Executive Summary

Treatment foster care (TFC; or professional foster care) is a type of out-of-home placement provided by foster parents who receive specialized training to care for children and with intensive emotional or behavioral needs. Treatment foster care is intended to maintain high needs children in family settings to reduce the need for more restrictive placements such as residential treatment centers (RTCs), psychiatric hospitals, or other group care settings. TFC placements are limited in length, typically 6 to 9 months, with the goal of stabilizing the child and subsequently placing them in a less restrictive home setting. Recent changes in federal child welfare policy through the Family First Prevention Services Act (FFPSA) place a strong emphasis on reducing reliance on group residential settings for children in foster care. With the FFPSA potentially decreasing the number of facilities that provide residential group care for high-needs children, family-like alternatives providing treatment services may become an even more important placement option in the continuum of substitute care.

In 2017, the Texas Legislature appropriated funding to implement Treatment Foster Care through contracts with three providers: CK Family Services, Arrow Child and Family Ministries, and the Bair Foundation. In September 2020, the Texas Center for Child and Family Studies partnered with these three provider agencies to conduct a mixed-methods descriptive study to examine characteristics of children in TFC, the restrictiveness of pre- and post-TFC placements, and TFC implementation in Texas.

Introduction

Treatment foster care (TFC; also called professional foster care) is a type of out-of-home care provided by foster parents who receive specialized training to care for children with intensive emotional or behavioral needs. Treatment foster care is intended to maintain high-needs children in family settings to prevent the need for more restrictive placements such as residential treatment centers (RTCs), psychiatric hospitalization, or other group care settings. The requirements for TFC homes are more intensive than the requirements for traditional foster homes. At least one parent in a TFC home must stay at home full time, and each home may only care for one or two children. Foster parents in TFC homes also receive more services, support, and specialized training to develop specific expertise in meeting the treatment needs of children who need the intensive care provided in a TFC setting. Further, TFC foster parents are treated as members of the child’s treatment team. because TFC requires a high level of foster parent qualification and at least one stay-at-home parent, this model of foster care is paid at a higher rate than traditional foster care. Treatment foster care is a temporary placement, typically six to nine months, meant to help stabilize children so they can be maintained in a less restrictive setting. Placements in TFC can reflect “stepping down” or “stepping up” toward the goal of preventing group residential placements. When used as a step-down, TFC is an intermediate placement between a group residential setting or hospital to prepare for placement into a traditional foster home or another less restrictive setting. When used as a step-up, TFC helps regulate children who are at risk of placement into a group residential facility, so that children may return to a traditional foster home or other less restrictive setting. Whether children are stepping up or stepping down, TFC is the stabilizing center between traditional foster care and residential care facilities or psychiatric hospitalization.

Prior Research on TFC

With the Families First Prevention Services Act (FFPSA) potentially decreasing the number of facilities that provide residential group care for high-needs children, TFC homes may become an even more important placement option in the continuum of out-of-home care. Despite the potentially increased demand for TFC homes, there is limited evidence about whether it is effective at preventing more restrictive placements and promoting better child outcomes.

Outcomes Associated with TFCAs TFC’s primary target population is children and youth with high emotional, behavioral, or psychiatric needs, most research evaluating the intervention has focused on outcomes related to mental health and functioning. Some prior research has found that TFC placement is associated with improved control of emotions,1 better internalizing behavior,2 increased resiliency skills,3 and improvements in day-to-day functioning.4,5,6 Beyond individual psychological wellbeing, TFC has also been evaluated for its impact on families, with previous research finding that TFC was associated with reduced caregiver stress7 and higher perceived levels of caregiver empathy.8 Compared to other placement settings such as group care,9 TFC has also been linked to better foster care outcomes,10 including an increased likelihood of reunification,11,12greater placement stability,13 and a reduction of future interactions with the child welfare system.14

Study Purpose and Method

Evaluating the effectiveness of TFC in Texas is important to understand how well the program is working to achieve its intended goals and to inform decisions on potential expansion and further investment in TFC throughout the state. While determinations about whether TFC is more effective than traditional foster care cannot be made within the scope of this study,3 we conducted a mixed-methods descriptive analysis to address the following questions examining how TFC is functioning in Texas:

1. What are the characteristics of children placed in TFC homes?

2. What proportion of children are placed in less restrictive settings after exiting TFC placements?

3. What is the average length of time children stay in a TFC placement?

4. How do CPAs who operate TFC homes perceive its effectiveness at meeting children’s clinical needs and promoting positive outcomes?

