Multidimensional Treatment Foster Care MTFC: Outcomes, Mechanisms,

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Multidimensional Treatment Foster Care (MTFC)
Outcomes, Mechanisms, Implementation

• Patricia Chamberlain, Ph.D.
• Center for Research to Practice
• Oregon Social Learning Center

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Overview

• Brief summary of MTFC model
• Recent Outcome Studies
• Girls (MTFC-A)
• Regular Foster Care (KEEP-Prevention version)
• Young children (MTFC-P)
• Implementation Research
• Examples of structures and strategies to scale up
  interventions
• Testing implementation methods and fidelity using
  an experimental design

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MTFC Treatment Model

• Alternative to treating children youth in
  aggregate-care settings (group home, residential,
  incarceration, hospital)
• Placements are individual in foster homes (1
  child per home) where foster parents receive
  intensive training and support
• Treatment for the child/youth and their
  biological family (Individual Family therapy)
• Intensive parent management training is provided
  weekly to biological parents (or other aftercare
  resources)
• Youth attend public schools
• Daily fidelity monitoring of implementation

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MTFC model designed to promote resiliency
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Who has participated in the U.S. randomized
trials?

• Children and adolescents from CWS leaving a state
  psychiatric hospital (Chamberlain Reid, 1991)
• Boys from juvenile justice for chronic
  delinquency (Chamberlain Reid, 1998 Eddy
  Chamberlain, 2000)
• Girls from juvenile justice with severe mental
  health problems and abuse histories (Leve,
  Chamberlain Reid, 2005 Chamberlain, Leve,
  DeGarmo, 2007)
• Child welfare challenging children
  (Chamberlain, Moreland Reid, 1992)
• Child welfare- universal prevention (Chamberlain
  et. al, 2008 Price et. al, 2007)
• 6th grade girls in foster care-prevention
  (Chamberlain, Leve, Smith, 2006)
• Young children in foster care (Fisher Kim,
  2007 Fisher et.al., 2007 Fisher, Burraston
  Pears, 2006)

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MTFC Family of Programs
Multidimensional Treatment Foster
Care (MTFC-A) BLUEPRINTS PROG
MTFC-P (preschoolers)
MTFC-C (latency aged children)
Infancy Preschool Primary School Adolescence
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Studies Focusing on Girls

• We know less about the developmental precursors
  to delinquency and therefore about treatment
  elements for females
• Rates of female delinquency are increasing
• The rate of violent offenses is increasing for
  girls
• Girls commit fewer, less serious offenses than
  boys but tend to have more co-occurring problems
  (drug use, mental health HIV risk behaviors)
• Early parenthood is a strong predictor of
  problems for offspring
• Communities are challenged to develop treatments
  for girls

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Range of Problems

• 12 average lifetime arrests (first arrest at age
  12 ½ 72 had at least 1 felony)
• 66 report serious drug use in last year (36 use
  drugs 1-7 times/week)
• 22 had contracted an STI by baseline 50 at
  3-yrs. Post-BL
• 78 academically below grade/age level
• gt50 have had a documented suicide attempt

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Family History and Trauma Exposure among Juvenile
Justice Girls

• 79 had at least one parent convicted of a crime
  
• 93 have a history of documented physical or
  sexual abuse (95 have been in the Child Welfare
  System)
• First sexual abuse (self-report) at age 8
• 79 have witnessed domestic violence
• 17 transitions in parent figures (6 before age
  13)
• 2.8 prior out-of-home placements

(Leve Chamberlain, 2004)
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The Study Randomization and Assessment Process

• Baseline assessment
• Enter randomized
• placement

Each participant had at least one criminal offense
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Decrease in Arrest Rate over Time (in 12-month
increments Study 1)
Number of Arrests
(Chamberlain, Leve, DeGarmo, 2007)
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Decrease in Arrest Rates Girls compared to Boys
Number of Arrests
(Chamberlain Reid, 1998 Leve et al., 2005)
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Girls Decrease in Days in Locked Settings (in
12-month increments in Study 1)
Days in Locked Settings
(Chamberlain, Leve, DeGarmo, 2007)
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Decrease in Days in Locked Settings Girls
Compared to Boys
Days in Locked Settings
(Chamberlain, Leve, DeGarmo, 2007)
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Mediating effects of homework completion during
treatment
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Cascading Dissemination of a Foster Parent
Intervention KEEP

• Collaboration with
• San Diego Department of Health and Human Services
  (Mary Harris, Director)
• Child and Adolescent Services Research Center
  (Landsverk Price)
• OSLC (Chamberlain, Reid, Leve)
• Universal preventive intervention that targets
  permanency outcomes

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The Context for Prevention

• 50 of foster placements disrupt and placement
  disruptions gt child mental health problems
  (Newton, Litrownik, Landsverk, 2000)
• Universal intervention enrolled all 5-12 year
  olds who are receiving a new foster or kinship
  placement (N700)
• Could be first entry into care
• Could be disrupting from a previous placement
• An average of 3.3 foster youth in each home
• Intervention delivered by paraprofessional staff

