Specialized foster care: treating seriously emotionally disturbed children - "Transitions," Oregon Social Learning Center program, Eugene, Oregon

Specialized Foster Care:

What can be done to help a 9-year-old girl with a lifelong history of severe physical and sexual abuse? Jenna is her name, and she had been removed from and returned to her natural family on several occasions. She had developed violent tendencies toward others, would sometimes injure herself, and could explode at the drop of a hat. She had a speech articulation problem, perhaps due to brain injury, and an attention span that barely covered a T.V. commercial break. Most of the time Jenna acted anxious and withdrawn and had virtually no skills for relating to her peers. Jenna, a ward of the court, was in the state hospital where she had made some progress. Yet she still had difficulty relating to others, threw frequent and long-lasting tantrums, and was way behind in school. Thousands of dollars and hundreds of hours had been devoted to her treatment. She finally seemed to be on the right track, but what would the next chapter reveal? It was so easy to envision her slipping back. She always had.

Enter "Transitions," a Specialized Foster Care program for seriously emotionally disturbed children and youth based at the Oregon Social Learning Center in Eugene, Oregon. OSLC, a private, nonprofit organization focusing on research and treatment to strengthen families, also operates "Monitor," a Specialized Foster Care (SFC) program for chronically delinquent youths. A world apart from traditional foster care, the SFC programs capitalize on both the homelike foster family setting and proven methods of behavior change to work with children and teenagers who are headed into or out of institutions.

Transitions uses behavioral strategies based on social learning principles. These strategies are implemented by foster parents, who are the agents of change and who simultaneously expose the children to normal family life. Transitions recruits parents who engage in very specific and predetermined treatment activities. The parents--who are considered professional foster parents--are carefully screened, given intensive pre-placement training, provided with daily support and consultation, and encouraged to support one another in weekly meetings. They are also compensated at a rate above that normally allotted for foster care, and they are accountable for their performance. Only one child is placed in each

The foster parents are expected to implement a daily treatment plan analogous to a school individual educational plan. In Jenna's case, this meant following a chart that laid out her daily schedule, with specific expectations about self-care, chores, school performance, and social behaviors. The chart showed pictures of these tasks so she could easily understand them. Each time she completed a required activity, she received points that could later be traded for small prized and special privileges. Conversely, she could lose points or earn a time-out for problem behaviors, such as not following through, hitting, or for being rude or defiant.

Jenna also participated in weekly therapy sessions devoted to sexual abuse issues and social skills training. She was enrolled in a special education class in the local school, and her progress was carefully monitored by her foster parents and case manager. Jenna also attended a yoga class to help her relx and learn to sustain attention. Her foster parents took part in weekly meetings with other foster parents and project staff. As Jenna progressed, or when new treatment goals were identified, modifications in her schedule and point system were made.

The foster family's link to the program is the case manager, who is responsible for 10 youths, far fewer than the 40 to 100 families typically carried by caseworkers in public agencies in Oregon. The family receives about three to five hours of direct contact each week by project staff, and foster parents are seen individually at least once a week. Youngsters are also seen once a week individually. Their natural parents or other relatives who might be available to provide aftercare for them are also seen in weekly family therapy. Unlike conventional foster care, virtually all program services provided to the youth and his or her parents are delivered or directly monitored by the case manager, who is available 24 hours a day and who exercises a great deal more autonomy than the typical caseworker.

From the beginning of her placement in Transitions, Jenna adjusted well. She reported that she liked her foster parents, and she began to visibly relax and become comfortable at home. She was also progressing nicely at school. Her teacher organized Jenna's work and schedule to accommodate her short attention span and low level of academic fuctioning. In the individual therapy sessions, her therapist used role play to help her learn and practice new skills, such as how to start a conversation with peers, how to share and take turns while playing, and how to talk about anger rather than act it out.

