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Multidimensional Treatment Foster Care (MTFC)

SW 741 Review of Research in Social Work

Wade Wolfe Angie Evans Patricia Kaleiwahea Mike Makekau

Introduction The number of children in the United States who experience neglect and maltreatment has risen steadily for several decades, with an estimated 3.3 million referrals to child welfare authorities involving 6 million children during 2005 (U.S. Department of Health and Human Services, 2007). It has been estimated that 7% of all children and adolescents will have some involvement in the child welfare. Placements in foster care have dramatically increased over the past 10 years. Despite the increasing numbers, children and adolescents in foster care often lack many needed supports and resources.
Key Findings: On September 30, 2011, there were an estimated 400,540 children in foster care. More than a quarter (27 percent) were in relative homes, and nearly half (47 percent) were in nonrelative foster family homes . About half (52 percent) had a case goal of reunification with their families. About half (52 percent) of the children left the system to be reunited with their parents or primary caretakers . Close to half of the children (46 percent) who left foster care in FY 2011 were in care for less than 1 year.

Children in foster care live in a variety of placement settings and may move among or between settings while in care. For example, a child may move from a group home to a relative foster home. The estimated 400,540 children in foster care on September 30, 2011, were in the following types of placements: 47 percent in nonrelative foster family homes 27 percent in relative foster homes 9 percent in institutions 6 percent in group homes 5 percent on trial home visits (situations in which the State retains supervision of a child and the child returns home on a trial basis for an unspecified period of time and after 6 months are considered a discharge from foster care) 4 percent in preadoptive homes 1 percent had run away 1 percent in supervised independent living


Being removed from their home and placed in foster care is a difficult and stressful experience for any child or adolescent.
Multiple placements are thought to have detrimental effects to the well-being of foster children. A significant proportion of adolescents in foster care experience placement instability. Placement changes disrupts the childs emotional, social, and educational experiences. Reasons for foster care placement include abuse and neglect, severe behavioral problems, illness, incarceration, and alcohol/substance abuse. Increasingly, research has concluded that placement instability leads to deterioration in behavioral functioning and depends as much on the characteristics of the foster parent and worker than on the behavioral characteristics of foster children.

Evidence-Based Practice
The use of evidence-based interventions for children in foster care has the potential to decrease the placement disruptions and increase the likelihood of children achieving permanency. Evidence-based practice (EBP) is a body of scientific knowledge about treatment practices and their impact on children and adolescents with emotional or behavioral disorders. The phrase refers to treatment approaches, intervention and services, which have been researched and shown to make a positive difference in their lives. Multidimensional Treatment Foster Care looks to address the anti-social behaviors observed in these adolescents in order to reduce them and teach the adolescent and their caregivers new behaviors in order to reduce and eliminate these behaviors in the future. In this case, MTFC is being used in order to eliminate failed foster care placements, thereby reducing the number of foster care placements that adolescents are assigned.

Research Question:
Does Multidimensional Treatment Foster Care reduce the number of foster care placements among adolescents with behavior problems?

BACKGROUND: The Oregon Social Learning Center (OSLC) Multidimensional Treatment Foster Care (MTFC) Program was developed as an alternative to institutional, residential, and group care placement for teenagers with histories of chronic and severe criminal behavior. In most communities, such juveniles are placed in out-of-home care settings prior to being sent to closed custody incarceration. The first MTFC program was established in 1983 in Eugene, Oregon. The first implementation in another community began in 2002. As of mid-2009, approximately 115 sites have implemented MTFC, of which 96 are in operation or in the preparation phase. It is estimated that between 3,000 and 4,000 youth and their families have participated in MTFC programs. The first implementation outside the United States took place in 2004 in Ontario, Canada. Since then, MTFC has been implemented in Denmark, Ireland, New Zealand, the Netherlands, Norway, Sweden, and the United Kingdom.