5. What are the benefits and challenges of implementing a TFC program?

6. What are the recruitment experiences for finding TFC homes?

7. How do TFC foster parents perceive its effectiveness at meeting children’s needs?

8. What are the benefits and challenges of being a TFC foster parent?

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Quantitative Findings

All Children in TFC (Active and Discharged)

Among all children served by TFC through the three DFPS-contracted agencies to date (N=233), 97 are currently4 in a TFC placement, and 136 have been discharged. The three agencies that provided data for this study are contracted with DFPS to provide TFC. Those agencies, however, also provide TFC through contracts with Single Source Continuum Contractors (SSCCs). Among children who are or have been in TFC, the majority (71%) were served through a DFPS contract, while the remainder were served through contracts with OCOK (13%), Saint Francis Ministries (9%), Family Tapestry (4%), or 2INgage (2%).

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Qualitative Findings

The research team conducted a qualitative analysis to gather first-hand information from DFPS, provider agencies, and TFC foster parents. The findings from the qualitative portion of the study provide an in-depth look at the requirements for TFC homes, the processes through which children are placed in TFC, and stakeholders’ perceptions of the effectiveness of TFC at achieving the intended goals. The key findings are summarized below. Child Referral Characteristics During the qualitative data collection process, the research team explored the characteristics of children that make them a good candidate for TFC. Although organizations emphasized that the referrals are somewhat subjective and children’s behaviors are considered for TFC on a case-by-case basis, there are some key indicators for a child that might do well in a TFC home.

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Limitations

All research studies have limitations to consider alongside the findings. The quantitative data used in the analysis is retrospective and cross-sectional and has a relatively small sample size. It is a snapshot of TFC at the specific point in time when the study was conducted; results may have been different if the sample were larger, if the program had been in operation longer, or if there were more than three providers included. There are also limits to the information that was available for the analysis. For example, we were only able to obtain data on the next placement immediately following TFC discharge. We were not able to look at any placements beyond the one that occurred immediately post-TFC, so we do not have a way to know whether children were maintained in less restrictive settings after discharge from TFC. Qualitative interview participants mostly included foster parents who were satisfied, in general, with TFC. Therefore, the themes and recommendations are centered in overwhelmingly positive experiences. Considering the turnover rate and difficulty recruiting TFC parents, future research on TFC will need to include more diverse and balanced perspectives, including parents who might have served as a foster parent in TFC and left the program.

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Discussion and Recommendations

Prior research on the effectiveness of TFC is limited and, though there are some findings suggesting improved outcomes across several domains, somewhat inconclusive. Assessing the effectiveness of TFC in Texas is further challenging because most prior research focuses on older children in juvenile justice populations rather than younger children in foster care populations, and there are no known prior studies specifically examining the model of TFC used in Texas. Though this study cannot produce rigorous evidence of TFC effectiveness, this analysis found some promising indicators that the program is operating as intended. Children placed in TFC have high levels of need, as evidenced by the fact that 94 percent of children in TFC have a mental health diagnosis, children are prescribed an average of 3.3 medications, and the overwhelming majority (82%) are prescribed at least one psychotropic medication. Even with these indicators of high need, the majority of children placed in TFC are discharged to a less restrictive placement. Further, foster parents and provider organizations perceive that TFC is working to move children into less restrictive settings and to manage and minimize challenging behaviors for high-needs children.

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