While therapeutic foster care programs vary considerably, they have some features in common. Children are placed with foster parents who are trained to work with children with special needs. Usually, each foster home takes one child at a time, and caseloads of supervisors in agencies overseeing the program remain small. In addition, therapeutic foster parents are given a higher stipend than that given to traditional foster parents, and they receive extensive preservice training and in-service supervision and support. Frequent contact between case managers or care coordinators and the treatment family is expected, and additional resources and traditional mental health services may be provided as needed.

Therapeutic foster care programs are inexpensive to start (few requirements for facilities or salaried staff) and have lower costs than more restrictive programs. In Ontario, a study found that therapeutic foster care cost half that of residential treatment center placement for the same period of time (Rubenstein et al., 1978).

There have been four efficacy studies, each with randomized, controlled designs. In the first study, 20 youths who had been previously hospitalized were assigned to either therapeutic foster care or other out-of-hospital settings, such as residential treatment centers or homes of relatives. The youths in therapeutic foster care showed more improvements in behavior and lower rates of reinstitutionalization, and the costs were lower than those in other settings (Chamberlain & Reid, 1991). In another study, which concentrated on youths with histories of chronic delinquency, those in therapeutic foster care were incarcerated less frequently and for fewer days per episode than youths in other residential placements. Thus, at 2-year followup, 44 percent fewer children in therapeutic foster care were incarcerated (Chamberlain & Weinrott, 1990). In a third study, outcomes for children in therapeutic foster care were compared with those of children in standard foster care. Children in therapeutic foster care were less likely during a 2-year study to run away or to be incarcerated and showed greater emotional and behavioral adjustment (Clark et al., 1994). In the most recent study, therapeutic foster care was compared with group care: children receiving the former showed significantly fewer criminal referrals, returned to live with relatives more often, ran away less often, and were confined to detention or training schools less often (Chamberlain & Reid, 1998).

All four studies of treatment effectiveness showed that youths in therapeutic foster care made significant improvements in adjustment, self-esteem, sense of identity, and aggressive behavior. In addition, gains were sustained for some time after leaving the therapeutic foster home (Bogart, 1988; Hawkins et al., 1989; Chamberlain & Reid, 1991).

There are also promising indications from uncontrolled studies. Looking at 18 reports from 12 therapeutic foster care programs across the country, Kutash and Rivera (1996) concluded that between about 60 and 90 percent of youth treated in therapeutic foster homes are discharged to less restrictive settings. Three programs also reported followup data, indicating that about 70 percent of youth treated in therapeutic foster homes remained in less restrictive settings for a substantial amount of time after treatment.

It is clear from these studies that therapeutic foster care produces better outcomes at lower costs than more restrictive types of placement. Furthermore, with the fairly recent development of standards for therapeutic foster care, as well as a standards review instrument (Foster Family-Based Treatment Association, 1995), services can be monitored for quality and fidelity to the therapeutic approach, making it easier to ascertain if the approach taken produces the favorable outcomes.

Therapeutic Group Homes
For adolescents with serious emotional disturbances the therapeutic group home provides an environment conducive to learning social and psychological skills. This intervention is provided by specially trained staff in homes located in the community, where local schools can be attended. Each home typically serves 5 to 10 clients and provides an array of therapeutic interventions. Although the types and combinations of treatment vary, individual psychotherapy, group therapy, and behavior modification are usually included.

There are two major models of therapeutic group homes. The first is the teaching family model, developed at the University of Kansas, then moved to Boys Town in Omaha, Nebraska (Phillips et al., 1974). The second is the Charley model, developed at the Menninger Clinic. Both models use their staff as the key agents for change in the disturbed youth; selection and training of the staff are emphasized. Both models employ couples who live at the homes 24 hours a day. The teaching family model emphasizes structured behavioral interventions through teaching new skills and positively reinforcing improved behavior. Other group homes use individual psychotherapy and group interaction.

There is a dearth of research on the effectiveness of therapeutic group home programs targeted toward emotionally disturbed adolescents. These homes have been developed primarily for children under the care of juvenile justice or social welfare. A dissertation (Roose, 1987) studied the outcomes of 20 adolescents treated in a group home. Adolescents with severe character pathology or major psychiatric disorders were not admitted. Twenty group home adolescents were compared with 20 untreated adolescents. At an 18-month followup, 90 percent of the treated group had fair or good functioning, defined by improved relationships with parents, peers, and fellow workers. Only 45 percent of the untreated group achieved similar functioning. The treated group experienced a significant decrease in psychopathology, while the untreated group did not.