Multidimensional Treatment Foster Care (MTFC)

Logic or Explanation: MTFC was developed as an alternative to group home treatment or State training facilities for youths who have been removed from their home due to conduct and delinquency problems, substance use, and/or involvement with the juvenile justice system. MTFC aims to help youth live successfully in their communities while also preparing their biological parents (or adoptive parents or other aftercare family), relatives, and community-based agencies to provide effective parenting and support that will facilitate a positive reunification with the family.

Youths are individually placed with highly trained and supervised foster parents and are provided with intensive support and treatment in a setting that closely mirrors normative life. MTFC typically lasts 6-9 months and relies on coordinated, multimethod interventions conducted in the MTFC foster home, with the youth's biological or aftercare family, and with the youth. Involvement of the youth's family is emphasized from the outset of treatment to facilitate the youth's return to the family and maximize training and preparation for post-treatment care. Progress is tracked through daily telephone calls with the foster parents.



Population it is Intended to Serve: Adolescents - ages 12-17 Inclusion Criteria: Have a current diagnosis that is based on a complete multiaxial, face to face, evaluation of the youth performed by a licensed psychologist or psychiatrist within the past 60 days prior to admission. Have serious behavior problems associated with their Axis I diagnoses which may include delinquent behaviors. Examples of severe behavior problems may include severe defiance, opposition to authority figures, aggression, property destruction, deceitfulness, theft, and or serious rule violations such as curfew violations, school truancy, running away, and/or delinquent behaviors. Youth who do not present with severe behavior problems are not appropriate for the program.

The behaviors warrant out-of-home placement and cannot be effectively addressed in a less restrictive level of care.
Documented treatment in a less restrictive setting has been provided by a mental health professional, and/or careful consideration of treatment within a less restrictive environment than that of MTFC, and the direct reasons for its rejection, have been discussed and documented.

An aftercare family, which may be the youths biological, adoptive, pre-adoptive or foster care family, has been identified or the expectation is that the youth will transition to independent living upon discharge.

MTFC is based on the Social Learning Theory:

Four key elements are targeted during foster care placement and aftercare:


Providing youth with a consistent reinforcing environment where they are mentored and encouraged to develop academic and positive living skills 2. Providing youth with daily structure that includes clear expectations and limits and well-specified consequences delivered in a teaching -oriented manner. 3. Providing close supervision. 4. Helping youth to avoid deviant peer associations while providing them with the support and assistance needed to establish pro-social peer relationships.

The MTFC Model

Treatment is provided in a family setting New skills are practiced and reinforced in-vivo Treatment is facilitated by core program components for: (1) Youth (2) Families (3) MTFC Parents

Objective Change the negative trajectory of negative behavior by improving social adjustment across settings. How is this achieved? Simultaneous & well-coordinated treatments in multiple settings: (1) Home (2) School (3) Community (4) Peer Group

The MTFC Program Team Approach to Treatment

Foster Parents the primary change agents Individual Therapist supports the youths adjustment in the program and acts as the youths advocate Family Therapist works with the youths biological family (or other identified aftercare resource) to prepare them for the youths return Skills Coach supports youths adjustment and success, but in a different context from the individual therapist Parents Daily Report (PDR) Caller has daily contact with the foster parent to get a checklist type report of the youths behavior Referring Agency depending on individual situations, the referring agency may be child welfare, the juvenile court, or parole/probation

Goals of the MTFC Program

The key objectives of MTFC are to provide youth with the opportunity to live successfully in a family setting and to coach the youths parents or other aftercare family to effectively manage his/her behavior so that progress is sustained after the youth returns home. Research studies have shown that when compared to youth placed in group care or residential facilities, youth who received MTFC-A What are the short-term outcomes? Had higher rates of treatment completion Were less likely to run away from the program Associated less with delinquent peers Were more likely to attend school and complete homework

What are the long-term outcomes? Up to 2 years after referral, youth who participated in MTFC: Were less likely to be incarcerated and spent fewer days incarcerated? Had fewer arrests, less self-reported criminal behavior, and fewer violent offenses. Spent more days living with family. Had lower rates of tobacco, marijuana, and other drug use. Exhibited improved mental health (fewer internalizing and externalizing symptoms). Were less likely to become pregnant.

