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Treatment Foster Care Oregon

Blueprints Program Rating: Model

A therapeutic foster care program that serves as an alternative to residential treatment by placing chronic delinquents in foster homes in the community with the goals of reuniting the families, reducing delinquency and teen violence, and increasing prosocial behavior and participation in prosocial activities. The program includes behavioral parent training and support for foster parents, family therapy for biological parents, skills training and supportive therapy for youth, and school-based behavioral interventions and academic support.

  • Patricia Chamberlain, Ph.D.
  • Clinic Director
  • Oregon Social Learning Center
  • 10 Shelton McMurphey Boulevard
  • Eugene, OR 97401
  • (541) 485-2711
  • (541) 485-7087
  • pattic@oslc.org
  • www.oslc.org
  • Delinquency and Criminal Behavior
  • Illicit Drug Use
  • Teen Pregnancy
  • Tobacco
  • Violence

    Program Type

    • Community Supervision and Aftercare
    • Foster Care and Family Prevention
    • Juvenile Justice, Other

    Program Setting

    • Community (e.g., religious, recreation)
    • Home
    • Transitional Between Contexts

    Continuum of Intervention

    • Indicated Prevention (Early Symptoms of Problem)

    A therapeutic foster care program that serves as an alternative to residential treatment by placing chronic delinquents in foster homes in the community with the goals of reuniting the families, reducing delinquency and teen violence, and increasing prosocial behavior and participation in prosocial activities. The program includes behavioral parent training and support for foster parents, family therapy for biological parents, skills training and supportive therapy for youth, and school-based behavioral interventions and academic support.

      Population Demographics

      Adjudicated serious and chronic delinquents (average of over 13 previous offenses) at the point of being removed from their homes by the juvenile authorities. All youth are referred by the juvenile justice system after other home-based interventions have failed. The Treatment Foster Care program has been adapted to meet the needs of other populations, including adolescents with severe emotional and behavioral problems referred by mental health and child welfare systems, youth with developmental disabilities who also have a history of sexual acting out, and a younger population of youth (12-16 years old). The evaluations on these populations show promise, but have not been as thoroughly tested.

      Age

      • Early Adolescence (12-14) - Middle School
      • Late Adolescence (15-18) - High School

      Gender

      • Male and Female

      Gender Specific Findings

      • Male
      • Female

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity/Gender Details

      The program is suitable for all ethnic groups. The program has been demonstrated effective for both boys and girls.

      Risk: Chronic delinquency, poor family management practices, lack of supervision, inconsistent, lax, and/or overly harsh discipline, association with delinquent peers, poor school attendance and performance, history of multiple arrests, early history of antisocial behavior at home and in school.

      Protective: Bonding with a prosocial adult, involvement in normative social activities, age-appropriate self-care and social skills, relationships with positive peers.

      • Neighborhood/Community
      • Family
      • School
      • Peer
      • Individual
      Risk Factors
      • Individual: Antisocial/aggressive behavior, Early initiation of antisocial behavior, Favorable attitudes towards antisocial behavior, Physical violence
      • Peer: Interaction with antisocial peers*
      • Family: Poor family management*
      • School: Poor academic performance
      Protective Factors
      • Individual: Clear standards for behavior, Problem solving skills, Prosocial behavior, Prosocial involvement, Rewards for prosocial involvement, Skills for social interaction
      • Peer: Interaction with prosocial peers
      • Family: Attachment to parents, Opportunities for prosocial involvement with parents, Parent social support, Rewards for prosocial involvement with parents
      • School: Rewards for prosocial involvement in school
      • Neighborhood/Community: Opportunities for prosocial involvement, Rewards for prosocial involvement

      *Risk/Protective Factor was significantly impacted by the program.

      See also: Treatment Foster Care Oregon Logic Model (PDF)

      Treatment Foster Care Oregon (TFCO), formerly Multidimensional Treatment Foster Care, is a cost effective alternative to group or residential treatment, incarceration, and hospitalization for adolescents who have problems with chronic antisocial behavior, emotional disturbance, and delinquency. Community families are recruited, trained, and closely supervised to provide TFCO-placed adolescents with treatment and intensive supervision at home, in school, and in the community; clear and consistent limits with follow-through on consequences; positive reinforcement for appropriate behavior; a relationship with a mentoring adult; and separation from delinquent peers. TFCO utilizes a behavior modification program based on a three-level point system by which the youth are provided with structured daily feedback. As youth accumulate points, they are given more freedom from adult supervision. Individual and family therapy is provided, and case managers closely supervise and support the youths and their foster families through daily phone calls and weekly foster parent group meetings. There is a learning emphasis on teaching interpersonal skills and on participation in positive social activities including sports, hobbies, and other forms of recreation. Placement in foster parent homes typically last for about six months. Aftercare services remain in place for as long as the parents want, but typically last about one year.

      The Treatment Foster Care Oregon (TFCO) Program was developed as an alternative to institutional, residential, and group care placement for teenagers with histories of chronic and severe criminal behavior. In most communities, such juveniles are placed in out-of-home care settings prior to being sent to closed custody incarceration. Typically, these settings include some type of group home or cottage on a larger institutional campus where youngsters reside with others who have similar problems and histories of offending. On a continuum of care, TFCO is a relatively non-restrictive community-based placement that can be used in lieu of residential or group care or that can be used for youth transitioning back to the community from such settings. TFCO is less expensive than placement in group, residential care, or institutional settings.

      The fundamental philosophy behind the program is reinforcement and encouragement of youth. Prior to placement, the case manager meets with an adolescent in detention to review the program model and program components. TFCO adolescents go through a behavior modification program which is based on a three-level point system by which the youth are provided with structured daily feedback. The youth have the opportunity to earn points throughout the day for expected activities outlined in the treatment, including going to class on school days. They lose points for any type of rule infraction, including attitude. The system emphasizes positive achievements, and point loss is handled matter-of-factly. Once the youth earn a total of 2100 points (this usually takes three weeks), they are able to ascend to a higher level. At each level, the youth are able to benefit from a more extended list of privileges, including home visits. At level three, the youth are even able to be involved in community activities without direct adult supervision.

      There is a learning emphasis on teaching interpersonal skills and on participation in positive social activities including sports, hobbies, and other forms of recreation.

      Once the program begins and an adolescent has been placed with a TFCO family, daily telephone contact is made and behaviors are assessed through the Parent Daily Report (PDR). These calls are brief and are designed to monitor the occurrence of problems during the past 24 hours. Points earned and lost are also tracked along with any incidents that may be affecting treatment. The youth is also assigned to an individual therapist who provides support and assists in teaching skills needed to relate successfully to adults and peers. Meetings with the individual therapist occur on a weekly basis. Family therapy sessions help parents prepare for the youth's return home and help them become more effective at supervising, encouraging, supporting, and following through with consequences. Parents are then able to practice these skills during home visits once the child has reached level two of the program. They work through a modification of the point level system being used in the TFCO home, which more closely aligns with the TFCO system as time goes on and home visits become longer and more frequent.

      Another component of the program is school monitoring. Youth have a school card, which they carry to class, and have teachers sign off on attendance, behavior, and homework completion. The cards are collected daily by the TFCO parents, and the teacher ratings transfer into points on the daily program. Once the program has been completed (typically 6 - 9 months) and the youth have returned home, families continue to receive aftercare support. Case managers remain on-call to families, and the point level system remains in place. Parents can participate in group sessions with other families, where they can continue to learn specific parenting skills, as well as receive feedback and support from other parents. Aftercare services remain in place for as long as the parents want, but typically last about one year.

