Therapeutic Foster Care for Antisocial Youth

Justine Harris

Clinical Director

Youth Horizons Trust

Auckland, New Zealand

Who is Youth Horizons Trust? NGO who specialises in working with young

people diagnosed with Severe Conduct Disorder Provide both community, foster care and

residential options Provides treatment to the young person, their

family and work with the community using systemic principles, parent management training and cognitive behavioural therapy

What is SCD?

Severe Conduct Disorder (DSM IV)

A pattern of behaviour where the rights of others or major age appropriate norms or rules are violated

Criteria for Conduct Disorder

Aggression Destruction of property Deceitfulness or theft Serious violation of

rules

Epidemiology 3-5% of children Increase in prevalence

after 12 years of age More common in boys

than girls 2:1

Aetiology

Studies suggest Parental antisocial behaviour Marital discord Poor parenting strategies Impaired patterns of interaction Genetic factors driving environmental

vulnerability.

What works for this client group?

“…not for the faint hearted” Emeritus Professor John Werry

Consistent parenting High monitoring Behaviour management Intervening across systems, peers, school etc Ensuring treatment generalisability

Why use therapeutic foster care?

Routes in deinstitutionalisation and foster care system

Cost effective Least restrictive environment Minimises the influence of peers with similar

problems Reduction in antisocial behaviour

Oregon Social Learning Centre Eugene, Oregon Part of University Parent Management Training (PMT) Multidimensional treatment foster care (MTFC) Started delivering services in 1983 High rates of incarceration in Oregon compared to other

states Treatment group – antisocial youth, hospitalised youth

with mental health problems, medical problem

MDFC

Model and theory Evidence and cost Caregiver interventions System intervention

Individual family therapySchool and peer interventions

Special Issues

Recruitment Training Supervision and case coordination Females Early intervention

Model and Theory

OSLC – pre MDFCProblems with delivering PMT in the communityProblem solving componentClinically difficult to treat

Conflict in familyInfluence of peer groupSafety of the community

Model and Theory continued

Residential option – influence of the peer groupE.g. positive peer cultureNo evidence for peer approaches Longitudinal research suggests that association with

delinquent peers result in development and escalation of delinquency

Long-term success based on support once the youth returns to the community

Group Home continued

Teaching families home Some successSmaller numbersSchool interventionsBehaviour mangmentRelationship with family home staff

Research on Delinquency & Drug Use

Condensed Longitudinal Model

Family

School

DelinquentPeers

DelinquentBehavior

Prior DelinquentBehavior

Low Parental MonitoringLow AffectionHigh Conflict

Low School InvolvementPoor Academic Performance

Elliott, Huizinga & Ageton (1985)

-

-

+

+

MDFC

Began in 1983 Alternative to incarceration Based on the vile weed model – Stages in the

Coercion Model (Figure 9.1) Case study

Conduct problem development model

MDFC – research guiding practice

CD stable over time

Without intervention problems escalate

Childhood onset more severe

Impact on the environment and vice versa

Relating research to intervention

What works Interventions that target child, parent and environment“Multimodal interventions that simultaneously target

multiple settings and systems, although more expensive, complex, intensive and restrictive than single focused approaches to outpatient family therapy, show promise, for the treatmetn of such youths”

Chamberlain, 2003

Barriers that need to be overcome if treatment is to be successful

AttritionLikely to be severe casesImportance of engagement

Family stress and lack of social supportFamily therapy less successful when children are olderParents resistance to treatment

Family

DisciplinePermissive or rigidcoercion

Monitoring or supervision Structure consistency

Deviant Peer Group

Avoid aggregating peers Support and skill yp’s for association with

prosocial peer group

School

Coercive style with teachers and classmates Clear consistent rules Good supervision Reinforcement Social skills

Evidence Evaluations of MTFC have demonstrated that program youth

compared to control group youth: Spent 60% fewer days incarcerated at 12 month follow-up; Had significantly fewer subsequent arrests; Ran away from their programs, on average, three time less

often; Had significantly less hard drug use in the follow-up period;

and Quicker community placement from more restrictive settings

(e.g., hospital, detention).

