similar re-entry rates as compared to mixed exiting from other types. Finally, youth care type. Children in foster care aged 3 to exiting from a mixed placement type were 5 had a 20% re-entry rate and aged 0 to 2 most likely to reach the age of majority, had a 14% re-entry rate. Overall, kinship while still in child welfare supervised out care had the lowest rates of re-entry for all of home care. age groups: 0 to 2, 10%, 3 to 5, 12% , 6 to 12, 13%, and 13 to 18, 12%. 2.3.4 Residential Mental Health Group Care for In a comparison of race by placement Child Welfare Supervised Children in type per age group, black children who California exited from congregate care had the high- Decision making mechanisms that promote est re-entry rate at 25% of all races by type the use of group care for the most disturbed of placement (Wulczyn, Hilsop, & Goerge,

16 Institutions vs. Foster Homes 2001), although black children also had to have placement disruptions in that they generally higher rates of re-entry when had a .55 predicted probability of disruption they left foster care and kinship foster care, whereas the average child had a .17 proba- regardless of age. when they left. Hispanic bility of disruption. Although there was no children in congregate care had a rate of direct comparison to group care, the authors 21%. Children in foster care of all races suggest that the placement disruption rate for experienced similar re-entry rates ranging their Therapeutic Foster Care Program was, from 13 to 15%, depending on race, at 18% in the first 6 months and 9% in the respectively. Children in kinship care of all second six months, lower than rates identi- races had the lowest re-entry rates, ranging fied by other investigators. These figures do from 9 to 12%, respectively. seem to be at least as low, and probably lower, than those (cited above) of the general 2.3.6 Placement Disruption Rates adolescent group care population, Relatively little is know about how placement instability might differ between types of out of home care. Smith, Stormshak, Chamberlain, & Whaley (2001) explored placement disruption rates for emotionally and behaviorally disordered youth in the Oregon Social Learning Center’s treatment foster care (OSLC TFC) program. The OSLC TFC program consists of placement of usually one child per home with treatment foster parents who are trained and supervised by program staff. The sample was comprised of 90 youth (51 male, 39 female) divided into two different age groups: 12 and Exhibit 5 under (n=61) and 13 and up (n=29). The 2.4 Long-term Success/Adult Outcomes Rate of Re-entry by Age and average number of Axis 1 diagnoses for the Assessing the long-term benefits of Placement Type sample was 3.33 and the average number of services is critical to evaluating their value placements was 4.75. Smith et al. (2001) (Barth & Jonson-Reid, 2000). The chal- found that the disruption rate for the first six lenges and rewards of this form of research months of treatment was 18% or 16 of the are great, explaining why only a handful of 90 youth experiencing a disruption. The dis- such studies are available. ruption rate for the second 6 months of treatment was 9% with 7 of 76 (the number 2.4.1 Long-Term Effects of Foster Care and Group still in TFC) experiencing disruption. The Care overall disruption rate was 26% or 23 of 90 One of the most comprehensive reviews of youth disrupting. Of those experiencing dis- literature on outcomes of foster care and ruption, 70% experienced a disruption dur- group care is very often cited, unfairly, as ing the first 6 months of treatment. Age was showing that children do worse in group found to be a significant predictor of disrup- care. McDonald, Allen, Westerfelt & tion with older children more likely to dis- Piliavin (1996) synthesized research that rupt than younger children. In terms of gen- assessed the long-term effects of foster der and age, older girls were the most likely care. In terms of placement type and out-

