Stressed welfare systems impede evidence-based support for foster children

Flood affected women and children fill their drinking water coolers at drinking water tank at relief camp established in Karachi, Pakistan. Photo: Asianet-Pakistan /
Stressed welfare systems impede evidence-based support for foster children
07 February 2013

Maltreated children placed in foster care are at heightened risk for a wide range of negative outcomes related to their emotional, behavioral and neurobiological development, as well as poor social relationships.

These are catalogued in a recent practitioner review by UK and US researchers that also identifies interventions that have demonstrated their effectiveness in improving the wellbeing of children in foster placements. Yet the delivery of evidence-based interventions for foster children and families lags behind other service sectors such as mental health and education. Why is this?

The international research team, led by Leslie Leve of the Oregon Social Learning Center and Gordon Harold of Leicester University, begin their investigation with an overview of the areas of risk and vulnerability in foster children’s lives.

Here, a substantial research literature highlights problems with emotional and behavioral deficits, brain and neurobiological impairments and poor social relationships with parents and peers. These difficulties are frequently preceded by early abuse and neglect and exacerbated after children are placed in foster care by movement between different placements and multiple changes of caregiver.

Promising interventions

Responding to the multiple, complex needs of children in foster care is undoubtedly challenging. However, from a review of the research literature, the authors identify eight promising interventions spanning different ages and stages of development. Their selection of programs was restricted to those that have achieved positive results in randomized controlled trials involving at least 15 foster children in the intervention and the control group, and where randomization took place at individual child level.

For foster children in their early years, there were three promising models: Attachment and Biobehavioral Catch-up (ABC); Multidimensional Treatment Foster Care for Preschoolers; and the Bucharest Early Intervention Project. The generalizability of the latter may, however be restricted since it worked with children who had been institutionalized since birth, comparing a group placed in foster care, with another who remained in an institutional setting.

Four interventions were identified for children in the middle years: A modified version of the widely-used Incredible Years (IY) parenting program; Keeping Foster Parents Trained and Supported (KEEP) which also trained foster parents to use behavior management strategies; a Middle School Success (MSS) program derived from KEEP; and the Fostering Individualized Assistance Program (FIAP). The latter sought to improve placement stability and reduce behavioral and emotional problems by wrapping services around foster children based on an assessment of their individual and family needs.

Just one intervention was found that had demonstrated positive outcomes with young people: Multidimensional Treatment Foster Care for Adolescents (MTFC-A).

This places young people with behavioral and other problems with specialized foster carers who are intensively trained to provide support, close supervision and mentoring. During a typical 6 to 9 month placement, the program also works with the young person’s school, peers and birth parents.

For the most part, the eight interventions were derived from either models for promoting secure attachment between children and their caregivers or from parenting interventions based on social learning frameworks.

For example, ABC, which encourages caregivers to be more sensitive to a child’s emotions and more nurturing has proved successful in normalizing foster children’s stress responses and promoting more secure attachments. KEEP focuses on helping parents to apply behavior management strategies and has been shown to reduce both the number of placements that children experience and speeding up their return home to either biological parents, relatives or adoptive parents.

Statistically, the size of the positive effects that ABC, KEEP and most of the remaining six interventions achieved on outcomes for foster children were rated small to moderate. It is also worth noting that there was a tendency for improved outcomes to deteriorate over time – although a lack of follow-up data for many of the interventions mean there are no definitive answers about how long positive effects can be expected to last without further intervention.

Systemic challenges to implementation

However, having identified promising interventions (plus others that deserve further research), the researchers assert that most foster children do not, and will not, have access to them. Challenges to their implementation comes are, they argue, inherent in child welfare systems.

As a universal service for all children and young people with documented maltreatment, welfare services are required to respond to a diverse population and a wide age range. Foster parents often care for two or more children with different needs, while returning children “original biological caregiving environment” may not be a safe option.

But beyond that, say the authors: “Child welfare systems are subject to pressures related to high caseloads, high staff turnover, and a continual influx of new cases, creating stressed, difficult work climates that interfere with the sustained use of effective interventions”

Leve and her colleagues make a series of suggestions for increasing the opportunities to provide effective services in austere times. These include the use of robust screening tools to identify children’s mental health needs, so resources and interventions can be better matched. They also recommend raising awareness of evidence-based practice among child welfare workers. [See: Can training help child welfare workers to broker better services?]

Greater emphasis on increasing children’s wellbeing alongside their protection would also be welcome. As the authors observe: “Shifting to a more robust focus on a child’s well-being and linking it to safety and permanence could set the stage for stronger emphasis on implementing evidence-based interventions in the child welfare system”.



Leve, L.D., Harold, G.T., Chamberlain, P., Landsverk, J.A., Fisher, P.A. and Vostanis, P. (2012). Practioner Review: Children in foster care - vulnerabilities and evidence-based interventions that promote resilience processes.Journal of Child Psychology and Psychiatry, 53(12), 1197-1211.


Incredible Years

The Incredible Years is an early intervention program that aims to improve family interaction and prevent early and persistent antisocial behavior in children aged three to 12.

Designed by Carolyn Webster-Stratton at the University of Washington, it includes components for children (often referred to as the Dinosaur program), for parents and for teachers. Each can be administered separately but they are believed to be more effective in combination. The approach uses video and group interaction to teach children, parents and teachers how to handle stressful situations. Programs are designed to be developmentally appropriate for each age group.

The Incredible Years is a Blueprints Model Program.

Multidimensional Treatment Foster Care

Based on research at the Oregon Social Learning Center, Multidimensional Treatment Foster Care (MTFC) targets children aged 3-18 who demonstrate chronic antisocial behavior, emotional disturbance and delinquency. Children are placed in a 'treatment foster family' where a positive, consistent and structured environment is provided to encourage pro-social and age-appropriate behavior. Young people aged 3-5years (MTFC-preschool), 6-11years (MTFC-latency) and 12-18 years (MTFC-adolescent) are referred to the program from youth justice, foster care and mental health agencies. Multidimensional Treatment Foster Care is a Blueprints Model Program.

The Bucharest Early Intervention Project (BEIP)

The BEIP is the first ever randomized trial of foster care as intervention for social deprivation associated with institutionalization. It aims to examine the effects of institutionalization on the brain and behavioral development of young children, determine if these effects can be remediated through intervention, in this case: foster care, and improve the welfare of children in Romania by establishing foster care as an alternative to institutionalization.

Principal Investigators and collaborators: Charles Zeanah, Anna Smyke (Tulane University), Nathan Fox (University of Maryland), Sebastian Koga (University of Virginia), Dana Johnson (University of Minnesota), Peter Marshall (Temple University), Charles A. Nelson (Harvard Medical School).

Keeping Foster Parents Trained and Supported

Keeping Foster Parents Trained and Supported or KEEP is a less intensive version of the training component of Multidimensional Treatment Foster Care (MTFC), a Blueprints Model Program. KEEP offers manualized training, supervision and support for foster parents over a 16 week period. Foster parents are rewarded for their participation. The training teaches foster parents about the techniques and benefits of positive reinforcement of their foster children. An experimental evaluation by program originators, the Oregon Social Learning Center, suggests modest impact on the behavior of foster children, with the largest impact on children displaying higher rates of behavior problems at the outset.

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