      Social Learning Theory drives the program model. The rationale asserts that daily interactions between family members shape and influence both prosocial and antisocial patterns of behavior that children develop and subsequently bring with them into their interactions outside of the family. Reinforcement of negative behaviors by parents and response to coercive tactics of the child creates the antisocial behavior that puts the child at risk for, over time, the development into delinquent behavior, association with delinquent peers, and may result in school drop-out and drug use. Adolescent adjustment can be enhanced by the extent to which parents are able to effectively supervise their teenager, follow through with consequences when necessary, and promote positive involvement in school and other normative activities.

      • Attachment - Bonding
      • Behavioral
      • Social Learning

      Treatment Foster Care Oregon is a cost effective alternative to residential placement for chronic delinquents who have a long history with the juvenile court system and are also exhibiting chronic antisocial behavior and emotional disturbance. The initial evaluation randomized 85 serious juvenile male offenders determined by the juvenile court as eligible for out-of-home placement to either treatment or residential group care. After six months, the goal of the treatment was to return the boys, when possible, back to their family of origin. Other randomized-controlled evaluations have proven the program to be effective for girls, younger populations, and children and adolescents leaving state mental hospital settings. The most recent evaluation reports on a version of the program adapted for use with preschoolers and finds effects on attachment-related behaviors.

      Short term effects found in the research studies indicate significant reduction in incarceration rates, declines in subsequent arrests, declines in running away from their programs, and significant reductions in hard drug use. Results have shown that the program is effective when implemented with different populations of youth, including both boys and girls, younger children, and adolescents leaving state mental hospital settings. A followup of serious male offenders two years after program enrollment indicates that treatment youth were significantly less likely to have official violent referrals and to self-report violent offenses than youth placed in services-as-usual group care. Substance use outcomes were also reduced after 12 and 18 months post-program. Program implementation with delinquent girls revealed effects on delinquency at both 12- and 24-months after program entry. The odds of girls in group care becoming pregnant were 2.44 times that of girls in treatment.

      In an evaluation of the program adapted for use with preschool aged children, intervention condition did not significantly predict mean levels of secure, avoidant, or resistant behaviors at the final assessment point. However, intervention status significantly predicted change over time, such that intervention children showed significantly more positive change over time than controls on both secure and avoidant behaviors. There were no overall effects on trajectories of resistant behaviors.

      When implemented with delinquent boys, significant program effects, relative to a comparison group, included:

      • Incarcerated 60% fewer days 12 months after baseline
      • Fewer subsequent arrests 12 months after baseline
      • Less self-reported other drug use at 12 and 18 months, and tobacco and marijuana use at 18 months post-program
      • Fewer violent offense referrals (21% in treatment vs. 38% of Controls) two years after enrollment
      • Fewer self-reported violent offenses (10.5 incidents for treatment group vs. 32.6 incidents for control group) two years after enrollment
      • Ran away from their programs, on average, three times less often

      When implemented with delinquent girls, significant program effects, relative to a comparison group, included:

      • Fewer days in locked settings, fewer criminal referrals, lower caregiver-reported delinquency, and more time on homework at 12-months post-baseline
      • Reductions on a combined measure of days spent in locked settings, criminal referrals, and self-reported delinquency at 24-months post-baseline
      • Odds of becoming pregnant in group care 2.44 times higher than that of girls in treatment 24 months post-baseline (Kerr et al. 2009)

      Significant Risk and Protective Factors:

      • Family management skills and deviant peer association functioned as mediators of the effect of treatment condition on subsequent youth antisocial behavior.

      Data from two randomized samples (one male and one female sample) were combined, with adolescents either in treatment or group care. Path analyses showed that treatment youth had fewer associations with delinquent peers at 12 months than did the group care youth. Further, associating with delinquent peers during the course of the intervention mediated the relationship between group condition and 12-month delinquent peer association. All conditions for the test of mediation were met (Leve and Chamberlain, 2005).

      Mediation analyses in van Ryzin and Level (2012) supported the theoretical model by showing that the program reduced deviant peer affiliations at 12 months, which in turn reduced general delinquency and a construct of the number of days in a locked setting and number of criminal referrals at 24 months. These indirect effects of the program on the outcomes were small, with standardized coefficients of -.04 and -.06.

      Correlations of the program with the outcomes ranged from -.14 to -.20, indicating small to medium effects sizes.

      Since its initial study of adolescent delinquent boys, the program has been implemented with success with girls, younger children, and emotionally disturbed youth who are being placed out of mental hospitals. The program is designed to work with difficult populations of chronic offenders, and is individualized to meet the needs of its population. Study 4 (Chamberlain & Reid, 1994) was conducted on chronic juvenile offenders, in order to glean program differences between males and females. While support for differential outcomes by gender existed, researchers in this study caution that more exploration in this area should be conducted.

      • Blueprints: Model
      • Coalition for Evidence-Based Policy: Top Tier
      • Crime Solutions: Effective
      • OJJDP Model Programs: Effective
      • SAMHSA: 2.8-3.1

      San Diego Center for Children
      3002 Armstrong Street
      San Diego, CA 92111
      Contact Stewart Holzman, Program Director
      (858) 569-2116
      sholzman@centerforchildren.org

      Leake and Watts Services
      1529 – 35 Williamsbridge Road
      Bronx, NY 10461
      Contact Debra McCall, LCSW, Director of Foster Boarding Home Programs
      (718) 794-8274
      DMcCall@LeakeAndWatts.org

      Or
      Stephanie Glickman-Londin, LCSW
      TFCO Program Supervisor
      (718) 794-8453
      SGlickman@LeakeAndWatts.org

      International
      Youth Horizons Trust
      42 Vesty Drive, Mt. Wellingotn
      Auckland 1060
      New Zealand
      Contact Louisa Webster, Clinical Director
      + 64 95730954 ext. 215
      Louisa.Webster@youthorizons.org.nz

      Chamberlain, P. (1990). Comparative evaluation of specialized foster care for seriously delinquent youths: A first step. Community Alternatives: International Journal of Family Care, 2, 21-36.

      Chamberlain, P. (1997). The effectiveness of group versus family treatment settings for adolescent juvenile offenders. Paper presented at the Society for Research on Child Development Symposium, Washington, D.C., April 3.

      Chamberlain, P., Leve, L. D., & DeGarmo, D. S. (2007). Multidimensional Treatment Foster Care for girls in the juvenile justice system: 2-year follow-up of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 75(1), 187-193.

      Chamberlain, P., Moreland, S., & Reid, K. (1992). Enhanced services and stipends for foster parents: effects on retention rates and outcomes for children. Child Welfare League of America, Vol. LXXI(5),387-401.

      Chamberlain, P., Ray, J., & Moore, K. (1996). Characteristics of residential care for adolescent offenders: A comparison of assumptions and practices in two models. Journal of Child and Family Studies, 5, 285-297.

      Chamberlain, P., & Reid, J. B. (1991). Using a specialized foster care treatment model for children and adolescents leaving the state mental hospital. Oregon Social Learning Center. Draft.

      Chamberlain, P., & Reid, J. B. (1994). Differences in risk factors and adjustment for male and female delinquents in Treatment Foster Care. Journal of Child and Family Studies, 3, 23-39.

      Chamberlain, P., & Reid, J. (1998). Comparison of two community alternatives to incarceration for chronic juvenile offenders. Journal of Consulting and Clinical Psychology, 5, 857-863.

      Eddy, J., Whaley, R., & Chamberlain, P. (2004) The prevention of violent behavior by chronic and serious male juvenile offenders: A 2-year follow-up of a randomized clinical trial. Journal of Emotional and Behavioral Disorders, 12(1), 2-8.