Institutions vs. Foster Homes 17 comes for foster children, McDonald et assessments of their lives (Festinger, 1983). al.’s review led them to conclude that, gen- More positive outcomes for adults who erally, children who stayed in family foster had been in group care versus family foster care tend to have better functioning when homes included: having closer and less neg- adults than those who spent at least some ative contact with biological family; more of their time in residential care. McDonald likelihood of marriage, and, for men, a et al. also noted that this outcome may be greater probability of having custody of due to the problems that some children their own children (Jones & Moses, 1984). have that make it more likely that they will Thus, the sum of these conclusions led enter into group care—severe emotional, McDonald et al. (1996) to the belief that physical and mental difficulties. outcomes for children from family foster Because McDonald et al. (1996) based homes are better than those from group many of their findings on the work of care. They do caution, however, that given Festinger (1983) and Jones & Moses the nature of these studies it is difficult to (1984), these studies are worthy of a brief make interpretations of causality. Finally, review. Festinger studied 277 young adults, they point out that it does appear that chil- aged 18 to 21, who had been discharged dren who go into group care are usually from foster care in New York City in 1975 those with the most significant problems and had spent five continuous years in and that group care does not seem to ame- care. Festinger used a combination of in- liorate those problems. They suggest that person interviews, telephone interviews family foster homes be developed to meet and questionnaires to assess current func- the special needs of these children. tioning and obtain their views on the foster care experience. Jones and Moses (1984) 2.4.2 Treatment Foster Care versus assessed the current functioning of 328 Group Care adults, aged 19 to 28, who spent at least The historic debate about foster care vs. one year in foster care in West Virginia group care is increasingly likely to be between 1977 and 1984. Jones and Moses honed down to a debate about treatment also primarily employed personal inter- foster care vs. group care. Few studies that views with youth. compare the two methods of serving chil- These studies concluded that subjects dren, have been completed. Chamberlain who were in family foster care functioned (1998) described a particular model of better than children in group care in the Treatment Foster Care (TFC) developed by following areas: they attained higher levels the Oregon Social Learning Center (OSLC) of education (Festinger, 1983); had a lesser as an alternative to residential and group likelihood of arrest or conviction care for juvenile offenders. In this model, (Festinger, 1983); reported fewer substance families are recruited and given special use problems (Jones & Moses, 1984); had training and ongoing consultation to pro- a lesser likelihood of dissatisfaction with vide treatment to the youth. TFC character- the amount of contact they had with bio- istics include close supervision of youth at logical siblings (Festinger, 1983); and were home, school and community; minimiza- less likely to move, to be living alone, to tion of association with delinquent peers; be single, head of the household parents consistent discipline and rule monitoring; and to be divorced (Festinger, 1983). and one-on-one mentoring by TFC parents. Adults formerly in family foster homes TFC has expanded to include populations were also more likely to have close friends beyond juvenile delinquents, including (Festinger, 1983) and stronger informal youth involved in the mental health and support (Jones & Moses, 1984). They also child welfare systems. had more satisfaction with their income Chamberlain (1998) concluded that levels and more optimism about their eco- evaluations of TFC have found the model nomic future; and had more positive to be more cost effective and producing bet-

18 Institutions vs. Foster Homes ter outcomes for children and families in longer than any other form of care. For comparison to alternative residential treat- kinship homes, median stay was 20 ment models. A large comparative study of months; foster homes, 13 months, group 79 male juvenile offenders, aged 12 to 17, homes, 12 months, and other type, 9 assessed post-discharge outcomes between months. FFA also had the longest median adolescents randomly assigned to group lengths of stay for all age groups, the pro- care or TFC (Chamberlain & Reid, 1998). portion. Yet, these placements are also One year after completing the programs, quite stable—over a 6 year period, children TFC youths has significantly fewer arrests in FFAs had the highest percentage of chil- and a greater probability of no arrests after dren still in their first placement (63% at treatment than did youths in group care. In age 2) in comparison to foster (28%) and addition, TFC youths had fewer incarcera- group homes (27%) (see Exhibit 6). tions and spent more time living at home or A permanence index can also be com- with relatives as compared to the group puted for these children. The index is cal- care participants. Also, three times as many culated by dividing the number of children group care youths were expelled or ran achieving permanence (reunified, adopted, away than the TFC group. with guardian) by the sum of children Chamberlain & Reid (1998) also found achieving permanence and the number of four program factors that were predictive children still in care and or re-entered care. of arrests post-discharge: supervision, dis- For care entries between 1988 and 1991, cipline, positive relationship with care-tak- children in FFAs had a lower permanence ing adult, and non-association with deviant index in comparison to foster and group peers. Chamberlain (1998) concluded from homes (see Exhibit 7). Rates for children in evaluation data on TFC that association group care were most similar to those of with delinquent peers was the most power- children in foster care, but still lower. ful predictor of further offending by the youths. This association with delinquent 2.4.3 After Group Care peers appeared to be a dependent factor Perhaps the greatest weakness of out-of- related to the amount and quality of super- home care is that re-entry rates are high vision and discipline from care-taking adults. Adult caretakers may provide protection from deviant peers and, thus, further arrests. Although there is evidence that treatment foster care can achieve outcomes that are similar to group care, for children referred for mental health or juvenile justice reasons and there are almost no after care services Exhibit 6 (Chamberlain, 199x), little is know about available to ease the transition to the home. 1989–1995 Entries: First how treatment foster care and group care Hagen (1982) compared the outcomes of a Spell Median Length of Stay by Placement Type compare in their use in the child welfare group of 20 boys and their parents who services system. This was examined in received aftercare services after residential California, for children in their first spell of care at St. Vincent’s School in California out-of-home care in California. Treatment with a matched group of 20 boys from the foster care is associated with much longer same program who graduated before after- lengths of stay than either foster are or care services were implemented—thus, group care. Median lengths of stay were they did not receive such services. for treatment foster homes (called FFAs Aftercare services consisted of twice [foster family agencies]) were 25 months, monthly home visits with the boys with the