Not surprisingly, Jenna continued to experience some problems. There were occasional temper tantrums, the ever-present hyperactivity, residual fears, and headaches. The foster parents were charged with observing and tracking these problems, collaborating on the design of specific intervention techniques, and implementing the interventions. Consultation and supervision from the program took place via daily telephone contact between parents and the case manager. Interventions were continuously evaluated and revised.

Transitions foster parents work hard, often without immediate payoffs. Program staff employ a variety of devices to help keep foster parents satisfied: (support, incentives, special awrds), energized (respite) care, and stimulated (inservice) training. Good specialized foster parents are hard to find, and veteran couples are the very best recruiters of prospective foster parents. Therefore, much effort is devoted to minimizing turnover by maintaining high morale.

Unlike most program youths who either return home or move to traditional foster care, Jenna continues to live with her Transition parents. They have decided to adopt her. Occasionally, SFC parents do decide to adopt the child placed with them, and Transitions supports them in doing so. In these cases--ther have been three to date--no additional foster children were placed with the family. While this causes a loss of experienced treatment parents for the program, it is a gain for each of the children involved.

Jenna is still, and probably always will be, a girl with special needs. Her speech, although improved, is still difficult to understand at times. Academically, she is not yet at grade level. But now she happily participates in public school, temper tantrums are a thing of the past, and the overall quality of her social relationships is much improved. She no longer reacts to frustration in a way that escalates to violent attacks. She has loving and learning relationships with her parents and members of their extended family.

Working with the Child's

Natural Parents

Although it was not the case with Jenna, over half of the children who participate in the SFC programs have parents or other relatives who are available to resume caring for them. Maximizing the natural family's capabilities to effectively care for their child is a priority treatment goal. Weekly family therapy sessions are conducted with the goal of helping the parents learn and practice effective family management strategies. These include methods for encouraging, disciplining and supervising their child and learning to talk about and solve problems.

Typically, the family therapy has three stages. During stage one, the therapist workds to engage the parents and to assure them that the focus of the treatment will not be to affix blame; rather, it will be on the here and now and on specific methods that they can use to help their child. In stage two, parents are given a rationale for and shown how to use the daily point program that their child is accustomed to in the foster home. Parents have a chance to practice using the program during their child's regularly scheduled home visits. These first visits are only one to two hours in length, and gradually, as progress is made, are expanded to overnight and finally, to full weekends. If there are other youngsters living in the home, point programs may also be developed for these children, and the parents will be helped to practice their use. In stage three, parents and the youth meet together and the focus expands to include problem solving and communication skills. Practice exercises and role play are used often in stage three.

How Well Does SFC Work?

Jenna's success has been more the rule than the exception. Thus far, the two SFC programs at the Oregon Social Learning Center have accepted nearly 100 youths. In two separate evaluation studies, each child who participated in an SFC program was compared to a child in a control or comparison group. The study of the Transitions program, which was funded by the Children's Bureau, Administration for Children, Youth and Families, used a randomized design in which cases from the state hospital were assigned to SFC or to other treatments available to them in their communities. Children in both groups were then followed to see how well they were able to adjust outside of a hospital setting. On the average, the children had spent 240 days in the Oregon State Hospital Child/Adolescent Treatment Program during the year previous to th eir participation in the study.

Children assigned to Transitions were placed with a specialized foster family about 82 days after the initial referral. For the control group children, placement in a community-based program took more than twice as long (average-182 days). Thirty percent of the children in the control group never left the hospital setting during the one-year period of follow-up which the study examined. All of the cases in the Transitions group were placed in family settings, and on the average, Transitions participants spent 79 percent of their next year living and learning in a family setting in their communities. Children in the control group spent only 49 percent of their time in the community, and only 40 percent were ever placed in family settings. This study found that compared to available treatment alternatives, Transitions resulted in lower rates of institutionalization and was also cost-effective, saving more than $ 10,000 in hospitalization costs per case. [1]