      Eddy, J. M., & Chamberlain, P. (2000). Family management and deviant peer association as mediators of the impact of treatment condition on youth antisocial behavior. Journal of Consulting and Clinical Psychology, 68, 857-863.

      Fisher, P. A. & Kim, H. K. (2007). Intervention effects on foster preschoolers' attachment-related behaviors from a randomized trial. Prevention Science, 8, 161-170.

      Kerr, D. C. R., Leve, L. D., & Chamberlain, P. (2009). Pregnancy rates among juvenile justice girls in two randomized controlled trials of Multidimensional Treatment Foster Care. Journal of Counseling and Clinical Psychology, 77(3), 588-593.

      Leve, L. D., & Chamberlain, P. (2005). Association with delinquent peers: Intervention effects for youth in the juvenile justice system. Journal of Abnormal Child Psychology, 33(3),339-347.

      Leve, L. D., & Chamberlain, P. (2007). A randomized evaluation of Multidimensional Treatment Foster Care: Effects on school attendance and homework completion in juvenile justice girls. Research on Social Work Practice, 17(6), 657-663.

      Leve, L. D., Chamberlain, P., & Reid, J. B. (2005). Intervention outcomes for girls referred from juvenile justice: Effects on delinquency. Journal of Consulting and Clinical Psychology, 73(6), 1181-1185.

      Leve, L. D., Kerr, D. C. R., & Harold, G. T. (2013). Young adult outcomes associated with teen pregnancy among high-risk girls in a randomized-controlled trial of Multidimensional Treatment Foster Care. Journal of Child & Adolescent Substance Abuse, 22(5), 421-434.

      Rhoades, K. A., Chamberlain, P., Roberts, R., & Leve, L. D. (2013). MTFC for high-risk adolescent girls: A comparison of outcomes in England and the United States. Journal of Child & Adolescent Substance Use, 22(5), 435-449.

      Rhoades, K. A., Leve, L. D., Harold, G., Kim, H. K., & Chamberlain, P. (2014). Drug use trajectories after a randomized controlled trial of MTFC: Associations with partner drug use. Journal of Research on Adolescence, 24(1), 40-54.

      Smith, D. K., Chamberlain, P., & Eddy, J. M. (2010). Preliminary support for Multidimensional Treatment Foster Care in reducing substance use in delinquent boys. Journal of Child & Adolescent Substance Abuse, 19(4), 343-358.

      Van Ryzin, M. J., & Leve, L. D. (2012). Affiliation with delinquent peers as a mediator of the effects of Multidimensional Treatment Foster Care for delinquent girls. Journal of Consulting and Clinical Psychology, 80(4), 588-596.

      Westermark, P. K., Hansson, K. & Olsson, M. (2011). Multidimensional Treatment Foster Care (MFTC): Results from an independent replication. Journal of Family Therapy, 33, 20-41.

      TFC Consultants, Inc.
      John D. Aarons, President
      12 Shelton McMurphey Blvd.
      Eugene, Oregon 97401
      Telephone: 541-343-2388 ext. 204
      johna@tfcoregon.com
      Website: www.tfcoregon.com

      Study 1

      Chamberlain, P. (1997). The effectiveness of group versus family treatment settings for adolescent juvenile offenders. Paper presented at the Society for Research on Child Development Symposium, Washington, D.C., April 3.

      Chamberlain, P., Ray, J., & Moore, K. (1996). Characteristics of residential care for adolescent offenders: A comparison of assumptions and practices in two models. Journal of Child and Family Studies, 5, 285-297.

      Eddy, J., Whaley, R., & Chamberlain, P. (2004) The prevention of violent behavior by chronic and serious male juvenile offenders: A 2-year follow-up of a randomized clinical trial. Journal of Emotional and Behavioral Disorders, 12(1), 2-8.

      Smith, D. K., Chamberlain, P., & Eddy, J. M. (2010). Preliminary support for Multidimensional Treatment Foster Care in reducing substance use in delinquent boys. Journal of Child & Adolescent Substance Abuse, 19(4), 343-358.

      Study 6

      Chamberlain, P., Leve, L. D., & DeGarmo, D. S. (2007). Multidimensional Treatment Foster Care for girls in the juvenile justice system: 2-year follow-up of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 75(1), 187-193.

      Leve, L. D., & Chamberlain, P. (2007). A randomized evaluation of Multidimensional Treatment Foster Care: Effects on school attendance and homework completion in juvenile justice girls. Research on Social Work Practice, 17(6), 657-663.

      Leve, L. D., Chamberlain, P., & Reid, J. B. (2005). Intervention outcomes for girls referred from juvenile justice: Effects on delinquency. Journal of Consulting and Clinical Psychology, 73(6), 1181-1185.

      Study 7

      Kerr, D. C. R., Leve, L. D., & Chamberlain, P. (2009). Pregnancy rates among juvenile justice girls in two randomized controlled trials of Multidimensional Treatment Foster Care. Journal of Counseling and Clinical Psychology, 77(3), 588-593.

      Leve, L. D., Kerr, D. C. R., & Harold, G. T. (2013). Young adult outcomes associated with teen pregnancy among high-risk girls in a randomized-controlled trial of Multidimensional Treatment Foster Care. Journal of Child & Adolescent Substance Abuse, 22(5), 421-434.

      Rhoades, K. A., Leve, L. D., Harold, G., Kim, H. K., & Chamberlain, P. (2014). Drug use trajectories after a randomized controlled trial of MTFC: Associations with partner drug use. Journal of Research on Adolescence, 24(1), 40-54.

      Van Ryzin, M. J., & Leve, L. D. (2012). Affiliation with delinquent peers as a mediator of the effects of Multidimensional Treatment Foster Care for delinquent girls. Journal of Consulting and Clinical Psychology, 80(4), 588-596.

      Delinquent Boys Study
      (Chamberlain, Ray, & Moore, 1996; Chamberlain, 1997; Smith, Chamberlain, & Eddy, 2010; Eddy, Whaley, & Chamberlain, 2004)

      Intervention: Foster parents were recruited based on their experience with adolescents, willingness to act as treatment agents, and nurturing family environment. The selection process included a telephone screening, application, home visit, and 20-hour preservice training conducted by project case managers and a former TFC parent who served as foster parent trainer. Training emphasized behavior management methods to provide the boys with a structured living environment. Parents were taught how to implement an individualized plan for each youth. A three-level system was used where the boy's privileges and level of supervision were based on compliance with program rules, adjustment in school, and general progress. There were weekly foster parent meetings run by a case manager. Ongoing supervision was also accomplished through daily phone calls to check on the progress, problems, and potential solutions with each case (Parent Daily Report). Additional meetings were scheduled, as needed, to deal with routine problems in implementing the program.

      TFC youth participated in weekly individual therapy focused on skill building in problem solving, social perspective taking, and nonaggressive methods of self-expression. Once youth were allowed home visits, the visits began with one- to two-hour visits and increased to overnight visits. Youth carried a school card for teachers to sign off on attendance, homework completion, and attitude. Consequences for rule infractions included point and privilege loss, demotions to a lower level, work chores, and sometimes short stays in detention. Consequences were delivered even for small rule infractions. Youth were strictly supervised, and their whereabouts known at all times. All free time was prearranged, and peer associations were closely monitored with prohibitions against associating with peers with known histories of delinquency.

      Biological parents participated in weekly family sessions focused on parent management training (e.g., supervision, encouragement, discipline, and problem solving). During home visits by youth, parents used the same individualized program used in the TFC home. Following the home visit, the family therapist met with the biological parents and the youth to review problems and progress.

