Therapeutic Foster Care for Antisocial Youth

1. Therapeutic Foster Care for Antisocial Youth Justine Harris Clinical Director Youth Horizons Trust Auckland, New Zealand

2. 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

3. 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

4. Criteria for Conduct Disorder • Aggression • Destruction of property • Deceitfulness or theft • Serious violation of rules

5. Epidemiology • 3-5% of children • Increase in prevalence after 12 years of age • More common in boys than girls 2:1

6. Aetiology Studies suggest • Parental antisocial behaviour • Marital discord • Poor parenting strategies • Impaired patterns of interaction • Genetic factors driving environmental vulnerability.

8. 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

9. 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

10. 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

11. MDFC • Model and theory • Evidence and cost • Caregiver interventions • System intervention • Individual • family therapy • School and peer interventions

12. Special Issues • Recruitment • Training • Supervision and case coordination • Females • Early intervention

13. Model and Theory • OSLC – pre MDFC • Problems with delivering PMT in the community • Problem solving component • Clinically difficult to treat • Conflict in family • Influence of peer group • Safety of the community

14. Model and Theory continued • Residential option – influence of the peer group • E.g. positive peer culture • No 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

15. Group Home continued • Teaching families home • Some success • Smaller numbers • School interventions • Behaviour mangment • Relationship with family home staff

16. Research on Delinquency & Drug Use Condensed Longitudinal Model Prior Delinquent Behavior Family - + Low Parental Monitoring Low Affection High Conflict Delinquent Peers Delinquent Behavior + School - Low School Involvement Poor Academic Performance Elliott, Huizinga & Ageton (1985)

17. MDFC • Began in 1983 • Alternative to incarceration • Based on the vile weed model – Stages in the Coercion Model (Figure 9.1) • Case study

18. Conduct problem development model

19. MDFC – research guiding practice • CD stable over time • Without intervention problems escalate • Childhood onset more severe • Impact on the environment and vice versa

20. 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

21. Barriers that need to be overcome if treatment is to be successful • Attrition • Likely to be severe cases • Importance of engagement • Family stress and lack of social support • Family therapy less successful when children are older • Parents resistance to treatment

22. Family • Discipline • Permissive or rigid • coercion • Monitoring or supervision • Structure • consistency

23. Deviant Peer Group • Avoid aggregating peers • Support and skill yp’s for association with prosocial peer group

24. School • Coercive style with teachers and classmates • Clear consistent rules • Good supervision • Reinforcement • Social skills

25. 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).

26. 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 programme • Caregivers receive contract fee per year of $30,000 • Yp’s cost • Case coordination costs

27. 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

28. Foster home environment • Consistent tangible rewards and sanctions • Immediately delivered • Teenage learn from feedback

29. Young Person’s Response • Low level of social skills • Feel “hard done by” • “destructive entitlement” • Firm but fair approach with some room for negotiation

30. 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

31. 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

32. 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

33. Family • Discipline • Taught to give corrective feedback • Consequences e.g. taking away points • Ways to control the parents own anger • Sequencing • Roleplays • Communication, negotiation and problem solving • Rules and regulations regarding home visits

34. 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

35. 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

36. Peers • Close supervision and monitoring • Teach pro-social skills so youth can attract non-delinquent peer group • Teach problems solving, and conflict resolution

37. 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….

38. 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

39. 4 Step Screening Process • Initial contact where programme is explained • Application form and reference checks • Home visit • Screening with welfare services

40. Training • 20 hour pre-service – • with overview of TFC • 4 step process for analysing behaviour • Knowing when a problem is a problem • Defining the problem behaviour • Examine the antecedents of the problem • Change the consequences that maintain the problem

41. 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

42. Foster Parent Support • Foster parent meeting • Clinical meeting • Foster parent daily structured feedback • 24 / 7 on call support • Respite care

43. 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

44. Females • In treatment girls behaviour worsened • No differences in sexual behaviour or significant female outcome • Current adaptation of treatment programme

45. Adaptation of treatment programme (Patricia Chamberlain) • Address relational aggression • Address emotional dysregulation • Address risky sexual behaviour • Female mentor • Focus on safety, stability and containment

46. Early Intervention • Preschoolers with behaviour problems • Children with developmental delay • Maltreated children

47. 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