Institutions vs. Foster Homes 19 group was followed for five years post-release and the 1987 group for three years. Kapp et al. (1994) found that 20% of the entire sample were sentenced to prison as adults. Most of the youths were imprisoned within three years of release from the program. Juvenile recidivists were more likely to commit offenses in adulthood than non-recidivists. In addition, non-white juvenile recidivists were more likely than Exhibit 7 goal of aiding the boys and their families other groups to be imprisoned as adults. 1988–1991 Entries: with the children’s adjustment to the com- Child welfare supervised children were Permanence Index at 4 munity (thereby, offering support, advoca- just as likely to be imprisoned as former Years by Placement Type cy, and resource information to families). delinquents. However, given the predictive The boys were aged 10 to 15 and the variables, the most vulnerable group was author specified that no child was psychot- non-white, juvenile recidivists who were ic or mentally retarded. Hagen (1982) released to non-home settings. Thus, the found that the parenting skills of the par- least vulnerable group was white/juvenile ents of the aftercare group continued to non-recidivists released to their own homes improve after discharge while parents of (they had 4.5 times lower likelihood of the non-aftercare group showed regression adult imprisonment compared to the most (as rated by a parenting scale developed by vulnerable group). the author). They also found that, after six months post-discharge, parents of the after- 2.5 Cost care group were more likely to seek com- The cost of a placement must be under- munity-based support than the parents of stood in relation to its long and short-term the non-aftercare group. In addition, after meanings. There is no doubt that group six months, aftercare children seemed to care is more expensive on a daily basis. sustain gains in behavior better than the Yet, if group care is a high short-term cost non-aftercare group. Hagen (1982) also that reduces long term costs then the cost found that more improvement in parenting advantage might fall to group care. Webster skills was related to improvement in chil- (1999) indicates that about 8.4% of children’s behavior. Hagen (1982) argued that dren in California were in group care on these results, although ambiguous by the any given day and that they cost 36.9% of weak research design, support the benefit all dollars spent—roughly 4.4 times the and need for family focused aftercare serv- average unit cost. Treatment/specialized ices as a distinct phase of intervention after foster care agencies, by comparison, children leave residential care. accounted for 12.6% of placements and Kapp et al. (1994) described adult 25.4% of the dollars—roughly twice the imprisonment outcomes for a longitudinal overall unit cost. study of youth who completed a residential Not surprisingly, then, children in kin- treatment program, Boysville of Michigan. ship care are 47% of the caseload but The sample consisted of 563 male delin- require 17% of the budget and foster care quents and those involved in the child wel- had 30% of the children but only used fare system who were released from the 19.9% of the budget. In other words, the Boysville in 1985 and in 1987. The 1985 board and care provided to children in

20 Institutions vs. Foster Homes group care cost 6.6 times what a child in in many federal and state laws), clients foster care cost and more than twice what a should be served in the least restrictive, child in treatment foster care costs. More safe setting (Kavale & Forness, 2000; dollars were spent in 1996 on the 8.4% of Marty & Chapin, 2000). According to this children in group care than were spent on basic principal, children who can be cared the 76.7% of children in foster care and for in treatment foster care or foster care kinship foster care. should be cared for in those least restrictive Some of these group care costs may levels of care. There is no evidence that the offset expenses that would have been overall quality of care is better in group incurred by local communities. Group care homes yet they cost many times more, and treatment foster care costs often leaving a balance sheet that clearly favors include mental health services. Group care the less expensive alternative. Although costs may also include educational servic- children in group care may have a some- es, although this is not always the case. what lower likelihood of reporting that Indeed, one of the substantial difficulties in they were abused or neglected, these rates determining the relative value of group are not sufficiently low enough to counter- care is the heterogeneity of residential pro- vail the many developmental advantages of grams. Group care is provided for children spending time with families that can share in the child welfare system whether or not the expectations, responsibilities, and they have mental health problems, which endearments of family life. makes it difficult to determine the impact Most important, children who cannot of the care on their mental health out- return home and need a family to adopt comes. Mental health group home care them and help them grow into mature with educational services was determined adults, have their greatest chance of finding to cost in excess of $6,000 per month per such a family in the foster family that cares child, nearly a decade ago (Hoagwood & for them. They have virtually no chance of Cunningham, 1992). Even without a guar- gaining support for independent living antee of treatment and education, the costs from group home providers. Although of group care must be assumed to be many Maluccio, Ainsworth, and Thoburn (2000) times higher than foster care and substan- indicate that some providers in the U.K. tially higher than treatment foster care. see group care as a desirable setting for youth who are about to emancipate, this Section 3. Policy and Program seems far less than ideal. For example some children leave group care without Implications ever having gone food shopping—which is The evidence about foster and group care done during the day when they are in fails to generate laser bright conclusions school (personal communication, June, 6, but casts major shadows over the use of 2001). More generally, many group care group care. The findings illuminate several settings provide so much structure that policy and program implications which are, youth are not able to exercise much discre- herein, organized according to the evidence tion or learn to take responsibility for they offer for situations in which group themselves (McKenzie, 1999). This struc- care is generally not appropriate and those ture comes with a deep financial cost and in which it might be. at a cost to the development of youth.

