Therapeutic Foster Care: What Will It Take?
(Originally published December 2021)
Last month’s Sounding Board described a foster care crisis consisting of several factors: (1) chronic shortages of foster homes made worse by deliberate efforts in Family First legislation to reduce (through onerous regulations) the use of residential care; (2) naïve, poorly informed or disingenuous claims regarding strategies such as targeted recruitment of foster parents, enhanced supports for kinship care and evidence based prevention programs to compensate for the loss of residential care resources; and (3) the unwillingness of policymakers and most child welfare leaders to consider the only immediately viable options to staffed residential programs for behaviorally troubled and/or severely physically disabled children and youth, i.e., a cadre of professional foster parents and much larger investments in therapeutic foster care (TFC) models.
There has been a stubborn refusal by policymakers and child welfare directors to discuss investments in professional foster parenting and/or therapeutic foster care even after large increases in several states (including Washington) in hotel placements, office placements and 24-hour placements. Texas’ child welfare system has begun to use a category, “Child Without Placement” (CWOP), to refer to foster children for whom there is no licensed home or facility. A recent news story reported that conservatorship caseworkers (i.e., foster care caseworkers) in Texas work on CWOP cases more than 35 hours per week, i.e., almost the entire work week. Nevertheless, there is no indication that Texas child welfare leaders have a realistic plan to eliminate hotel placements and office placements for CWOP cases. There has been little public outcry in Washington to news stories regarding hotel placements and office placements despite an increase from 125 days of hotel placements in 2015 to 2500 days in 2021. The systemic abuse of foster youth has become business as usual in Washington state, with little or no serious discussion of realistic solutions in any public forum.
The disinclination to make large new investments in foster care of any type (except kinship care), and wishful thinking regarding the possibility of reducing entries- into- care through changes in IV-E funding rules for placement prevention services suggests that many child welfare leaders would rather allow foster care systems to collapse than to make a determined effort to improve them. The antipathy to residential care reflected in Family First has been extended to family foster care. However, the effects of Family First on placement prevention will take a decade or more to play out; and it is far from certain how most states will respond to new opportunities to create effective placement prevention services for children of substance abusing or mentally ill parents. Currently, there are more than 400,000 children in foster care, half of whom have behavior problems and a quarter of whom need a professional level of care. A volunteer foster care model has been a proven failure for behaviorally troubled children whose behavior problems often worsen through multiple placements, misuse of psychotropic medications, and (sometimes) further maltreatment in foster homes or residential care settings, as well as failed permanent plans.
However, there have always been commendable examples of therapeutic care, both among foster parents and residential care programs. It is past time to recognize best practices and to invest in the development of a cadre of professional foster parents – about 10% of non-kin licensed homes initially - and in model TFC programs, and in the rigorous evaluation of these initiatives.
This commentary discusses the requirements and challenges of creating a therapeutic foster care system for behaviorally troubled and severely physically disabled children and youth. Child welfare agencies will need an experimental mind set, along with a willingness to collaborate with private agency staff and experienced foster parents in developing policies and practices to support therapeutic foster care. The idea that evidence based TFC programs can be identified on authoritative websites and successfully implemented through strict adherence to program manuals is mistaken. Local flexibility and “buy in” at the community level are necessary to take evidence-based programs to scale.
Investments in programs or parents?
Public agency investments in TFC care usually support programs administered by private agencies for several reasons: (a) private agencies provide organizational supports for foster parents that would otherwise have to be delivered by public agency staff; (b) fees paid to private agencies conceal enhanced reimbursement to foster parents some policymakers oppose on principle; (c) private agencies that deliver services over decades are easier to effectively regulate than foster homes which are transitory. However, funding private agencies to administer TFC limits the reimbursement paid to foster parents with the result that a single foster parent or low income foster parents may need to work outside the home. Effective TFC programs need at least one foster parent who devotes their energies full time to parenting without the parent maintaining other employment.
The funding of TFC programs is not a substitute for investments in professional foster parents on which these programs depend.
Professionalism requires education in a knowledge base, certification or licensing, apprenticeship, standards of practice (including ethical standards), a career ladder and social recognition. Training in a specific TFC model should not be confused with professional training. Furthermore, a large-scale expansion of TFC depends on the ability to attract persons of all ages to professional foster parenting rather than commitment to a specific agency. Child welfare caseworkers do not become professionals through basic training programs and adherence to policy manuals. This is how paraprofessionals are trained and managed. Committed professionals study their profession and develop knowledge and skills that define their expertise. The same guideline applies to professional foster care.