      Each case was assigned to a case manager, who coordinated all treatment and supervision services. Case managers were on-call 24 hours per day, seven days per week. They worked with the program director and clinical consultant, and supervised the individual and family therapists in weekly meetings. The program manager oversaw all clinical and management aspects of the program, and served as back-up for case managers. The program manager was also responsible for monitoring the program implementation and treatment integrity. This was accomplished through periodic review of the youth's daily point and school cards, weekly monitoring of the PDR data, conducting program evaluations, and through supervising the case managers.

      Evaluation Methodology

      Design: Seventy-nine boys, who were mandated into out-of-home care by the juvenile court, were randomly assigned to placement in Group Care (GC) or Multidimensional Treatment Foster Care (MTFC) between 1991 and 1995 (37 MTFC, 42 GC). Eighty-five boys were originally randomized, but parents of three boys in each condition declined to participate.

      In GC, boys lived with six to fifteen others who had similar histories of delinquency. In MTFC, a boy was placed in a home with a family who had been recruited from the community. MTFC parents were trained in the use of behavior management skills and were closely supervised throughout the boys' placement. In both conditions, treatment lasted for an average of seven months. Assessments were conducted at baseline (while boys were still residing in juvenile detention), 3 months after their placement through TFC, and at subsequent six-month intervals.

      Sample: These 79 subjects had spent an average of 76 days in detention. All of the boys had previously been placed out of their homes at least once. Seventy percent had one prior out-of-home placement, and 30% had at least two prior placements. The mean age at entry into study was 14.9 years (SD = 1.3 years), and the mean age at first arrest was 12.6 years (SD = 1.82). Eighty-five percent were Caucasian, 6% African-American, 3% American Indian, and 6% Hispanic. Boys who participated were from 12 to 17 years old (average age, 14.3), had an average of thirteen previous arrests and 4.6 prior felonies, and half had committed at least one crime against a person. All participants had extensive previous contacts with the juvenile justice system, had been supervised by parole or probation officers, and were labeled by the Department of Youth Services as chronic offenders. Their offenses included both misdemeanors and felonies; parole violations and status offenses were not included in the boys' offense counts. All boys were on parole or probation, depending on whether they had previously been committed to the state training school (in which case they were on parole), and were supervised by a parole/probation officer throughout the course of their placement and in aftercare. The period of time that parole/probation supervision lasted after treatment varied depending on the length of the jurisdiction, the boy's age, and whether he had completed restitution. There were no differences in parole/probation supervision for the two groups. There were no significant differences between the two groups with regard to age, arrest, and pre-treatment detention rates.

      Measures: Official arrest data recorded by the Oregon Youth Authority was collected before and after referral at one and two years posttreatment. Self-reported delinquency data was collected for three consecutive six-month periods (at referral for the previous 6 months, and at 6 and 12 months post referral). The self-report data measured how many times the boys engaged in criminal behaviors during a specific time frame. Three subscales were used: General Delinquency, Index Offenses, and Felony Assaults. Records on each youth were also kept regarding the number of days each month youngsters were actually in care, at the home of parents or relatives, on the run, in detention, or in the state training school. Records were also kept to determine whether or not the boys completed the programs.

      Analysis: A two-by-two (group by time) analysis of variance (ANOVA) was used on the official arrest data to assess criminal and delinquent activity. A multiple regression analysis, controlling for age at first arrest, age at baseline, and number of prior offenses, was used to determine whether any of these factors had an effect on subsequent arrests after enrollment in the program. Hierarchical regression analysis was used, using the same control variables, to predict the number of self-reported criminal activities during the year after referral.

      Outcomes

      3-Months Post-Baseline (Chamberlain, Ray, & Moore, 1996):
      After boys had been in placement for 3 months, caretakers and boys were interviewed on five occasions over a two week time period, using the Parent Daily Report Checklist (PDR) to assess problem behaviors over the past 24 hours. There were no differences in caretaker-reports of problem behavior frequency or on measures of peer contact and influence (time spent recreating with peers, time spent with nonprogram delinquent peers, or degree of influence negative peers had over boys). According to both caretaker and self-reports, Treatment Foster Care boys were disciplined significantly moreso than control boys. Caretaker reports also reveal significantly greater levels of adult supervision for TFC boys, relative to controls, though boys' self-reports showed no difference on this measure. Finally, TFC boys reported significantly less recreational contact with peers, significantly lower levels of influence from negative peers, and significantly lower frequencies of problem behaviors than control boys.

      Mediating Effects (Eddy & Chamberlain, 2000):
      Only 53 of the 79 participants in the randomized trial were included in this analysis of mediating effects, which occurred 3 months after placement, while youth were still in their placements. The final sample of 53 youth had fewer criminal referrals prior to baseline and spent less days in detention in the year prior to baseline than the 26 excluded youths. However, self-reported crimes in the year prior to baseline, number of pre-baseline felony referrals, age of first criminal referral, and age at entry into the study were not significantly different between the included and excluded groups. Within the sample of 53, there were no differences between GC and MTFC youth in terms of the number of days with at least one criminal referral prior to baseline, the number of self-reported crimes, the number of felony referrals, the age of first criminal referral, and the age at baseline.

      Results: Family management skills and deviant peer association functioned as mediators of the effect of treatment condition on subsequent youth antisocial behavior.

      12-Months Post-Baseline (Chamberlain, 1997; Chamberlain & Reid, 1998):
      This report focuses on criminal behavior outcomes in the first year after referral to the study. Boys participating in the TFC program spent significantly fewer days actually in their placement than did boys in the GC condition (mean = 77 vs. 130 days). Fewer boys in TFC ran away from their placement than boys in GC (31% vs. 58%), and a greater proportion of TFC than GC boys ultimately completed their programs (73% vs. 36%). During the year after program enrollment, boys in TFC, compared to GC, spent twice as much time living with parents or relatives (mean = 59 vs. 31 days).

      On the measure of criminal and delinquent activity, 41% of boys in the TFC group had no further arrests during the 12-month post-treatment period; this was true for only 7% of the GC boys. Multiple regression analysis, when controlling for age at first arrest, age at baseline, and number of prior offenses, revealed that the only significant predictor of post-referral arrests was group assignment, with the TFC youth showing significantly fewer arrests. Self-report data also indicate that TFC boys reported significantly fewer criminal activities (general delinquency, index offenses, and felony assaults). In addition, boys who stayed in treatment longer than 3 months were compared to those who left within or prior to the 3-month mark. Boys who remained in the program longer than three months reported fewer criminal activities (general delinquency and index crimes) than all boys in GC and TFC boys who left treatment before three months.

      12 and 18 Month Substance Use Outcomes (Smith, Chamberlain, and Eddy, 2010):
      The boys in the experimental condition had significantly lower levels of self-reported other drug use at 12 months (but not tobacco, marijuana, or alcohol use), and lower levels of tobacco, marijuana, and other drug use at 18 months (but not alcohol use).

      2-Years Post-Baseline (Eddy, Whaley & Chamberlain, 2004):
      This report focuses on violent behavior, as indexed by official records of violent offenses and self-reported violent behavior. Violent offenses were the number of times each participant had an official criminal referral for assault, menacing, kidnapping, unlawful weapons use, robbery, rape, sexual abuse, attempted murder, and murder. The self-reported violence index included several measures of hitting, attacking someone, using force or strong-arm methods, gang fights, and rape. Regression analysis was used, with controls for prebaseline factors and using one-tailed tests.

