This is the current release of the guideline.

Violent behavior

Assessment of Therapeutic Effectiveness
Prevention

Family Practice
Pediatrics
Preventive Medicine
Psychiatry
Psychology

Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers

To determine the effectiveness of therapeutic foster care programs in preventing violence

Youths with a history of chronic delinquency or severe emotional disturbance

1. Cluster therapeutic foster care
2. Program-intensive therapeutic foster care

• Measures of conduct disorder (i.e., conduct in which "the basic rights of others or major age-appropriate societal norms or rules are violated")
• Measures of externalizing behavior (i.e., rule-breaking behaviors and conduct problems, including physical and verbal aggression, defiance, lying, stealing, truancy, delinquency, physical cruelty, and criminal acts)
• Rates of delinquency
• Rates of arrest for violent crime
• Rates of conviction for violent crime
• Rates of incarceration

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Overview of Process

For each Community Guide topic, a multidisciplinary team conducts a review that includes the following:

• Developing an approach to selecting the interventions for review
• Systematically searching for, retrieving, and evaluating evidence of effectiveness of selected interventions
• Assessing the quality of, summarizing the strength of, and drawing conclusions from the body of evidence
• Assessing cost and cost-effectiveness analyses and identifying applicability and barriers to implementation of all effective interventions
• Summarizing information regarding evidence of other effects of the intervention
• Identifying and summarizing research gaps

Search Strategy

Electronic searches for intervention studies were conducted in Medline, Embase, Applied Social Sciences Index and Abstracts, National Technical Information Service (NTIS), PsychLit (now called PsycInfo), Sociological Abstracts, National Criminal Justice Reference Service (NCJRS), and Cinahl. The references listed in all retrieved articles were also reviewed, along with additional reports as identified by the team, the consultants, and specialists in the field. Journal articles, government reports, books, and book chapters were all included.

Inclusion Criteria

To be included in the review of effectiveness, studies had to be consistent with the following criteria:

• Be primary investigations of an intervention rather than, for example, guidelines or reviews
• Provide information on at least one outcome of interest from a list of violent outcomes selected in advance by the team
• Be conducted in an established market economy
• Compare outcomes among persons exposed to the intervention with outcomes among persons not exposed or less exposed to the intervention (either concurrent comparison between different groups or before-and-after comparison within the same group)
• Have been published before December 2001.
• Meet Community Guide quality criteria for study design and execution.

A systematic search identified five studies that reported the effects of therapeutic foster care programs on violence by juveniles.

Weighting According to a Rating Scheme (Scheme Not Given)

The strength of the body of evidence of effectiveness was characterized as strong, sufficient, or insufficient on the basis of the number of available studies, the suitability of study designs for evaluating effectiveness, the quality of execution of the studies, the consistency of the results, and the effect size.

Systematic Review

Each study that was consistent with the inclusion criteria was evaluated by using standardized abstraction criteria and was assessed for suitability of the study design and threats to validity. On the basis of the number of threats to validity, studies were characterized as having good, fair, or limited execution. Results on each outcome of interest were obtained from each study that had good or fair execution. Measures adjusted for the effects of potential confounders were used in preference to crude effect measures. A median was calculated as a summary effect measure for outcomes of interest. Unless otherwise noted, the results of each study were represented as a point estimate for the relative change in the rate of violent outcomes associated with the intervention. Calculations were made in the same way for study outcomes measured as rates or proportions (e.g., arrest rates) and for outcomes measured in scales (e.g., levels of conduct disorder assessed in a behavior checklist).

Other

Task Force recommendations are based primarily on the effectiveness of interventions as determined by the systematic literature review process. In making recommendations, the Task Force balances information about the effectiveness of an intervention with information about other potential benefits and potential harms. To determine how widely a recommendation should apply, the Task Force also considers the applicability of the intervention in various settings and populations. Finally, the Task Force reviews economic analyses of those interventions found to be effective and summarizes applicable barriers to intervention implementation. Economic information is provided to assist the reader with decision making but generally does not affect the Task Force's recommendation.