Alternatives to Group Care Should be Pursued Centralized Emergency Shelters are Not Necessary and are Likely to Be Inefficient 3.1.1 Foster Care and Treatment Foster Care are More Desirable and Efficient than Institutional Care Many municipalities have no centralized According to widely held principles of emergency children’s shelter or “receiving human services care (which are embodied home.” Instead, they operate with a series

Institutions vs. Foster Homes 21 of emergency foster homes and, for older only way to achieve efficient assessment youth, emergency group homes (of the 6 to and triage. According to Neil Halfon, a 8 bed variety). In some settings, these leading figure in the provision of health emergency group care settings are limited and mental health care to foster children to 30 days or less, although many children and author of a soon-to be-released report remain in these placements for longer. In on the subject, several cities are effectively some counties, the group care is limited to working with decentralized approaches to older children In other locales, older chil- assessment. Once children have received dren who are being placed for the first time an initial, comprehensive medical assess- are separated from children who have expe- ment, they are referred on to regionalized rienced repeated placements in order to try developmental and mental health assess- to reduce the contagion that can arise when ment centers for these children, and children of different ages and experiences approach that is “potentially more viable co-habitate in the same setting. and feasible given current delivery sys- Shelters have been asked to do a lot for tems” (Halfon, personal communication, child welfare agencies: to provide a setting August 31, 2001). for a child to remain while the child welfare worker determines the next placement, to 3.1.3 An Alternative: Receiving Centers Plus provide a site for multi-disciplinary team Emergency Foster Care or Small Group Care review, and to house children for month The needed functions of emergency shel- after month as a substitute for a family like ters can be achieved by combining receiv- setting (and when no other more therapeutic ing centers and emergency foster care or placement can be found.) They often fail to small group care (for older children). This achieve their goals of providing a family would require considerable expansion of liking setting and sometimes even fail to one little used component of a system of provide a safe environment (Lucas, 2001). care that is an alternative to shelter care— Alternatives to shelters must, then, provide the receiving center (Contra Costa County, at least these functions which call for the August 24, 2001). Several advantages of development of specialized services. receiving centers were identified in a site Exhibit 8 offers a framework for think- visit and conversation with Linda Canan, ing about alternative forms of care for chil- the conceiver and manager of the dren first entering out-of-home care. Down Receiving Centers (personal communica- the left hand side are functions of care and tion, June 26, 2001). The idea was born across the top are the primary sources of out when her agency was beginning to imple- of home care, following a child’s removal. ment new policies requiring that child wel- None of these approaches, alone, are opti- fare workers assess kin, including criminal mal for all children. Although children’s record checks, before placing children. shelters provide the benefit of allowing a This approach also took pressure off child child welfare worker to freely go about the welfare workers to place children who business of screening possible foster care were sitting in their car or office. and kinship care placements and can have a Because children can remain at the centralized assessment center, the downside receiving center for up to 24 hours (and is that they are institutional, house children receive considerable car while there), the of many ages (which can result in conta- emergency foster parents who take children gious exposure to problem behavior of older have been please with the greater ease of children), have high run away rates, and, in their work. They can now accept children some cases, have lower licensing standards in a more convenient way—allowing them than day care centers, foster homes, or small to better meet the needs of children already community-based group homes. in their care—and to receive children who Centralized assessment centers that are are already bathed, fed, clothed, de-loused parts of shelter care facilities are not the and comforted. According to Ms. Canan,

22 Institutions vs. Foster Homes Exhibit 8

Functions Emergency Emergency Children’s Receiving Foster Shelter Foster Kinship Shelter Center Home (Small Group Home) Care Care

Safe setting Good Good Good Good Good Depends for child upon ability to conduct safety background check prior to placement

Facilitative Good Good Uncertain or setting for child poor due to assessment decentralization

Provides Uncertain or Good, Good Uncertain or Uncertain or opportunity to poor because because poor because poor assess placement setting is not stay is setting is not options family like brief family like

Houses children Yes No longer Yes Yes Yes Yes until appropriate than 23 placement can hours be found

Comforts children Uncertain or Good Good Uncertain or Good Good if poor because poor because relative is of long stays of group care known to and institutional rules child conditions

Help child get Good Good Good Good Good Good prepared for placement

Facilitate visiting No No Good Uncertain Good Good by biological parents or poor

Facilitates search Good Good Good Good Uncertain or Poor, if of child welfare poor because this is first worker (CWW) this home placement for optimum may not be and kin have placement optimum not had home or background check