      The results indicated that two years after program enrollment, the Multidimensional Treatment Foster Care (MTFC) youth were significantly less likely to commit violent offenses (controlling for prebaseline factors) than youth placed in services-as-usual group care (GC). Twenty-four percent of the GC youth had two or more criminal referrals for violent offenses in the 2 years following baseline versus only 5% of MTFC youth. Additionally, the rates of self-reported violent offending for the MTFC youth were in the normative range following baseline, whereas rates for the GC youth were 4 to 9 times higher. Lastly, MTFC youth were significantly less likely to report incidents of common violence, such as hitting. Based on these results, the MTFC program had a positive effect not only on general rates of offending and on self-reports of serious violent behavior, but also on rates of official violent offenses and self-reports of more common violent behaviors.

      Chamberlain, P. (1990). Comparative evaluation of specialized foster care for seriously delinquent youths: a first step. Community Alternatives: International Journal of Family Care, 2, 21-36.

      Evaluation Methodology

      Design: Participating youth (n=16) had been committed to a training school in Oregon and then diverted to the Specialized Foster Care (SFC) program at the Oregon Social Learning Center. The 16 comparison group members were randomly selected from a pool of 435 youths based on their commitment and diversion to traditional community treatment programs, such as group homes, intensive parole supervision, or residential treatment centers, and matched to the SFC participants on sex, and age and date of commitment (within a three-month window. Four pairs were matched within a six-month window). The treatment youth were placed with foster parents who were chosen on the basis of their positive parenting skills and family environment.

      The application process was three-fold. First, applications were filled out and references checked. Then a home visit occurred in order to explain the program and observe the home and family environment. Lastly, eligible families attended an eight-hour training session held by an experienced foster parent and the program director. Parents who were chosen were trained and supervised specifically according to the Social Learning Family Therapy approach. Participating families received one SFC youth, and followed the Treatment Foster Care model, including the behavior management level system for youth, daily monitoring through progress reports with a case manager, weekly individual youth therapy sessions, and family therapy with biological parents (when available). Among the comparison group subjects, eight were placed in group homes, four in a secure residential treatment center, two in their parents' homes with intensive parole supervision, and two in a program conducting an application of the SFC model in another community.

      Sample: Participants in this study were six girls and ten boys. Comparison youth were chosen according to the criteria outlined above. Average age of youth in both groups was 14.6. Group differences were then assessed based on a multitude of risk indicators of child maladjustment, including family risk factors, child risk factors, child dangerousness, and child school adjustment. The only significant difference found between the treatment and comparison group was on the greater proportion of treatment youth who had been adopted. Overall, subjects in the treatment group were comparable to but somewhat more at-risk than their counterparts in the control group.

      Measures: Oregon Children's Service Division (CSD) records, which track the number of days in out-of-home placements were examined at three time periods: pretreatment - the number of days that the youth was incarcerated in either of the two Oregon state training schools during the one-year period prior to placement in the diversion program; days in treatment - the number of days that the youth participated in a CSD-funded diversion program; follow-up - the number of days that the youth was incarcerated during the two years post-treatment.

      Analysis: A comparison of means was used to determine the average amount of treatment received by both groups. The number of days incarcerated was counted independently by two research assistants for each of the three time periods. Intercoder agreement was calculated by dividing the number of agreements by the number of agreements plus disagreements, yielding a reliability coefficient of 96%.

      Outcomes
      Post-test: There were no statistically significant differences between the treatment and comparison groups prior to treatment. There were also no statistically significant differences found in the average amount of days spent in the treatment phase (142 for treatment group compared to 146 among comparison group). A higher proportion of youth placed in the SFC program successfully completed their treatment (75%) than comparison youth (31%). Interestingly, two of the five youth in the comparison group who were successful in completing treatment were those participating in the other community application of SFC. Reasons for failure to complete treatment among both groups included revocation through incarceration (three treatment youth compared to 4 comparison youth), or runaway (one treatment youth compared to seven comparison youth).

      Long-term: During the year following treatment, 38% (6) of the treatment youth were reinstitutionalized, compared to 88% (14) of the control group youth. In year two of the follow-up, seven of the treatment youth and ten of the comparison youth were incarcerated. Comparison youth also spent a higher average of days incarcerated (66.8 days compared to 44.3 days among treatment youth). Overall, during the two years following treatment, eight of the SFC youth and 15 of the comparison group youth were reincarcerated at least once. This difference was statistically significant. There was also a significant correlation between the number of days in treatment and the number of days of subsequent incarceration. The more days spent in treatment, the fewer days later spent incarcerated. No such relationship was found for the comparison group.

      Outcomes - Brief Bullets

      • More youth participating in the treatment foster care program successfully completed treatment, compared to youth who participated in other diversion programs.
      • One year following treatment, youth participating in the treatment foster care program spent, on average, 46% fewer days institutionalized than those in the matched comparison group.
      • Two years following treatment, experimental participants spent 34% fewer days incarcerated than comparison group youth.
      • With fewer youth spending fewer days incarcerated following treatment, cost benefits for youth participating in the treatment foster care program were significant (a difference of $88,000 after one year, $122,000 in the second year).

      Generalizability
      The sample size in this replication was quite small and therefore, caution should be used in generalizing the results of this replication to larger samples. Additionally, the single criterion measure (incarceration) limits the generalizability of the findings.

      Chamberlain, P., & Reid, J.B. (1991). Using a Specialized Foster Care treatment model for children and adolescents leaving the state mental hospital. Oregon Social Learning Center. Draft.

      Evaluation Methodology

      Design: Participating youth (n=20) were referred from the state mental hospital and then randomly assigned to either the Specialized Foster Care (SFC) group or to existing alternative treatment groups in their communities. This evaluation looked specifically at how the treatment foster care program would benefit a population of severely disturbed youth.

      The SFC model used for treatment participants included recruitment and screening of foster parents, preservice training, daily management of the child in the home and community, ongoing supervision and support for foster parents, family treatment, individual child treatment, and case management and community liaison services. Of the 10 control participants, 7 were placed in community settings during the evaluation. The other three youth remained in the state hospital. Of the 7 community placements, 3 were sent to residential centers, including a juvenile corrections training school, a group home, and a secure residential treatment center. Four went to family or relative's homes. The treatment received by control subjects included milieu therapy for those in the residential centers and the hospital. Types of therapy ranged from highly structured to more general. All but one control youth received some individual therapy. Amount of therapy ranged, with the least amount received by youth placed in a home setting. Group therapy also occurred for youth placed in the residential settings and for 2 of the 4 subjects placed in the home settings.

      Sample: Participants were referred to the study by a multidisciplinary team of staff from the Oregon State Hospital. Team members had worked with each case. Referrals were ready for community placement. After referral, subjects were randomly assigned to the treatment or control condition. A total of eight males and 12 females participated in the evaluation. Average age of participants was 13.9 years for treatment group and 15.1 for control group. Treatment participants had an average of 5.1 out-of-home placements prior to the current hospitalization, whereas control participants had an average of 5.0. Analyses revealed no significant differences between the two groups with regard to family make up, risk variables, or special clinical concerns (suicide attempts, drug/alcohol dependency, multiple runaways, chronic truancy, sexual abuse). Between both groups, four treatment and two control subjects had IQ scores that were at least one standard deviation below the normal range. On average, treatment participants had slightly lower IQ scores than those in the control group, although this difference was not statistically significant. During the year preceding referral to the study, treatment youth had been hospitalized an average of 245.1 days, compared to the 236 days for control youth.