For the current guideline, the guideline development team developed an analytic framework for therapeutic foster care intervention, indicating possible causal links between therapeutic foster care and the outcomes of interest. To make recommendations, the Task Force required that studies demonstrate decreases among program participants in the selected direct or proxy measures for violence. If both direct and proxy measures were available, preference was given to the direct measure.

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

The systematic review team identified two economic evaluations of therapeutic foster care programs. A cost-analysis study assessed program costs for therapeutic foster care provided adolescents with chronic delinquency problems. Only those program costs incurred by state and local governments were considered in the analysis, including costs for personnel (i.e., case manager, program director, therapists, recruiter, and foster parent trainer) and foster-parent stipends, as well as additional health services (e.g., mental health care). Average program costs (in 1997 dollars) ranged from $18,837 to $56,047/youth, depending on the emotional state of the child, the intensity of services required, and Medicaid and juvenile corrections division reimbursement rates.

The second study was an incremental cost-benefit analysis of a therapeutic foster care program compared with standard group care. The study found that for every dollar spent in justice system costs, therapeutic foster care saved $14.07. Incremental program costs (in 1997 dollars) were $1,912/ youth. Incremental benefits for a 37% reduction in crime were $83,576/youth, including taxpayer benefits ($22,263/youth) and crime victim benefits ($61,313/youth). Taxpayer benefits included reduced burden on and expense of sheriff offices, courts and county prosecutors, juvenile detention, juvenile probation, juvenile rehabilitation, adult jail, state community supervision, and the department of corrections. Crime victim benefits included reductions in medical expenses, productivity losses, and pain and suffering. Total net benefits (benefits minus costs) ranged from $20,351 to $81,664/youth. This estimate does not include benefits to youth in the programs (e.g., increased earnings and improved life course).

External Peer Review
Internal Peer Review

The guideline was submitted for extensive peer review, including review at various stages by a "consultant team," an external team of subject matter and methodologic experts, and peer review of the finished product by agencies and professional groups.

Overview

The original guideline document assessed two similar, but differing interventions, distinguished by both the ages and underlying problems of the target populations. Separate assessments were made of the effectiveness of these two program types.

The first type of intervention studied was therapeutic foster care for the reduction of violence by children with severe emotional disturbance (SED) (hereafter referred to as cluster therapeutic foster care). Two studies assessed interventions in which, with some guidance from program personnel, clusters of five foster-parent families cooperated in the care of five children (aged 5–13 years) with SED. These programs were of relatively long duration (average length: 18 months).

The second type of intervention studied was therapeutic foster care for the reduction of violence by chronically delinquent adolescents (hereafter referred to as program-intensive therapeutic foster care). Three studies assessed interventions in which program personnel collaborated closely and daily with foster families caring for older juveniles (aged 12–18 years) with a history of chronic delinquency. The average duration of these programs was 6–7 months.

Recommendations

• The Task Force found insufficient evidence to determine the effectiveness of cluster therapeutic foster care in preventing violence among children with SED. Insufficient evidence means that, given available evidence, it was not possible to determine whether or not the intervention works.
• On the basis of sufficient evidence of effectiveness, the Task Force recommends program-intensive therapeutic foster care on the prevention of violence among adolescents with histories of chronic delinquency.

None provided

The type of evidence supporting the recommendations is not specifically stated.

Communities can use the Task Force recommendation supporting program-intensive therapeutic foster care on prevention of violence among adolescents with a history of chronic delinquency to support, expand, and improve existing programs and to initiate new ones.

Not stated

Although the Centers for Disease Control and Prevention (CDC) provides staff support to the Task Force for development of the Community Guide, the recommendations presented in the original guideline document were developed by the Task Force and are not necessarily the recommendations of CDC, the Department of Health & Human Services (DHHS), or other participating agencies.

In selecting and implementing interventions, communities should carefully assess the need for such programs (e.g., the burden of violence committed by chronically delinquent adolescents). For local objectives to be achieved, recommendations provided in the Community Guide and other evidence should be used in the context of local information (e.g., resource availability; administrative structures; and the economic and social environments of communities, neighborhoods, and health-care systems). Program selection and design should consider the range of options relevant to the particular communities.