Expectations of professional foster parents
Professional foster parents need to be knowledgeable regarding common mental health conditions and skillful in responding to both externalizing and internalizing behavior problems. However, professional knowledge and skills can have therapeutic benefits only when foster parents have an unwavering commitment to the children and youth in their home. Concretely, this means that foster parents are committed to difficult to manage youth through thick and thin, i.e., there can be no emergency ejections of a youth from their home, no unplanned moves. Some emotionally troubled youth may occasionally need psychiatric hospitalization or may need to be moved to a home or residential setting that can better meet their needs; but moving a youth from one home to another should never reflect rejection – an intent to sever all ties to the youth.
Unwavering commitment to a child or youth can only occur when foster parents have the confidence and skills to cope with “meltdowns” with minimal use of physical restraints and with the goal of helping an out-of-control child recognize their triggers for loss of emotional control; and learn ways of limiting the severity of “meltdowns.” School age children who cannot avoid explosive reactions to stress or who cannot control their behavior once a “meltdown” has begun cannot adapt to the demands of school, develop friendships, or stay out of criminal trouble during adolescence. A liability to “meltdowns” is an indicator of trauma; it is a severe disability which endangers both family life and the ability to live outside institutional settings. First and foremost, trauma informed care assists children and youth regulate their emotional reactions to stress and safety threats. Therapeutic foster parents must have these skills, though not necessarily for every troubled youth. TFC homes must be staffed and organized in a way that ensures the safety of both caregivers and all children in the home.
Every TFC parent needs intensive training in how to manage children’s oppositional behavior without becoming trapped in unproductive
power struggles (easier said than done); and reverting to harsh punishment to suppress unruly behavior. Foster parents must model approaches to conflict resolution that preserve rather than destroy positive relationships. Finding effective responses to oppositional behavior is the decisive test for therapeutic foster parents, a test they are sure to face with oppositional youth and other children as well. If a foster parent cannot pass this test, it’s unlikely they will last long in TFC.
Highly skilled foster parents do more than effectively manage challenging behavior; they also identify and disconfirm the dysfunctional beliefs implicit in a child’s self-defeating behavior. John Sprinson and Ken’s Berrick’s book, Unconditional Care: Relationship–Based Behavioral Intervention with Vulnerable Children and Families (2010) is eloquent on this subject. Examples of common beliefs that lead to troubled behavior include:
No one can be trusted; I’m on my own
I don’t need anyone
I am not afraid; I will make others afraid
It’s a dog-eat-dog world
It’s better to be feared than pushed around
I’m unlovable; it would have been better if I was never born.
Sprinson and Berrick refer to the constellation of beliefs that motivate behavior as the child’s “internal working model.” Behaviorally troubled children seek to confirm their model of the world even at great cost to themselves. It is the job of TFC parents to discern through careful observation a difficult child’s implicit beliefs, and to repeatedly disconfirm those beliefs in responses to oppositional behavior, and through spontaneous acts of affection and positive recognition of desirable behavior.
TFC parents should pay careful attention to a youth’s interests and incipient talents; and seek out opportunities for the youth to develop those talents. School age children and youth who have difficulty in school need to develop a prosocial talent that leads to positive social recognition. For adolescents with mental health problems, there may be a limited window of opportunity to discover a prosocial talent before they develop an identity based on antisocial behaviors.
It is the job of TFC parents to reach out to children’s parents, siblings, and other extended family members, and to develop partnerships with family members to the extent possible. Maintaining and strengthening family connections benefits most -- but not all - troubled youth. There are parent-child relationships that cannot be salvaged due to horrible past events. However, for most children and youth emotional healing requires the repair and nurture of family relationships. Foster parents can also coach and mentor parents toward reunification, a goal that is not realistic in all cases. Nevertheless, even when reunification is not possible, therapeutic
foster parents should do everything in their power to minimize additional losses of children’s family ties.
Ideally, therapeutic foster parents function as extended family members after a youth has left their home, and parents or other caregivers should be able to call upon a foster parent as needed following reunification.
Challenges and dilemmas in a state child welfare system
(This information was provided by Judith Schagrin, a veteran child professional who worked in Maryland’s child welfare system for many years.)
Maryland’s child welfare system has utilized therapeutic (aka treatment) foster care for more than 3 decades. The expansion of therapeutic foster care (TFC) was a major factor in Maryland’s large reduction in use of residential care. However, there were some youths who could not be safely cared for in a family home. Maryland’s experience indicates that TFC cannot totally replace the need for residential care and institutional care.