Institutions vs. Foster Homes 23 the institution of the Receiving Centers has rehabilitative services. Small group care helped to reverse the resignations of emer- can be effective in helping to reduce run gency foster home parents and made this a away behavior because of the 24-hour much more attractive role. supervision, although group care does not Child welfare workers value receiving eliminate running away (NSCAW Research centers because they can talk confidentially Team, 2002). Youth who have run away and candidly with foster parents, while from kinship or foster home care despite receiving center staff care for the children. the institution of appropriate procedures Further, in some cases, they save on the (Barth, 1986) may be more adequately time required to transport the children to served in group care. Prior assumptions foster care because the foster parents can should not be made, however, that group come and pick up the children at the care is always needed for youth—youth receiving center. Child welfare workers are generally prefer foster and kinship care to also able to provide the foster parents with group care and there is reason to try these better information about the child’s likes settings first. and dislikes—summarized by the receiving center staff. When children are returned 3.2.2 Youth who are destructive or self-destructive home, they often have a new change of Group care can provide additional supervi- clothes, their original clothes are washed, sion and observation for youth who are and they are rested and content. Receiving destructive of self- and others. There is evi- center and health staff also begin to enter dence that youth who would otherwise be information into the health and educational hospitalized can be equally well-served passport. Receiving centers also have a with community based services cost, although they can be combined with (Henggeler, Schoenwald, Borduin, existing community based organizations Rowland, & Cunningham, 1998) there may (e.g., family resource centers) to reduce still be some advantages of short-term unit costs. spells in group care for youth who need Receiving centers may be least effective substantial amounts of supervision to break in assisting “high end” children who have patterns of destructive behavior. Although had repeated placement breakdowns we lack controlled studies of group care vs. because of diminished odds of finding treatment foster care for this group, anec- another appropriate setting in less than a dotal evidence indicates that foster parents day. Some of these youth do send time in often ask to have destructive youth emergency group home placements, if fos- replaced into group care. Concerned par- ter care homes are not available. ents are also turning to direct placement of their children in group care when they see 3.2 Special Problems that Group Care Can no community alternatives that can assist Help Solve them (Rimer, 2001 ). Efforts to test the efficacy of treatment foster care for youth 3.2.1 Youth who have previously run away from who are dually involved in the juvenile jus- foster care tice and mental health systems are now Group care has a role in the solution of underway (Farmer, 2000). several problems that routinely arise in the One way to boost the efficacy of insti- delivery of child welfare services. Children tutional care for dealing with destructive in out of home care have high rates of run- youth is to increase family involvement. In ning away (Courtney & Barth, 1996; the last half-century, institutional care has Wulczyn, Hilsop, & Goerge, 2001). evolved substantially from large dormitory Children who run away are largely adoles- style buildings to smaller cottages and cents. When children run away, they often community-based settings and continues to put themselves at high risk of victimiza- evolve—in the next century that evolution tion, and limit their chances to receive should result in increased involvement of

24 Institutions vs. Foster Homes family members with children in care could provide benefits to our most serious- (Whittaker, 2000). Several recent studies ly troubled children. Residential treatment indicate that family-involvement appears programs could, then, make an important strongly associated with obtaining better contribution to the continuum of child wel- outcomes for youth with serious mental fare and mental health care. health problems. Leichtmann et al. (2001) investigated outcomes of 123 adolescents 3.2.3 Youth who are moving back to the community placed in an intensive short-term residen- from more restrictive care tial treatment program at the Menninger Many of the youth who enter group care Clinic. The program offers psychiatric come there from other more restrictive lev- services comparable to hospital programs, els of care—e.g., psychiatric hospitals and including pharmacotherapy, psychotherapy, juvenile detention facilities. This can be an group and family therapy. The program is appropriate role for group care in the over- “short-term” because its lengths of stay are all system of care because it is short-term considerably less than traditional residen- and planned with a clear goal of reunifica- tial programs and it employs principles of tion. If combined with a family-focused short-term therapy. These principles reunification program, this use of group include treating a finite number of the most care could provide more time to implement severe symptoms aggressively in conjunc- the plan than is typically available when tion with their families, so that the adoles- children are returned directly home from cents may move down to other less inten- psychiatric facilities. sive and less expensive settings. The program also has a significant orientation 3.3 Summary towards helping the adolescent transition Group care is expensive and restrictive and back into the community and thus, works should be used only when there is clear with outside resources including extended and convincing evidence that the outcomes family, schools, and recreation programs. will be superior to those of foster care and At 3 months post-discharge, 49% of other community-based services. Some adolescents showed reliable improvement communities and states have legislation (improvement of greater than 13 points) that all but precludes the use of group care and 70% showed clinically significant with younger children. Consistent with that improvement in YSR scores (mean score policy direction, the International closer to the normal average). On the Development Corporation has recently CBCL scores, as rated by parents, 71% called for the dismantling of all group care showed reliable improvement (by five for the routine placement of children (IDC, points) and 53% clinical improvement 3 2001). months after discharge. In terms of the At the same time, ironically, some state CAFAS, 79% showed reliable improve- legislatures are considering the expanded ment in functioning 3 months post-dis- use of group home care because of a belief charge (at least a 40 point improvement) that it better provides for the needs of chil- and 65% showed clinically significant dren. Yet, this review indicates that there is improvement. Furthermore, at 12 months virtually no evidence to indicate that group post-discharge, adolescents retained care enhances the accomplishment of any improvements on all of these measures. of the goals of child welfare services: it is Although this study population is limit- not more safe or better at promoting devel- ed to children with severe psychiatric opment, it is not more stable, it does not symptoms and lacks a control group, the achieve better long-term outcomes, and it findings are still germane to this question is not more efficient as the cost is far in of foster care and institutional care. The excess of other forms of care. strong results of the study indicate that re- New models of care need to continue to designed residential treatment programs be developed. There is no empirical reason