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Scores on daily rates of problem behavior at
baseline predict placement disruption during
subsequent year

• After 6 behaviors, every additional behavior
  endorsed increases the probability of disruption
  by 17

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Logic Model for Prevention
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Keeping Foster Parents Supported(KEEP)

• 16 weeks of foster parent groups
• Based on principles of PMT customized for foster
  kin care providers
• Delivered by paraprofessional group facilitators
  with intensive supervision
• Augmented by data on your foster child Parent
  Daily Report

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Child Behavior Outcomes
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Predicted probability of negative exits by prior
placements and intervention group
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What Drives (Mediates) Positive Outcomes?
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Variation in Impact of Problems _at_ termination
X _at_ Baseline

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The Cascade

• No difference in effect sizes between
  developer-trained and San Diego team-trained
• 4th step--CASRC team trains and supervises
  interventionists from a local agency (Social
  Advocates for Youth SAY)
• County contracts with SAY to provide KEEP, CASRC
  supervises
• San Diego County won the 2007 National
  Association of Counties Achievement Award for its
  Project KEEP Implementation

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MTFC-P extension of model to 2-7 year olds that
examines intervention effects on the developing
brain (Fisher_at_oslc.org)
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Using Child Welfare System Data to Predict Risk
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Who Needs Treatment? Adrift in the foster care
system
Birth 1yr 2yrrs 3yrs
4yrs
5yrs
6yrs 7yrs
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When foster care works
Birth 1yr 2yrrs 3yrs
4yrs
5yrs
6yrs 7yrs
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Early intervention improves permanency outcomes
Birth 1yr 2yrrs 3yrs
4yrs
5yrs
6yrs 7yrs
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Successful permanent placements for children with
4 or more prior placements at study start

• Regular foster care 9 of 23 (39)
• MTFC-P 23 of 29 (79)

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Prior out-of-home placements effects on permanent
placement failures
Fisher, Burraston, Pears (2005), Child
Maltreatment
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Transferring advances social science research to
public health practice

• U.S. Federal government spends over 95 billion a
  year on research to develop new treatments

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• U.S. spends well over a trillion dollars a year
  on community-based services to people

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What is missing?
GAP
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Examples of Strategies to Scale-Up MTFC and
KEEP

• Rolling Cohort UK
• Cascading Dissemination (KEEP)- San Diego
• University/Agency Partnership Sweden
• Community Development Teams - Randomized trial in
  California

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NIMH Study Scaling up MTFC in California
2006-2011

• Collaborators
• Center for Research to Practice (Chamberlain,
  Reid, Fisher, Leve)
• California Institute for Mental Health
  (Marsenich)
• TFC Consultants Inc (Bouwman)
• University of South Florida (Brown, Wang)

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What about non-early adopters?

• In the U.S. only 10 of child service systems use
  evidence-based practices
• Are there conditions or contexts that could
  promote the uptake of research-based models in
  the other 90?
• What factors predict successful implementation?

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Study Design

• Randomizes 40 non-early adopting counties into 2
  conditions
• Individual consultation services as usual
• Community Development Teams (CDT)
• First matched into 3 equivalent cohorts to deal
  with feasibility (6 equivalent groups randomized
  to 2 conditions)
• Wait-list feature
• Which produces better implementation of MTFC?
• Fidelity to model
• Tests mediators and moderators
• youth placed and outcomes

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Individualized Consultation Services

• Delivered by TFC Consultants Inc
• Initiated by agency or system
• Involves multiple stages
• Feasibility
• Planning/readiness
• Training
• Implementation
• Consultation and fidelity monitoring
• Certification
• Ongoing fidelity checks
• Has been operating since 2001 in over 40 sites in
  the U.S. and Europe

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Community Development Teams

• California Institute for Mental Health
• (CiMH Bill Carter, Lynne Marsenich Todd
  Sosna)
• CiMH collaborated with Oregon to implement MTFC
  in 10 early adopting communities in California
  in 2003
• CDTs
• Create support structure for communities who are
  implementing the same practice
• Peer-to-peer exchange
• Group and individual consultation and technical
  assistance

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How do CDTs Operate? In ADDITION to regular
training from TFCC Inc

• 6 multi-county meetings with key stakeholders
  from multiple levels (system leaders,
  organizations/agencies, practitioners, consumers)
• List Serve
• Conference Calls
• Core Processes
• Planning
• Needs benefit analysis
• Monitoring and support
• Fidelity focus
• Peer to peer exchanges
• Technical assistance

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Evaluating adoption, implementation, fidelity
sustainability

• 10 Stages
• Engagement
• Decision to attempt implement
• Planning
• Readiness
• Staff training
• Foster parent recruitment and training
• Place youth
• Adherence to MTFC components
• Certification
• Long-term sustainability

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Influences on Implementation
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8

6 months
12 months
24 months
CDT Intervention
Sustainability Utilization - Foster homes
available - Youth placed Adherence - Daily
monitoring of MTFC components - FP meetings -
Clinical meetings Costs - Service cost analysis
pgm Youth Family -Number enrolled, completed,
restrictiveness of placement, satisfaction/barrier
s, services used Certification -maintains fidelity
Mediators? - Organizational Culture, Psych/Org
Climate, Attitudes Toward Evidence-based
Practice, Therapy Procedures Checklist, and
Practitioner Attitudes Toward Treatment Manuals.

