A Families-First Approach to Foster Care

It’s difficult to change systems even when they are widely acknowledged to be broken. That’s the situation facing the nation’s foster care system. According to the government’s most recent estimate, there were roughly 424,000 young people in foster care as of Sept. 30, 2009. Each year, about 30,000 of them turn 18 (or 21 in some states) and “age out” of foster care. What happens to them?
The results are not encouraging, according to a major study published in 2010. Although there are many wonderful foster parents and many foster care alumni who overcome tough odds, most struggle to live successfully as adults. By age 23 or 24, fewer than half of the former foster care youths in the study were working. Close to a quarter had no high school diploma or equivalency degree and only 6 percent had completed a two- or four-year post-secondary degree. Nearly 60 percent of males had been convicted of a crime and 77 percent of females had been pregnant.

When you are dealing with complicated social, emotional and mental health problems, there are no easy answers. But today there is a promising alternative to foster care that is gaining traction — although it faces an uphill battle because it represents a departure from long-held assumptions in our child welfare system. The idea is to help youths return to their original families wherever it is possible to do so safely by providing their parents, or in some cases other relatives, with an extensive array of in-home support services.
This approach may seem counterintuitive, given that child welfare agencies intervene when courts deem parents unfit to care for their children. However, evidence indicates that intensive in-home services can bring substantial changes in families — and produce more successful outcomes than out-of-home models like foster homes or institutional care. (The average foster care youth goes through more than three placement changes and 65 percent experience seven or more school changes (pdf). About a quarter suffer from post traumatic stress disorder, up to twice the rate for U.S. war veterans.)
One of the leading practitioners of the family-services approach is a Memphis-based organization called Youth Villages, which works in 11 states and the District of Columbia, focusing on kids who have serious emotional and behavioral problems. Youth Villages has provided more than 20,000 youths and their families with intensive in-home services to reunite families or prevent children from being placed in foster care. It works in tandem with child welfare, mental health and juvenile justice systems.
Youth Villages monitors outcomes for every child it serves and allows independent researchers access to its data. The organization reports that, two years after completing its in-home programs, 83 percent of youths served were living successfully in families, 85 percent were in school or had gained a high school or equivalency degree, and 82 percent reported no trouble with the law. Moreover, these services are less expensive than out-of-home care. In Massachusetts, for example, the average cost for Youth Villages’ four- to six-month Intercept program, which currently has a 78 percent success rate in the state, is $18,000 per youth. By contrast, one youth in residential care can cost the state more than $125,000 per year (the average length of a stay) — and the success rate is about 40 percent.
Youth Villages was established in 1986 to operate residential treatment centers for youth involved in Tennessee’s juvenile justice and child welfare systems. But in the late 1980s, Patrick W. Lawler, Youth Villages’ chief executive, began questioning whether they were actually helping the youth they were serving. Like most people in his field, Lawler assumed that residential treatment was the way to go. “When a child comes into juvenile court, the records show all the problems with the family as well as the child,” he recalled. “You deduce that the family is the problem. Get the kid out of the family, the kid will be better. It didn’t work out that way.”
From time to time, Lawler would run into family members of young people he had worked with. “I’d say, ‘How’s Thomas doing? Or how’s Charlotte doing?’ ” he recalled. Most of the time he heard, “Not so good.” He’d be told that children had dropped out of school, gotten pregnant, or gotten arrested. Some kids were homeless or on drugs; some had committed suicide. “It started wearing on me a little,” he said.
So Youth Villages started doing follow up phone calls every summer to see what had happened to the youths who had been discharged the year before. About half had bad outcomes. Lawler’s response was to work with his staff to improve their counseling. They created a new school and beefed up the recreation program. “But year after year, we kept making those phone calls and the data kept coming back the same,” he said.
In 1993, he hired a graduate who had completed an M.B.A. from Vanderbilt University named Lee Rone to conduct research. He chose Rone because he had good analytic skills but knew nothing about children’s services. “We wanted somebody who had fresh eyes,” Lawler said. “We called him ‘the blank slate.’ ” Rone set out to interview a range of experts in child welfare asking them which services they thought were most badly needed. After 126 interviews, the top response was “intensive in-home family services.”
“We had no idea what that was,” Lawler recalled.