Institutions vs. Foster Homes 25 to return to large residential facilities to care for children entering placements at the point of a family emergency or for those remaining in child welfare services for a longer time. There is no new or old evidence to indicate that shelter care, or group care in general, is a sound approach to caring for most children entering child welfare services. Group care should only be considered for those children who have the most serious forms of mental illness and self-destructive behavior.

26 Institutions vs. Foster Homes 3.4 References Chamberlain, P., & Reid, J. B. (1998). Achenbach, T.M. (1991a). Manual for the Comparison of two community alter- child behavior checklist 4–18 and 1991 natives to incarceration for chronic profile. Burlington: Department of juvenile offenders. Journal of Psychiatry, University of Vermont. Consulting and Clinical Psychology, 66, Achenbach, T.M. (1991b). Manual for the 624–633. youth self-report and 1991 profile. Choice, P., Montgomery, H., Prince, J., Burlington: Department of Frenkel, O., & Austin, M. (2000). Psychiatry, University of Vermont. Foster family agencies: Children’s charac- American Association of Children’s teristics and placement considerations. Residential Treatment Centers UC Berkeley, CA: Center for Social (AACRC). (2000). Outcomes in children Services Research. residential treatment centers: A national Contra Costa County. (August 24, 2001). survey. Washington, DC: AACRC. Receiving centers. Concord, CA: American Institutes for Research (2001). Contra Costa County Employment Education of foster group home children, & Human Services Department whose responsibility is it? Study of the Manual, A-1, 1–10. educational placement of children residing Courtney, M. & Barth, R. P. (1996). in group homes: Final report. Palo Alto, Pathways of older adolescents out of CA: American Institutes for Research. foster care: Implications for inde- Barth, R.P., Courtney, M., Berrick, J., & pendent living services. Social Work, Albert, V. (1994). From child abuse to 41, 75–83. permanency planning: Child welfare serv- Duchnowski, A. J., Johnson, M. K., ices pathways and placements. New Hall, K. S., Kutash, K., & Friedman, York: Aldine de Gruyter. R. M. (1993). The Alternatives to Barth, R.P., & Jonson-Reid, M. (2000). Residential Treatment Study: Initial Outcomes after child welfare services. findings. Journal of Emotional and Children and Youth Services Review., 22, Behavioral Disorders, 1(1), 17–26. 787–810 Farmer, E.M.Z. (2000). Issues con- Berrick, J. B., Barth, R. P., Needell, B., & fronting effective services in systems Jonson-Reid, M. (1997). Group care of care. Children and Youth Services and young children. Social Services Review, 22(8), 627–650. Review, 71, 257–274. Ferguson, C. (2001). The academic and Blackman, M., Eustace, J., & Chowdhury, school behavior outcomes of children in M.A. (1991). Adolescent residential foster care: A research synthesis. treatment: A one to three year follow- Unpublished manuscript, submitted up. Canadian Journal of Psychiatry, 36, for publication. Berkeley, CA: 472–479. University of California at Berkeley, Blatt, E. (1992). Factors associated with School of Social Welfare. child abuse and neglect in residential Festinger, T. (1983). No one ever asked care. Children & Youth Services Review, us…A postscript to foster care. New 14, 493–517. York: Columbia University Press. Chamberlain, P. (1998). Treatment Foster Fisher, A.Q. (2001). Finding Fish. New Care. Juvenile Justice Bulletin. York: Harper Collins. Washington, DC: U.S. Department of Garnier, P. G. & Poertner, J. (2000). Justice, Office of Justice Programs, Using administrative data to assess Office of Juvenile Justice and child safety in out-of-home care. Delinquency Prevention. Child Welfare, 79, 597–613.