Therapeutic group homes were compared with therapeutic foster care in two studies. The first study found equivalent gains for youth in the two interventions, but group home placement was twice as costly as therapeutic foster care (Rubenstein et al., 1978). A second study, a randomized clinical trial, compared the outcomes for 79 males with histories of juvenile delinquency placed in either group homes or therapeutic foster homes (Chamberlain & Reid, 1998). The boys treated in therapeutic foster homes had significantly fewer criminal referrals and returned more often to live with relatives, suggesting this to be a more effective intervention. The implication of these studies is that if therapeutic foster care is available, and if the foster parents are willing to take youth with serious behavioral problems, therapeutic foster care may be a better treatment choice for youth who previously would have been placed in group homes.

Existing research suggests that therapeutic group home programs produce positive gains in adolescents while they are in the home, but the limited research available reveals that these changes are seldom maintained after discharge (Kirigin et al., 1982). The conclusion may be similar to that for residential treatment center placement: long-term outcomes appear to be related to the extent of services and support after discharge. Adolescents who have been placed in therapeutic group homes because of mental disorders frequently have histories of multiple prior placements (particularly in foster homes), a situation that is associated with a poor prognosis. Thus, future programs would benefit from assessing alternative strategies for treatment after discharge from group homes.

Crisis Services

Crisis services are used in emergency situations either to furnish immediate and sufficient care or to serve as a transition to longer term care within the mental health system. These services are extremely important because many youth enter the mental health service system at a point of crisis. Crisis services include three basic components: (1) evaluation and assessment, (2) crisis intervention and stabilization, and (3) followup planning. The goals of crisis services include intervening immediately, providing brief and intensive treatment, involving families in treatment, linking clients and families with other community support services, and averting visits to the emergency department or hospitalization by stabilizing the crisis situation in the most normal setting for the adolescent. Crisis services include telephone hotlines, crisis group homes, walk-in crisis intervention services, runaway shelters, mobile crisis teams, and therapeutic foster homes when used for short-term crisis placements.

Crisis programs are small in order to facilitate close relationships among the staff, child, and family. Crisis staff are required to have skills and experience in the areas of assessment, emergency treatment, and family support. Short-term services are provided, with the staff meeting more frequently with the client at the outset of the crisis. A typical treatment plan consists of 10 sessions over a period of 4 to 6 weeks. Crisis services usually are available 24 hours a day, 7 days a week (Goldman, 1988).

Research on crisis services consists exclusively of uncontrolled studies. Kutash and Rivera (1996) reviewed 12 studies with pre-post designs. Positive behavioral and adjustment outcomes for youth presenting to crisis programs and emergency departments across the country were reported in all of the studies. Most programs also demonstrated the capacity to prevent institutionalization.

The most recent studies examine three different models: a mobile crisis team, short-term residential services, and intensive in-home service. The first study examined the Youth Emergency Services (YES) program in New York. This program included a mobile crisis team that sent clinicians directly to the scene of the crisis. The data showed that YES prevented emergency department visits and out-of-home placements (Shulman & Athey, 1993).

A second crisis program, in Suffolk County, New York, involved short-term residential services. In a study of 100 children served by the program over a 2-year period, more than 80 percent were discharged in less than 15 days. Most were diverted from inpatient hospitalization, and inpatient admissions to the state children’s psychiatric center for Suffolk County were reduced by 20 percent after the program was established (Schweitzer & Dubey, 1994).

In the third study, records were analyzed from a large sample of youth (nearly 700) presenting to the Home Based Crisis Intervention (HBCI) program in New York over a 4-year period. Youth received short-term, intensive, in-home emergency services. After an average service episode of 36 days, 95 percent of the youth were referred to, or enrolled in, other services (Boothroyd et al., 1995). The HBCI program was established at eight locations across the State of New York. Overall, programs with more access to community resources reported shorter average lengths of services.

Although crisis and emergency services represent a promising intervention, the research done so far only includes uncontrolled studies, limiting the conclusions that can be drawn. Kutash and Rivera (1996) recommend additional effectiveness research using controlled study designs and comparing differences between the various types of crisis services. Finally, there remains a need for investigation of cost-effectiveness as well as an exploration of the integration of crisis services into systems of care.