      Measures: All youth were assessed at baseline on their severity of emotional disturbance, level of social competency, self-reported symptoms, and the occurrence of problem behaviors. At 3 and 7 months later, all measures except the severity of emotional disturbance were assessed again. To measure severity of emotional disturbance, youth took the Child Global Assessment Scale (CGAS) to measure level of functioning. Measures taken at baseline, and then again at 3 and 7 months included: Parent Daily Report Checklist (PDR) to measure occurrence of problem behaviors on a daily basis (phone monitoring by case manager); Behavior Symptom Inventory (BSI) to measure level of symptoms and distress (self-reported); Social Interaction Tasks used to measure child's level of social skills and problem solving. The Adolescent Problem Inventory (API) was used for youth 12 years and older, and the Taxonomy of Problematic Social Situations (TPOS) was used for children under 12. To gauge success or failure of each case, institutionalization rates were tabulated during three time periods: 1) the year prior to referral, 2) time from referral to initial placement out of the hospital, and 3) time from initial placement through the subsequent 365 days.

      Analysis: A comparison of means was used to determine differences in institutionalization rates. Analysis of variance (ANOVA) was used on the measure of occurrence of problem behaviors. On the measure of level of social competency, analysis on the TPOS was calculated by dividing the number of agreements by the number of agreements plus disagreements at baseline.

      Outcomes
      Post-test: Once referred, experimental subjects were placed outside the hospital after an average of 81 days, as compared to the 182 days to placement for control youth (p = .05). Once placed, treatment youth spent an average of 288 days living in their communities. Three of these participants were rehospitalized during the first 6 months, and one was briefly hospitalized (for 10 days) and then returned to the foster home. Control subjects placed outside of the hospital (n=7) spent 261 days in the community. Two were rehospitalized during the first 6 months and 1 was briefly hospitalized (for 3 days) and returned to community placement. The difference in days spent in the community was not statistically different, although it should be noted that fewer control subjects received community placement. For those participants between both groups who were only placed in family homes (all treatment, 4 of 10 control), the difference in number of days in the community (288 for treatment, 251 for control) was not statistically significant. On the pretreatment measure of severity of emotional disturbance, analysis revealed that both groups fell into the second lowest category - major impairment in functioning in several areas. On the measure of occurrence of problem behaviors, complete PDR data were available for 7 youth in each group at baseline, 3 months, and 7 months post baseline. At baseline, mean daily rates of problem behaviors were high (over 20 reported problems per day). At 3 months, treatment youth rates dropped over 50%, while control youth rates showed no decrease. At 7 months, mean daily rates among the control group decreased, but not to the level of the treatment group. There was no overall significant group by time interaction at 7 months, although the group by time interaction did reach significance when comparing baseline to 3 month data (p<.05). However, it must be noted that at the 3 month period, only 3 of the control subjects had been placed in a community setting, whereas 7 of the treatment youths had been placed. Due to the small sample size and potential differences in the quality of ratings between hospital caretakers and parents, caution must be exercised in evaluating these results. However, data does suggest that youth did seem to show behavioral improvements when moved to less restrictive specialized foster care settings. On the measure of self-reports of symptoms, at baseline, treatment youth reported twice as many problems as control youth. At 7 months, treatment youth were still reporting more distress than control youth, but these differences were no longer statistically significant. On the measure of social competency, no improvement was seen for either group. In fact, declines for both groups were evident from pre- to post-tests (differences were not statistically significant). On the measure of success (i.e., those living in the community at follow-up; n=14) or failure (i.e., those rehospitalized at follow-up; n=6) of cases at follow-up, only 2 of 6 cases where the subject had a below average full scale IQ score was successful, compared to 12 of 14 cases where IQ score fell within the normal range.

      No long-term follow up evaluation was conducted.

      Outcomes - Brief Bullets

      • Youth participating in the SFC program found placement in the community at a significantly faster rate than control group youth, which was substantially more cost efficient.
      • Daily reporting of problem behavior occurrence significantly decreased among treatment youth after three months in the SFC program.

      Generalizability
      The sample size in this replication was quite small and therefore, caution should be used in generalizing the results of this replication to larger samples, or in ferreting out differential findings based on age and sex. In addition, BSI and social interaction task scores may have been restricted due to the fact that participants never approached the normal range of function. Different measures, designed specifically for this population should be developed and used in future evaluations. Further, it would likely have taken longer than 6 months for youth to feel adjusted and comfortable outside of the more structured environment of the hospital setting to report improvements in self-efficacy.

      Chamberlain, P., and Reid, J.B. (1994). Differences in risk factors and adjustment for male and female delinquents in Treatment Foster Care. Journal of Child and Family Studies, 3, 23-39.

      Evaluation Methodology

      Design: This study was designed to ferret out the differences in treatment needs between boys and girls who participated in the TFC program. Participants had been referred to the Monitor Program, which utilizes the TFC model, including recruitment and training of foster parents, subsequent monitoring by case managers, and weekly individual and family therapy. One adolescent was placed with each recruited family, and the average treatment phase lasted 6 months.

      Sample: Total sample size (n=88) consisted of 51 males and 37 females. There were several significant differences between the males and females in the evaluation. Males were younger at their time of first arrest (by 10 months), had more total arrests, were more often the perpetrators of sexual abuse, and had committed more felonies. Females had been placed outside of their home more often, had been a victim of sexual abuse as a child four times as much as the male participants, were more likely to have run away and attempted suicide.

      Measures: To measure initial levels of problem behavior and the occurrence of the daily rate of conduct problems among the males and females, the Parent Daily Report (PDR) administered by case managers to parents was used. This was a 34-item checklist of problem behaviors exhibited by the child in the home each day. To measure patterns of conduct behavior over time, the PDR was examined for the first and sixth months while the participants were in the treatment program. Official arrest data were collected to determine the number of offenses committed for the 365-day period after exit from the program for each case. Offenses were coded into 3 types: status, property, and person-to-person offenses. Case workers determined the presence or absence of a set of 18 risk factors for each case. In addition, the presence of special clinical concerns that might affect placement and treatment was tracked. This information was gathered from case files.

      Analysis: A comparison of mean rates was used to analyze the daily rates of conduct problems between boys and girls and the types of offenses committed from arrest data.

      Outcomes
      Post-test: There were no significant differences between males and females with regard to completion of the TFC program, where nearly three-quarters (71% males and 73% females) successfully completed the Monitor program. On the measure of daily rates of conduct problems, at one month, rates of female aggressive behaviors were lower than males, but by month 6, while male rates had dropped, those of female participants had increased to the level of the males in month 1. During the year prior to program participation, girls committed more status offenses than boys, and boys committed more property offenses than girls, for which they were arrested. There was no difference in the number of person-to-person arrests. From pre- to post-test in rates of arrest, both genders showed decreases in the rates of arrest for status offenses, although there was no differential change over time by gender. For property offenses, again both genders showed a decrease in rates of arrest over time, with boys showing greater rates of improvement. Rates of arrest for person-to-person offenses also dropped for both genders, with no significant differences according to gender. With regard to prevalence of offense types by sex, both boys and girls showed marked declines in status, drug, property, and person-to-person offenses. While boys showed a decrease in prevalence of traffic offenses committed, offenses committed by girls increased (from 0% to 6.3%). On the measure of sexual abuse as a risk factor, analyses revealed that abused subjects had significantly more total offenses than did nonabused subjects and more status offenses.

      Long-term: During the year after program completion, females remained consistent in maintaining a higher rate of arrest for status offenses than boys, but there were no gender differences in rates of arrest for any of the other categories.