Some therapeutic foster care placements in Maryland lasted for years when reunification had been ruled out, and when a child’s emotional well-being depended on a stable relationship with the foster parents. Most of these youth had a continuing relationship with one or both parents. According to Schagrin, “in my considerable experience, the most successful foster parents are the most diligent at engaging the biological parents in shared parenting.” The younger the child, the more important it was for the foster parent(s) to actively seek and support shared parenting.
In past years, Maryland’s TFC foster parents were paid a monthly “board rate” of $900 and a “difficulty of care” stipend of $1000 per month, inadequate compensation for the care of behaviorally troubled children and not adequate compensation to support a foster parent who lacked employment outside the home. Private agencies had difficulty recruiting “stay at home” foster parents, and sometimes turned a blind eye to marginal applicants due to the need for homes. Maryland’s experience suggests the difficulties of expanding TFC without professional foster parents who are paid enough to make a full-time career of foster parenting. Private agencies which administered TFC programs had an incentive to license questionable applicants, and occasionally ignored insensitive or emotionally abusive caregiving to maintain a supply of licensed TFC homes.
Economic considerations had a major impact on quality of care and on permanency decisions. Schagrin asserts that Maryland’s child welfare system never found a good solution to ‘step down’ policies, i.e., reduction of financial compensation to foster parents as a youth’s behavior improved. Schagrin states: “I’m sorry to say that when some sort of ‘step down’ was proposed it was startling how much a youth would reportedly regress.”
Child welfare staff in Maryland were sometimes faced with the dilemma of whether to move a child from a TFC home when the foster parent(s) would not agree to adoption or guardianship for financial or other reasons. According to Schagrin, some TFC parents would willingly accept lower adoption support or guardianship payments, but some would not. Child welfare staff were then faced with “Solomonic” decisions regarding the best interest of a youth who preferred stability in their current home to legal permanency with an unknown family.
There were periods in Washington state when agency policy required that children in TFC homes who could not return to parents be moved to a ‘step down’ home after 9 -12 months unless the foster parent agreed to adoption or guardianship. Children and youth were often emotionally damaged by these policies in the name of permanency or cost controls.
A sensible policy would reward TFC parents for outstanding performance (rather than financially punishing them) by paying foster parents a salary or set fee for 12-18 months and then paying a large bonus when a youth improves on a range of objective measures. However, there is no way around the dilemma that when a TFC parent makes a legal commitment to a foster youth, their capacity to take other troubled youth will likely be reduced.
Schagrin’s comments suggest the difficulties of TFC implementation. She states: “I’m not preaching against TFC, only intending to offer a cautionary note.” There is nothing easy about the care of behaviorally troubled youth; every placement alternative presents difficult challenges.
Can public systems afford professional foster care?
A recently published Child Trends report asserts that the federal government and state and local governments expended a total of $33 billion dollars on child welfare programs and services in FY 2018; 56% of this funding came from state and local governments. Any claim that a large increase in child welfare funding is impossible when the federal government spends less than $15 billion dollars annually on child welfare is nonsense.
In Washington State, DCYF has been spending an average of $2000 per night on hotel stays (2500 days in 2021) and as much as $300-$600 per night on 24-hour placements. It is not fiscal considerations that stand in the way of major investments in TFC and development of a cadre of professional foster parents; rather, it is the opposition of key legislators to the very idea of professional foster care combined with the opposition of some influential child advocates to additional investments in foster care improvements.
The idea that public systems must make a choice between investments in prevention and enhancements to current programs is child welfare ideology that does not reflect fiscal limitations or political realities. It is not difficult to convince persons of good will that children who have been removed from their parents deserve humane and therapeutic treatment in foster care. How then has a situation developed in which to advocate for foster care improvements urgently needed to stop systemic mistreatment of foster children/youth is viewed as retrograde (at best) and possibly ethically suspect?
Gardner, W., “A Growing Problem” Foster children without placement rise in Texas,” Community Impact Newspaper, December 22, 2021.
Rosinsky, N, Williams, S., Fisher, M & Haas, M., Child Welfare Financing 2018: A Survey of federal, state, and local expenditures (2021), Child Trends.
Sprinson, J. & Berrick, K. , Unconditional Care: Relationship-Based, Behavioral Intervention with Vulnerable Children and Families (2010),
Oxford University Press, Oxford / New York City.
Judith Schagrin – firstname.lastname@example.org; describes herself as a “professional lifer” in the child welfare system having spent 35 years as a social worker providing services across the child welfare continuum. “I spent 20 years as the foster care administrator in a large Maryland county department. Although I retired, I still can’t get enough of child welfare and continue to work part time on a child welfare consent decree and to teach social work. “