A second evaluation study has been conducted for teenagers participating in the Monitor program. Monitor takes referrals from the local juvenile department for 12- to 18-year-old boys and girls who have a history of chronic deliquency and have been placed, or are at risk for placement, at the state training school. Most also have severe problems with aggression, school adjustment and family relations. To assess the effectiveness of the SFC model for this population, Monitor youths were matched via computer to same-age/sex-counterparts with similar histories who had been placed in group homes or alcohol and drug treatment centers, or had participated in intensive probation. Youths in Monitor and matched cases were followed for two years after completing their programs, and the subsequent institutionalization rates for the two groups were examined. The main finding was that Monitor youths were incarcerated less frequently and for shorter periods of time than comparison youths. (Over a 2-year period, Monitor youths spent 34 percent fewer days incarcerated.) In addition, it was found that a greater proportion of Monitor youths completed their community programs than did comparison youths, who tended to run away more frequently. Again, the results indicate that SFC is a viable treatment model for severely troubled children.

The notion that parents can provide effective treatment for children with severe emotional and bahavioral problems was first highlighted in the early 1960s by studies on parent training models. This research showed that in many instances more progress on a child's behavior problems could be made through training parents to use systematic behavior management programs, implemented with the child on a daily basis in their own homes, than could be achieved in a weekly visit to a psychiatrist or psychologist. The Oregon Social Learning Center's SFC programs extended this method of working with severely troubled children and teenagers to the context of a highly skilled and supported community foster family.

Care in a family allows the child to be given intensive treatment in a non-restrictive setting that has several advantages over traditional group care. In the family setting, for example, the child is not exposed to peers with similar problems so the "contamination" factor is eliminated, and family members provide appropriate models for building relationships and developing socialization skills. Moreover, from an administrative standpoint, program costs go to direct treatment rather than facility upkeep, and the child's treatment plan can be individualized without regard for the needs of other children placed along with him or her.

The preliminary evaluation studies discussed here, along with other reports on Specialized Foster Care programs and the growing number of new SFC programs being implemented each year throughout the U.S., [2] support the efficacy of this model. It seems clear that for every severely troubled children and teenagers, placement and care in Specialized Foster Care can have all the direct measurable human benefits associated with living in a nonrestrictive community setting, along with the advantage of being able to provide them with effective individualized treatment plans.

Patricia Chamberlain, Ph.D., is Director of Specialized Programs and Clinical Director, Oregon Social Learning Center, Eugene, Oregon. Mark Weinrott, Ph.D., is a consulting and clinical psychologist practicing in Portland, Oregon.

[1.] Complete descriptions of the Transitions and Monitor studies are available from Patricia Chamberlain, Oregon Social Learning Center, 207 E. 5th Ave., Suite 202, Eugene, OR 97401.

[2.] See, for example, R.P. Hawkins, P. Meadowcroft, B. A. Trout and W. C. Luster, "Foster Family Based Treatment," Journal of Clinical Child Psychology, 14(1), 1985; S. Stepleton, "Specialized Foster Care: Families As Treatment REsources," CHILDREN TODAY, Mar.-Apr. 1987; and D. B. Webb, "Specialized Foster Care As An Alternative Therapeutic Out-of-Home Placement Model," Journal of Clinical Child Psychology, 17(1), 1988.

For examples of the use of Specialized Foster Care with another population -- children with severe and chronic medical needs -- see P. H. Foster and J. M. Whitworth, "Medical Foster Care: An Alternative to Long-Term Hospitalization," CHILDREN TODAY, Jul.-Aug. 1986; D.M. Yost, N.J. Hochstadt and P. Charles, "Medical Foster Care: Achieving Permanency for Seriously Ill Children," CHILDREN TODAY, Sept.-Oct. 1988; and M. Luginbill and A. Spiegler, "Specialized Foster Family Care: A Community-Based Program for Children with Special Needs," CHILDREN TODAY, Jan.-Feb. 1989.

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