MTFC Logic Model


Improvement in foster parent skills (increase reinforcement relative to discipline)

Decrease child problems

More stable and skilled foster parents

Increase reunification & decrease disruption

Methodology Research Initial Research Research Databases: EBSCO, PubMed, PsycINFO, ERIC and Google Scholar. Inclusion Criteria MTFC Foster Care Placements Placement Instability Adolescents/Youth Antisocial behavior Emotional Disturbance Delinquency

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Summary of Literature Review Research Designs Comparison Study = 1 Non-Randomized Design = 1 Correlational Design= 1 Experimental Designs = 2 Randomized Clinical Trial = 4 Research Demographics United States, England (1), Sweden (2) Youth under the age of 18 Pre-school: ages 3-6 (3) Delinquent Youth (5) Foster Families (1)

Results of Literature Review

Reunification Placement stability Permanency Delinquent behavior Treatment retention


Analysis MTFC support in the foster home leads to improvement in foster parent skills (increase in reinforcement relative to discipline). Effective foster parent skills and therapeutic interventions provided by MTFC staff lead to a decrease in child problems. A decrease in child problems increases successful reunification and decreases placement disruptions. The placement experience and accompanying support and guidance provided to foster parents results in increased model-specific skills, which benefits future placements in the home.

Conclusion MTFC does seem like a promising option for treating adolescents and children for anti-social behaviors. Not only does it involve a more comprehensive group of individuals who can help to address the adolescent in a wider range of circumstances when compared to other options such as Group Care, because of its more comprehensive nature, it involves a shorter response time for problems that do come up. The training that is provided to the parents and other support team members in MTFC also appears to be a critical component. It can be leveraged to help the parents, in particular, be better prepared to not only address behavioral problems as they arise but also to break the cycle of attention seeking behaviors and oppositional behaviors that the adolescents frequently engage in.

References Fisher, P., Chamberlain, P., Leve, L. (2009) Improving the lives of foster children through evidence-based interventions. Vulnerable Children and Youth Studies, 4(2), 122-127. Fisher, P., Kim, H., Pears, K. (2009). Effects of Multidimensional Treatment Foster Care for Preschoolers (MTFC-P) on reducing permanent placement failures among children with placement instability. Child and Youth Services Review, 31(5), 541-546. Kerr, D.C.R., Leve, L.D., & Chamberlain, P. (2009). Pregnancy rates among juvenile justice girls in two randomized controlled trials of Multidimensional Treatment Foster Care. Journal of Counseling and Clinical Psychology, 77(3), 588-593. Lee, B. R., & Thompson, R. (2008). Comparing outcomes for youth in treatment foster care and family-style group care. Children and Youth Services Review, 30(7), 746-757. Leve, L.D., Fisher, P.A., Chamberlain, P. (2009). Multidimensional Treatment Foster Care as a Preventive Intervention to Promote Resiliency among Youth in the Child Welfare System. Journal of Personality. 77(6), 1869-1902. Macdonald G.M. & Turner W. (2008). Treatment Foster Care for improving outcomes in children and young people. Cochrane Database of Systematic Reviews, 23(1). Price, J. M., Chamberlain, P., Landsverk, J., Reid, J.B., Leve, L.D., & Laurent, H. (2008). Effects of a foster parent training intervention on placement charges of children in foster care. Child Maltreatment, 13(1), 64-75. U.S. Department of Health and Human Services (2007). Child maltreatment 2005. U.S. Government Printing Office: Washington, DC. Westermark, P.K., Hannsson, K., Vinnerljung, B. (2008). Does MTFC reduce placement breakdown in foster care? International Journal of Child & Family Welfare, 4, 155-171. Westermark, P.K., Hansson, K. & Olsson, M. (2011). Multidimensional Treatment Foster Care (MFTC): Results from an independent replication. Journal of Family Therapy, 33, 20-41.