      Outcomes - Brief Bullets

      • After six months of treatment, girls exhibited an increase in problem/aggressive behaviors in the foster home, while boys showed declines.
      • Changes in prevalence rates of offending behavior showed decreases in status, property, drug, and person-to-person offenses for both genders from pretreatment to posttreatment.
      • Regardless of gender, the majority of program participants (over 70%) successfully completed the treatment foster care program.

      Generalizability: This evaluation was conducted on chronic juvenile offenders, in order to glean program differences between males and females. While support for differential outcomes by gender existed, researchers in this study caution that more exploration in this area should be conducted.

      Chamberlain, P., Moreland, S., & Reid, K. (1992). Enhanced services and stipends for foster parents: effects on retention rates and outcomes for children. Child Welfare League of America, Vol. LXXI (5), 387-401.

      This study is not a test of the program, but rather an attempt to evaluate effects of an increased stipend and enhanced support and training for foster parents.

      Evaluation Methodology

      Design: This study was designed to evaluate the effects of an increased stipend and enhanced support and training for foster parents. Participating children and their foster parents were placed into one of three conditions: enhanced support and training (ES&T) plus an increased payment of $70/month (n=31); increased payment of $70/month only (IPO; n=14); or foster care as usual (n=27).

      Sample: The sample included 72 children from three Oregon counties placed in foster care between 1988-1990 and their foster parents. Children were from four to seven years old and were expected to have been in foster care for at least three months. The children were predominantly Caucasian, and a majority were female. The leading stated reason for placement into foster care was parental neglect, followed by physical and sexual abuse. Foster parents were largely two-parent households (85%), with both parents in their early 40s. Average level of education among foster parents was some college, but not completed degrees. Average annual income was $20,000-$24,900. Families had an average of three biological children in the household. Foster parents in this evaluation had cared for an average of 21 foster children, indicating a high level of experience at providing care. There were no significant differences between the three conditions with regard to demographics or level of experience.

      Measures: Child behavior was measured using the Parent Daily Report, which measured problem behaviors on a daily basis. Data was collected at baseline and then at the three month mark. Foster parent measures included a dropout/retention rate, collected from Children's Services Division certifiers. A Staff Impressions Measure was used by study staff to rate impressions of foster parents' skills at discipline, their impression of the foster mothers' levels of personal strength, and the foster parents' levels of social skill. Surveys were also used by foster parents and caseworkers to determine the effectiveness of weekly training and support groups. These were administered only to those in the ES&T group. Children were also monitored on stability of foster care, by ongoing checks to determine whether foster children had left the home and if so, under what circumstances (returned home, ran away, or was moved to another foster home, residential or group care, juvenile detention, or psychiatric hospital.

      Analysis: A repeated measures analysis of change from baseline to the three month period was conducted on the parent daily report data. On the measure of staff impressions of foster mothers' ability to discipline appropriately, social skills, and level of personal strength, mean scores from each scale were compared.

      Outcomes
      Post-test: On the measure of foster parent retention, after two years, 16.6% of the foster families participating in the study discontinued providing foster care (compared to 40% statewide). Among the individual groups, the ES&T (9.6%) and IPO (14.3%) groups, which received additional services or a larger stipend, had lower dropout rates than the foster care as usual group (25.9%). On the measure of child outcomes, 18 of the 72 participating children were returned home during the two year period, due primarily to improvements observed by the caseworker in the family of origin's situation. Among those remaining, children stayed with their original foster home, were moved to another home, ran away, or were placed in a more restrictive setting. Among these remaining children, those in the ES&T group had significantly more successful days in care than children in either of the other two conditions. When combining the two treatment groups and comparing them to the control condition, the treatment group children had significantly fewer failures in their foster care placements (29% compared to 54%). On the measure of child behavior problems, at baseline, the ES&T group had a higher-than-normal frequency of daily problem behaviors than the other two conditions. However, by the three month follow up, foster parents in the ES&T group reported the greatest decline in problem behavior rates relative to the other two conditions. By three months, all three conditions were reporting problem behaviors in the normal range (3.85 - 4.56). The foster care as usual group actually slightly worsened over the three month period, as they had initially reported below normal levels of problem behaviors. On the measure of foster parent and caseworker satisfaction, foster parents overall reported satisfaction with the weekly group meetings, that the groups helped them deal effectively with their foster child's problems, and that they would definitely recommend the groups to other foster parents. Caseworkers also felt that the parents who participated in the weekly meetings benefited from the meetings, and that their ability to manage children's behavior problems improved. On the measure of staff impressions of the foster mothers' ability to discipline appropriately, social skills, and level of personal strength, significant differences were found on the discipline scale only. Foster mothers in the IPO group were rated as having significantly better discipline practices than those in the other two conditions.

      Outcomes - Brief Bullets

      • Foster parents who received additional training, monitoring, and/or financial support were less likely to discontinue foster care services than parents who received neither.
      • Children who were fostered by parents who received additional training and financial support had more successful days in foster care than children whose foster parents received only additional financial support or no additional services.
      • Children who were fostered by parents who received some type of additional service (training and/or stipend) were significantly less likely to fail in their foster care placement than children whose foster parents received no additional support.
      • Foster parents who received both additional training and a stipend reported the greatest improvement in child daily problem behaviors.
      • The cost benefit for additional staffing and other associated costs with a treatment foster care program is offset by the benefit of holding more families in the foster care system.

      Generalizability
      The researchers contend that because differences were found in the retention rates between all three conditions, particularly the control group, and those reported statewide, there may have been differences in foster parents', foster children's, or caseworkers' characteristics, or regional or sociocultural factors. Since no data was gathered statewide for comparison, generalizing the results of this study must be approached with caution. In addition, unsolicited comments from foster parents indicate that the positive benefits of participation in the study itself (feeling valued for contributing to the greater good of improving the foster care system) may have influenced some of the outcomes.

      Delinquent Girls - Study 1

      Leve, L.D. & Chamberlain, P. (2007). A randomized evaluation of Multidimensional Treatment Foster Care: Effects on school attendance and homework completion in juvenile justice girls. Research on Social Work Practice, 17, 657-663.

      Chamberlain, P., Leve, L.D., & DeGarmo, D.S. (2007). Multidimensional Treatment Foster Care for girls in the juvenile justice system: 2-year follow-up or a randomized clinical trial. Journal of Consulting and Clinical Psychology, 75 (1), 187-193.

      Leve, L.D., Chamberlain, P., & Reid, J.B. (2005). Intervention outcomes for girls referred from juvenile justice: effects on delinquency. Journal of Consulting and Clinical Psychology, 73 (6), 1181-1185.

      Evaluation Methodology

      Design: This study utilized a randomized, controlled design to examine program effects for girls in the juvenile justice system. Between 1997 and 2002, juvenile court judges in Oregon referred 103 girls to the program. These girls had all been mandated to out-of-home care for problems with chronic delinquency. Referred girls were screened for eligibility on four criteria: (1) between ages 13-17 years, (2) not currently pregnant, (3) at least one criminal referral in the prior 12 months, and (4) placed in out-of-home care within 12 months following the referral. 10 girls did not meet these criteria, while 8 refused to give consent to participate and another 4 could not be located. As a result, 81 girls (78.6%) were randomized to either the MTFC group (n = 37) or a control condition (n = 44). Girls and their current caregivers completed a 2-hour baseline assessment. At 3- to 6-months postbaseline, treatment fidelity measures were completed in the intervention setting. 2-hour follow-up assessments were conducted at 12- and 24-months postbaseline. Juvenile court records were also obtained.