Cost

The cost of the program per participant is $2,052 (extra to a group home)

Net financial benefits$21,836 to $87,622 (American $)

YHT caregiver programmeCaregivers receive contract fee per year of $30,000 Yp’s costCase coordination costs

Caregiver Interventions Emphasis on daily encouragement and reinforcing youths Individualised points systems – behaviour management

system Reinforcement and feedback

Material rewards more power for SCD yp’s

Teach prosocial behaviour Sanctions for behaviour problems

Tangible punishments more powerful

Three level system – less supervision as they go up the levels

Foster home environment Consistent tangible

rewards and sanctions

Immediately delivered

Teenage learn from feedback

Young Person’s Response

Low level of social skills Feel “hard done by” “destructive entitlement” Firm but fair approach with some room for

negotiation

Privileges and Rewards

They are well defined The fit the yp’s level of interest and maturity They must be affordable and readily available Criteria for reward should be realistic

Fines

Level 1 and 2 – points are taken for small infractions e.g. swearing, sulking

Caregivers take them away in a nonhostile and sympathetic way

Try to catch behaviours early in the sequence Lecturing ineffective

Working with the Family Preparing the family for the yp’s return from pre-entry Engagement – working with resistance Training and support PMT – weekly family therapy sessions

Behaviour management Discipline Supervision Improving communication and problem solving

Family Discipline

Taught to give corrective feedbackConsequences e.g. taking away pointsWays to control the parents own angerSequencing

Roleplays Communication, negotiation and problem solving Rules and regulations regarding home visits

Individual Therapy for the yp

Therapist seen as advocate and coach Steady support and encouragement Problem solving focus Facilitate adjustment to the programme and school Reenactment sessions Decreasing zapping amongst family members

Liaison with Schools

Wherever possible young people attend mainstream schools

Provide close supervision and follow-through Teach key staff principles of the programme Yp’s monitored On-call assistance for school staff School liaison worker

Peers

Close supervision and monitoring Teach pro-social skills so youth can attract non-

delinquent peer group Teach problems solving, and conflict resolution

Recruitment

Placing adds in local newspapers

Gulp!!I need a home for about a year! 12 year old girl who likes school needs a stable home. Prefer home with skilled parents where she can get plenty of attention. OSLC foster care program provides training, lots of support and monthly payment. For details contact….

Do You?Understand Impressionistic Art

Existential Philosophy, Quantum Physics …..

Then you are more than qualified to become a foster parent for the Oregon

Social Learning Centre. OSLC is looking for stable homes for children of various ages who need care for between 6 month – 1 yr. We provide training (no physics test

involved), lots of support (by a lively and philosophical staff), and $500 to $1200 per month (not just and impression) at

least phone in for details

4 Step Screening Process

Initial contact where programme is explained Application form and reference checks Home visit Screening with welfare services

Training

20 hour pre-service – with overview of TFC4 step process for analysing behaviour

Knowing when a problem is a problemDefining the problem behaviourExamine the antecedents of the problemChange the consequences that maintain the problem

Training cont

Procedure for using a 3-level system Working with the child’s natural family Common sources of stress on the team Treatment foster care policies and procedures On-call system and daily contact Foster parent support

Foster Parent Support

Foster parent meeting Clinical meeting Foster parent daily

structured feedback 24 / 7 on call support Respite care

Case consultation Case Manager (5 to 7

cases at a time) Daily contact Coordinate roles of

treatment team Supervises foster parents 24 hour crisis intervention Revises treatment plan as

needed

Females

In treatment girls behaviour worsened No differences in sexual behaviour or significant

female outcome Current adaptation of treatment programme

Adaptation of treatment programme (Patricia Chamberlain)

Address relational aggression

Address emotional dysregulation

Address risky sexual behaviour Female mentor

Focus on safety, stability and containment

Early Intervention

Preschoolers with behaviour problems Children with developmental delay Maltreated children

Summary MDFC – cost effective approach to dealing with SCD Provide a successful community living experience Effective principles

Consistent reinforcing environment Clear structure and limits Close supervision Prevent association with the youth and deviant peers and help

then develop appropriate peer relations