Institutions vs. Foster Homes 27 Hagen, J. V. (1982). Aftercare as a dis- Jones, M.A., & Moses, B. (1984). West tinct and necessary treatment phase: Virginia’s former foster children: Their Results of the St. Vincent’s aftercare experiences in care and their lives as study. Residential Group Care & young adults. New York: Child Treatment, 1(2), 19–29. Welfare League of America. Henggeler, S. W., Schoenwald, S. K., Kapp, S. A., Schwartz, I., & Epstein, I. Borduin, C. M., Rowland, M. D., & (1994). Adult imprisonment of males Cunningham, P. B. (1998). released from residential childcare: A Multisystemic treatment of antisocial longitudinal study. Residential behavior in children and adolescents. Treatment for Children & Youth, 12(2), New York: Guilford Press. 19–36. Hoagwood, K., Burns, B.J., & Kiser, L., Kavale, K.A. & Forness, S.R. (2000). Ringeisen, H., Schoenwald, S.K. History, rhetoric, and reality— (2001). 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The role of ecologi- multidimensional measure to assess cal variables in residential treatment. impairment: The child and adoles- Behavioral Disorders, 13(2), 98–107. cent functional assessment scale. Loeber, R., & Farrington, D. P. (Eds.). Journal of Child and Family Studies, 5, (1998). Serious and violent juvenile 445–467. offenders: Risk factors and successful inter- Hooper, S.R., Murphy, J., Devaney, A., ventions. Thousand Oaks, CA: Sage. & Hultman, T. (2000). Ecological Lucas, G. (April 12, 2001). State ordered outcomes of adolescents in a psy- to improve children’s shelters: choeducational residential treatment Rampant abuses, overcrowding report- facility. American Journal of ed. San Francisco Chronicle, A1, A5. Orhopsychiatry, 70(4), 491–500. Maluccio, A. N., Ainsworth, F., & Hunt, J. M., Mohandessi, K., Ghodessi, Thoburn, J. (2000). Child welfare out- M., & Akiyama, M. (1976). The psy- come research in the United States, the chological development of orphan- United Kingdom, and Australia. age-reared infants: Interventions and Washington, DC: Child Welfare outcomes. Gen Soc Gen Psychol League of America. Monogr, 94, 177–226. Marty, D.A. & Chapin, R. (2000). The International Development Corporation. legislative tenets of client’s right to (2001). Children in institutions. treatment in the least restrictive envi- Stockholm, Sweden: Ministry for ronment and freedom from harm: Foreign Affairs. Implications for community providers. Community Mental Health Journal, 36(6), 545–556. 28 Institutions vs. Foster Homes McDonald, T., Allen, R., Westerfelt, A., Shealy, C.N. (1995). From boys-town to & Piliavin, I. (1996). Assessing the oliver-twist—separating fact from fic- long-term effects of foster care: A research tion in welfare-reform and out-of- synthesis. Washington, DC: Child home placement of children and Welfare League of America. youth. American Psychologist, 50, McKenzie, R. B. (Ed.). (1999). Rethinking 565–580. Orphanages for the 21st Century. Smith, D. K., Stormshak, E., Thousand Oaks, CA: Sage. Chamberlain, P., & Whaley, R. B. National Survey of Child and (2001). Placement disruption in treat- Adolescent Well-Being (NSCAW) ment foster care. Journal of Emotional Research Team. (2002). One Year in and Behavioral Disorders, 9(3), 200–205. Foster Care: Draft Report. Research Spencer, J.W., & Knudsen, D.D. (1992). Triangle Park and Chapel Hill, NC: Out-of-home maltreatment—An RTI International and University of analysis of risk in various settings for North Carolina, School of Social children. Child and Youth Services Work. Review, 14(6), 485-492. Nelson, R. I, & Budd, K. S. (2001). The Straus, M., Hamby, S.L., Finkelhor, D., effect of foster care on Chinese adoptees’ Moore, D.W., & Runyon, D. (1998). developmental status. Presented at the Identification of child maltreatment 109th Annual Convention of the with the parent-child conflict tactics American Psychological Association, scales: Development and psychomet- August 27, 2001, California. ric data for a national sample of Pecora, P., J. Whittaker, J.K., Maluccio, American parents. Child Abuse and A.N. & Barth, R.P. (2000). Child wel- Neglect, 22(4), 249–270. fare challenge. (2nd Ed.). New York, U.S. Department of Health and Human Aldine De Gruyter. Services. (2000). Report of the Surgeon Peters, M., Thomas, D., & Zamberlan, General’s Conference on children’s mental C. (1998). Boot camps for juvenile health: A national action agenda. offenders: Program summary. Washington, D.C: USGPO. Washington, DC: OJJDP. Webster, D. (1998). Residential group care in Rimer, S. (September 10, 2001). Parents California: Placement dynamics and out- of troubled youths are seeking help comes. Paper presented at the at any cost. 