The original guideline document and the accompanying recommendation from the Task Force on Community Preventive Services can be used by public health policymakers, program planners and implementers, and researchers. It might help to secure interest, resources, and commitment for implementing these interventions and provide direction and scientific questions for additional empirical research to improve the effectiveness and efficiency of these programs.

Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2004 Jul 2

Task Force on Community Preventive Services - Independent Expert Panel

U.S. Department of Health and Human Services; Centers for Disease Control and Prevention (CDC)

Task Force on Community Preventive Services

Report Prepared by: Robert A. Hahn, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention (CDC); Jessica Lowy, MPH, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, CDC; Oleg Bilukha, MD, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, CDC; Susan Snyder, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, CDC; Peter Briss, MD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, CDC; Alex Crosby, MD, Division of Violence Prevention, National Center for Injury Prevention and Control, CDC; Mindy T. Fullilove, MD, New York State Psychiatric Institute, Columbia University, New York, New York, Task Force on Community Preventive Services; Farris Tuma, ScD, National Institute of Mental Health, Bethesda, Maryland*; Eve K. Moscicki, ScD, National Institute of Mental Health, Bethesda, Maryland*; Akiva Liberman, PhD, National Institute of Justice, U.S. Department of Justice, Washington, DC**; Amanda Schofield, MPH, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, CDC; Phaedra S. Corso, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, CDC

*Points of view are those of the contributor and do not necessarily reflect those of the National Institutes of Health.

**Points of view are those of the contributor and do not necessarily reflect those of the National Institute of Justice or the Department of Justice.

Task Force Chair: Jonathan E. Fielding, MD, Los Angeles Department of Health Services, Los Angeles, California

Members: Noreen Morrison Clark, PhD, University of Michigan School of Public Health, Ann Arbor, Michigan; John Clymer, Partnership for Prevention, Washington, DC; Alan R. Hinman, MD, Task Force for Child Survival and Development, Atlanta, Georgia; Robert L. Johnson, MD, New Jersey Medical School, Department of Pediatrics, Newark, New Jersey; Garland H. Land, MPH, Center for Health Information Management and Epidemiology, Missouri Department of Health, Jefferson City, Missouri; Patricia A. Nolan, MD, Rhode Island Department of Health, Providence, Rhode Island; Dennis E. Richling, MD, Union Pacific Railroad, Omaha, Nebraska; Barbara K. Rimer, DrPH; School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Steven M. Teutsch, MD, Merck & Company, Inc., West Point, Pennsylvania

Consultants: Robert S. Lawrence, MD, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; J. Michael McGinnis, MD, Robert Wood Johnson Foundation, Princeton, New Jersey; Lloyd F. Novick, MD, Onondaga County Department of Health, Syracuse, New York

Patricia A. Buffler, PhD, University of California, Berkeley; Ross Brownson, Ph., St. Louis University School of Public Health, St. Louis, Missouri; Mary Jane England, MD, Regis College, Weston, Massachusetts; Caswell A. Evans, Jr., DDS, National Oral Health Initiative, Office of the U.S. Surgeon General, Rockville, Maryland; David W. Fleming, MD, CDC, Atlanta, Georgia; Mindy Thompson Fullilove, MD, New York State Psychiatric Institute and Columbia University, New York, New York; Fernando A. Guerra, MD, San Antonio Metropolitan Health District, San Antonio, Texas; George J. Isham, MD, HealthPartners, Minneapolis, Minnesota; Charles S. Mahan, MD, College of Public Health, University of South Florida, Tampa, Florida; Patricia Dolan Mullen, DrPH, University of Texas--Houston School of Public Health, Houston, Texas; Susan C. Scrimshaw, PhD, University of Illinois School of Public Health, Chicago, Illinois; and Robert S. Thompson, MD, Department of Preventive Care, Group Health Cooperative of Puget Sound, Seattle, Washington also served on the Task Force while the recommendations were being developed.

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on September 16, 2004. The information was verified by the guideline developer on October 8, 2004.

No copyright restrictions apply.