They did some digging and through a chain of leads they were connected with a group of researchers at the Medical University of South Carolina, who had recently developed a treatment model called Multisystemic Therapy (MST), which had shown promise dealing with chronic and violent juvenile offenders. (MST has since been repeatedly validated in rigorous studies as superior to standard services.)
The key to MST was that it focused on helping youth in the context of their families, schools and communities. In particular, it worked to strengthen families, not replace them. Youth Villages began using MST with 12- to 17-year-olds who displayed anti-social behaviors. Over time, the results got better. It then developed another program, Intercept, which was focused on getting children at all ages in the child welfare system safely reunited with family members, while preventing children at risk from falling into state custody.
In both cases, they would identify problems that needed to be addressed within families — mental health issues, substance abuse, undiagnosed depression, behavioral issues  — and develop a viable placement plan, in conjunction with child welfare advocates and the courts. That might mean assisting parents or identifying and supporting relatives who could step in as caregivers. Counselors would do everything from help caregivers learn to manage their medication, parent effectively (be consistent, enforce rules, offer praise) or enlist support from schools and people in the community.
Today, Youth Villages has 2,300 employees and is one of the largest providers of child welfare services in Tennessee. It has a variety of programs but it’s best known for its in-home services, which have garnered praise from the White House. The model is radically different from the prevailing child welfare approach. Its counselors each serve four to five youths rather than 30 to 40. They work in teams with clinical consultants. They are on call 24 hours a day, 7 days a week. They make a minimum of three home visits a week and sometimes as many as six or seven. They visit clients at work during lunch hours, or at home early in the morning, in the evening, or on weekends if necessary.
Youth Villages’ results are challenging the prevailing notion that states can do better than vulnerable families at raising children. “I don’t know who came up with this idea many years ago that to fix a child, it was best to take the child out of the home and put him in a foster home, a group home, or a residential treatment facility,” says Lawler. “For a few months it’s tolerable and in many cases necessary. But for a child to grow up in the system is terrible. Unfortunately that’s been the protocol for decades now.”
The problem is that most child welfare agencies are not oriented around returning children to permanent families — and their funding does not lead them to prioritize this goal. Money intended for out-of-home care doesn’t follow the child home. In fact, the federal government dedicates much more money to out-of-home care than it does to programs that provide flexible in-home services like Youth Villages. Large institutional care providers don’t get paid by the government for successful youth outcomes; they get paid to fill beds. Some entrenched interests have even fought to keep Youth Villages from working in their states.
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In Tennessee, Youth Villages has been credited with playing a catalytic role, helping the state’s Department of Children’s Services to upgrade the foster care system. Help came in 2000 when Tennessee was sued by a group called Children’s Rights which alleged, among other things, that the state placed far too many children in institutional care. (Many states are today operating under court oversight because their child welfare systems fail to provide safety and permanency for children.) Tennessee settled the lawsuit and from 2000 to 2009, the number of children in out-of-home care in Tennessee dropped from 10,144 to 6,702. It’s vital to note that incidences of “maltreatment recurrence” decreased during that period, which indicated that the changes hadn’t compromised children’s safety. Tennessee also started paying providers based on their successes, not just their services.
The innovations that Youth Villages has helped advance show how other social service organizations might improve outcomes, as well. At the top of the list is Youth Villages’ rigorous attention to data and its willingness to invest in strengthening families — even when the conventional wisdom held that families were the problem.
Youth Villages’ work also shows the value of governments experimenting with social organizations who have innovative delivery models. Unfortunately, without the public-interest lawsuit filed by Children’s Rights, and the subsequent court oversight, it’s doubtful that the state government would have gotten as serious about improving services as it did. Finally, of course, like any successful organization, Youth Villages is only as good as its execution — and that hinges on a motivated, well-managed workforce armed with good research. All of these things are worth noting. But above all, Youth Villages’ successes grew out of Lawler’s and his staff’s unusual willingness to examine their own performance unmercifully and to conclude that, despite their best efforts, they were failing. That’s tough to do. But it’s often the first step in real change.

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