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30 Institutions vs. Foster Homes GLOSSARY OF TYPES OF Emergency Foster Home: A foster home OUT OF HOME CARE that is especially designed and funded to care for a few children for a Children’s Shelter/Receiving Home: few days, weeks, or months. This is a term used to describe cen- Emergency Foster Homes routinely tralized emergency shelters that chil- care for smaller children, but may dren were taken to by police or child also care for adolescents. Providers welfare workers while decisions were are typically given a per diem rate made about their future placements. per bed, whether or not the bed has a Typically these planned stays may be child in it—this assures that a space for as short as one night and as long will be available when needed. as 30 days—sometimes they last Children may enter Emergency much longer than this, however. Foster Home directly following pick “Children’s shelter” is a more apt up by the child welfare worker, fol- description than “receiving home” lowing a stay ad a Receiving Center, because these facilities do not fit the or following a stay at the Children’s characteristics of a “home.” Some of Shelter. Children do not stay in them are quite large—housing hun- Emergency Foster Homes after the dreds of children. Unlike a home, point at which it is clear that they are they are not permanent, personal, not going home and after the point at unique, and filled with family mem- which another foster home can be bers. Instead, they are filled with identified that will be part of the staff, relatively sterile, often over- reunification or permanency plan- crowded, and governed by rules that ning efforts. may be necessary for operating an institution (for example, no hugging Foster Home: In some child welfare sys- of children by staff). tems of care, children go first into foster homes. These homes may be Receiving Center/Transfer Center): A treatment foster care homes (see child-friendly, temporary environ- below) or traditional foster homes. ment in which children who have Child welfare workers must first been removed from their homes can identify that they have available wait, be fed, sleep, be comforted, and space and, ideally, assess whether or (as appropriate) be bathed and not the foster care provider would be deloused prior to going to their next likely to be able to provide a longer setting. A receiving center allows term (even permanent) placement for child welfare workers to gain the pri- a child. Because of the demands of vacy they need to contact possible making expeditious placements, it is placements and the time to go out difficult to use foster homes in such and visit possible kinship placements an ideal way. and do background checks to see if they are safe. Foster parents may Kinship Foster Home: In kinship foster pick children up at the Receiving home care, foster care is provided by Center. After hours child welfare the child’s relative (other than moth- staff have access to the Receiving er or father). These placements may Centers and staff to help with chil- eventually need to be licensed, but dren are on call at all hours. Because generally do immediately need to they are not licensed, children can- meet basic requirements like criminal not stay at Receiving Centers for record check clearance. Because kin- more than 23 hours. ship foster care providers may not Institutions vs. Foster Homes 31 meet the criminal record check in regular foster care. Treatment fos- requirements or be appropriate for ter care homes usually have no more providing care (because of their own than two children. health or familial constraints), some states are curtailing the practice of Juvenile Detention Center: Detention is having child welfare workers bring a secure, temporary facility where a children directly into kinship foster child in foster care may stay, if care and are first conducting prelimi- charged with a crime, while waiting nary assessments of kinship options. to go to court or until a placement can be arranged. Group/Congregate Care/Children’s Residential Center: A general term Sources for facilities that provide 24-hour care to children that is supervised by Bay Area Research in Social Welfare unrelated adults in shifts. Newsletter (2000, Summer). Receiving centers: Child-friendly Group Home: Generally a 6 to 8 bed environments for the assessment of facility that provides group care. children’s needs. Bay Area Social Some group homes serve as “emer- Services Consortium-Research gency shelters” for adolescents, and Response Team. CA: UC-Berkeley. have a payment arrangement similar American Association of Children’s to emergency foster homes. Residential Treatment Centers (AACRC). (2000). Outcomes in chil- Residential Treatment Center: An dren’s residential treatment centers: organization whose primary purpose A national survey. Washington, DC: is the provision of individually AACRC. planned programs of mental health Chamberlain, P. (1998, December). treatment, other than acute inpatient Treatment Foster Care. Juvenile care, in conjunction with residential Justice Bulletin. Washington, DC: care for seriously emotionally dis- U.S. Department of Justice, Office of turbed children and youth, typically Justice Programs, Office of Juvenile ages 17 and younger. CTCs have a Justice and Delinquency Prevention. clinical program within the organization that is directed by a psychiatrist, psychologist, social worker or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of more than half the clients is serious emotional distur- bance/behavior disorder that can be classified by the DSM-IV, other than moderate to severe mental retarda- tion or developmental delay (2).

Treatment/Specialized Foster Care/Home: An adult-mediated treatment model in which community families are recruited and trained to provide placement and treatment to youth who might otherwise have difficulty in maintaining placement 32 Institutions vs. Foster Homes