• 8

• Moderator
• ?
• Poverty index
• SOC/ history of collabor-ation
• Urban/ rural
• Consumer involve-ment

STAGES OF IMPLEMENTATION Engagement - Initial
contact - Stakeholder mtg Planning - Readiness
assess. - Implement T.L. Recruitment Training -
Staff FP trained
Utilization - Foster homes available - Youth
placed Adherence -Daily monitoring of MTFC
components with PDR - Foster parent meetings -
Clinical meetings Competence - Turnover, FP
staff - Weekly ratings by supervisors
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Outcomes

• How many MTFC programs will get implemented?
• How many youth will they serve?
• Will outcomes for youth and families be
  comparable to those obtained in randomized
  trials?
• Will the CDT intervention improve the odds of
  success on these outcomes?
• Will the programs sustain over time?

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Conclusions

• There is value in examining variations in impact
  and mediators of key outcomes
• We need studies on the factors that make or
  break implementations of researched-based
  practices
• Strong partnerships between practitioners and
  researchers are essential for addressing complex
  and relevant issues

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References

• Chamberlain, P., Brown, C. H., Saldana, L., Reid,
  J., Wang, W., Marsenich, L., Sosna, T., Padgett,
  C., Bouwman, G. (in press) Engaging and
  recruiting counties in an experiment on
  implementing evidence-based practice in
  California. Administration and Policy in Mental
  Health.
• Chamberlain, P., Price, J., Leve, L. D., Laurent,
  H., Landsverk, J., Reid, J. B. (in press).
  Prevention of behavior problems for children in
  foster care Outcomes and mediation effects.
  Prevention Science.
• Chamberlain, P., Price, J., Reid, J. B.,
  Landsverk, J. (in press). Cascading
  implementation of a foster parent intervention
  Partnerships, logistics, transportability, and
  sustainability. Child Welfare.
• Chamberlain, P., Leve, L. D., DeGarmo, D. S.
  (2007). Multidimensional treatment foster care
  for girls in the juvenile justice system 2-year
  follow-up of a randomized clinical trial. Journal
  of Consulting and Clinical Psychology, 75,
  187-193.
• Chamberlain, P., Leve, L. D., Smith, D. K.
  (2006). Preventing behavior problems and
  health-risking behaviors in girls in foster care.
  International Journal of Behavioral and
  Consultation Therapy, 4, 518-530.
• Chamberlain, P., Price, J. M., Reid, J. B.,
  Landsverk, J., Fisher, P. A., Stoolmiller, M.
  (2006). Who disrupts from placement in foster and
  kinship care? Child Abuse and Neglect, 30,
  409-424.
• Chamberlain, P., Moreland, S., Reid, K. (1992).
  Enhanced services and stipends for foster
  parents Effects on retention rates and outcomes
  for children. Child Welfare, 5, 387-401.
  Chamberlain, P., Reid, J. (1998). Comparison
  of two community alternatives to incarceration
  for chronic juvenile offenders. Journal of
  Consulting and Clinical Psychology, 6, 624-633.
• Chamberlain, P., Reid, J. B. (1991). Using a
  specialized foster care community treatment model
  for children and adolescents leaving the state
  mental hospital. Journal of Community Psychology,
  19, 266-276.
• Eddy, J. M., Chamberlain, P. (2000). Family
  management and deviant peer association as
  mediators of the impact of treatment condition on
  youth antisocial behavior. Journal of Consulting
  and Clinical Psychology, 68, 857-863.
• Leve, L. D., Chamberlain, P., Reid, J. B.
  (2005). Intervention outcomes for girls referred
  from juvenile justice Effects on delinquency.
  Journal of Consulting and Clinical Psychology,
  73, 1181-1185.
• Price, J. M., Chamberlain, P., Landsverk, J.,
  Reid, J. B., Leve, L., and Laurent, H. (in
  press). Effects of foster parent training
  intervention on placement changes of children in
  foster care. Child Maltreatment.
• Fisher, P. A., Kim, H. K. (2007). Intervention
  effects on foster preschoolers'
  attachment-related behaviors from a randomized
  trial. Prevention Science, 8, 161-170
• Fisher, P. A., Stoolmiller, M., Gunnar, M. R.,
  Burraston, B. (2007). Effects of a therapeutic
  intervention for foster preschoolers on diurnal
  cortisol activity. Psychoneuroendocrinology, 32,
  892-905.
• Fisher, P. A., Burraston, B., Pears, K. C.
  (2006). Permanency in foster care Conceptual and
  methodological issues. Child Maltreatment, 11,
  92-94.