      Sample: Girls were of an average age of 15.3 years. 74% were Caucasian, 2% were African American, 9% were Hispanic, 12% were Native American, 1% were Asian, and 2% were biracial or of another ethnicity. 63% were residing in a single-parent family and 32% lived in families with an income of less than $10,000. Prior to study entry, the average lifetime criminal referrals per girl was 11.9 and 70% had committed at least one felony. Nearly all girls had experienced prior maltreatment: 88% had documented physical abuse and 69% had documented sexual abuse.

      Measures: Delinquency was defined as engagement in an activity or behavior that could result in arrest and encompassed four measures: days in locked settings (detention or correctional facilities, jail, or prison), number of criminal referrals in the 12 months before and after treatment entry, caregiver-reported delinquency on the Child Behavior Checklist Delinquency Subscale, and self-reported delinquency measured by the Elliot Self-Report of Delinquency Scale. The 24-month postbaseline analysis collapsed these individual indicators into one delinquency construct, but did not include caregiver-reports.

      Educational engagement was also measured, through three items collected from the girls and their caregivers. These measures included: (1) the number of days in the past week that the girls spent at least 30 minutes per day on homework, (2) whether or not the girls did homework that day measured 3 times in one week, and (3) school attendance (1 = not attending, 2 = attending very infrequently, 3 = attending infrequently, 4 = attending more often than not, 5 = attending regularly, and 6 = attending 100% of the time).

      Analysis: 12-month post-baseline data were analyzed using ANCOVA with baseline scores as a covariate. Hypothetical mediating effects (examining whether homework completion during the intervention setting mediated the previously found effects of MTFC on days in locked settings) were tested using a path analysis based on Baron and Kenny's guidelines: (1) a direct effect of intervention group on the 12-month outcome in the absence of the mediating variable, (2) a direct effect of intervention group on the mediating variable, (3) a direct effect of the mediating variable on the 12-month outcome, and (4) a decrease in significance of the direct path from intervention group to the 12-month outcome in the presence of the mediator. Full information maximum likelihood was used to estimate means, variances, and covariances for the missing cases based on the observed data.

      Outcomes

      12-months post-baseline: Two publications report on 12-month outcomes. The first reports on delinquency outcomes measured through self-report, caregiver-report and the second reports on educational engagement as a mediator of days in locked settings. There was 12% attrition at 12-months but official records were obtained for all but 2% of the sample. Results of analysis of group differences at baseline showed no significant differences on demographic characteristics, past experience of abuse, or on the rates or types of past offenses.

      MTFC girls spent significantly fewer days in locked settings, had significantly fewer criminal referrals, and significantly lower scores on caregiver-reported delinquency than control girls. There were no significant differences between groups at follow-up for self-reported delinquency.

      MTFC girls also spent significantly more time on homework than controls and there was a marginally significant effect on school attendance for MTFC youth, relative to controls (p < .07). Results of path analysis indicate that homework completion significantly mediated the effect of MTFC on days spent in locked settings.

      24-months post-baseline: 5 MTFC girls (13.5%) and 9 control girls (20.5%) were lost to 24-month follow-up for an overall attrition rate of 17.3% from randomization, 28% of those eligible to participate attrited from the sample. However, data was analyzed using FIML (full-information maximum likelihood) and included all 81 girls.

      Effects found at 12-months were largely sustained. Compared to controls, MTFC produced significant effects on the overall delinquency measure and on days spent in locked settings. There was a marginally significant effect on the number of criminal referrals and, again, there were no significant effects on self-reported delinquency.

      Outcomes - Brief Bullets

      • Significantly fewer days in locked settings, fewer criminal referrals, lower caregiver-reported delinquency, and more time on homework for MTFC girls, relative to control girls, at 12-months post-baseline.
      • Homework completion significantly mediated the effect of MTFC on days spent in locked settings at 12-months post-baseline.
      • Significant reductions at 24-months post-baseline for MTFC girls, compared to controls, on a combined measure of days spent in locked settings, criminal referrals, and self-reported delinquency.
      • Program effects on days spent in locked settings were sustained at 24-months.

      Generalizability

      The relatively small sample sizes and predominance of Caucasian girls in these samples both limit generalizability of these findings. Additionally, data on attriters was estimated at follow-up assessments in order to include these girls in data analysis.

      Delinquent Girls - Study 2

      Kerr, D.C.R., Leve, L.D., & Chamberlain, P. (2009). Pregnancy rates among juvenile justice girls in two randomized controlled trials of Multidimensional Treatment Foster Care. Journal of Counseling and Clinical Psychology, 77 (3), 588-593.

      Leve, L. D., Kerr, D. C. R., & Harold, G. T. (2013). Young adult outcomes associated with teen pregnancy among high-risk girls in a randomized-controlled trial of Multidimensional Treatment Foster Care. Journal of Child & Adolescent Substance Abuse, 22, 421-434.

      Rhoades, K. A., Leve, L. D., Harold, G., Kim, H. K., & Chamberlain, P. (2014). Drug use trajectories after a randomized controlled trial of MTFC: Associations with partner drug use. Journal of Research on Adolescence, 24 (1), 40-54.

      Van Ryzin, M. J., & Leve, L. D. (2012). Affiliation with delinquent peers as a mediator of the effects of Multidimensional Treatment Foster Care for delinquent girls. Journal of Consulting and Clinical Psychology, 80 (4), 588-596.

      This study tests whether a behavioral intervention aimed at delinquency impacts pregnancy rates among adolescent girls in out-of-home placement.

      Evaluation Methodology

      Design: Participants were 166 girls who participated in one of two consecutively run randomized controlled trials; 81 participated in Trial 1 (see Study 6), 85 in Trial 2. The girls had been mandated to community-based, out-of-home care because of problems with chronic delinquency. Girls were 13-17 years of age at baseline, and were only recruited if they had at least one criminal referral in the prior 12 months, were not currently pregnant, and were placed in out-of-home care within 12 months following referral. Girls were randomly assigned to MTFC or group care. In this study (Trial 2), there were 44 MTFC and 41 GC girls.

      MTFC girls were individually placed in one of 22 highly trained and supervised homes with state-certified foster parents. Experienced program supervisors with small caseloads supervised all clinical staff; coordinated all aspects of each youth's placement; and maintained daily contact with MTFC parents to monitor treatment fidelity and to provide ongoing consultation, support and crisis intervention services. Interventions were individualized but include all basic MTFC components. In Trial 2 (the current study), the MTFC component also included an intervention component that targeted HIV-risk behaviors. The girls were provided with information on dating and sexual behavior norms and on HIV-risk behaviors and were taught strategies for being sexually responsible, including decision making and refusal skills. Girls were not randomly assigned to Trial 1 or Trial 2; participation in these consecutively run trials was based on when girls were court-mandated to out-of-home care. Group care (GC) girls were placed in 1 of 35 community-based GC programs located in Oregon. GC programs represented typical services for girls being referred to out-of-home care by the juvenile justice system. Both MTFC and GC program staff generally provided girls with guidance regarding reproductive services. These services were not a core part of intervention services in either condition, and neither the quality nor the types of these services were systematized in either setting.

      Leve et al. (2013): Young adult follow-up assessments were conducted at about seven years after baseline (though the follow-up period ranged from 3-13 years) when participants were about 22 years old, and then again six months later, or about 7.5 years after baseline. Of the 166 baseline participants, 164 were known to be living at the time of the follow-up. Of the 164, 85-96% completed each of the outcome measures, resulting in sample sizes ranging from 139 to 157. Key outcomes were substance use, miscarriage, and child welfare involvement for own parenting.

      Sample: 74% of the girls were Caucasian, 2% African American, 7% Hispanic, 4% Native American, 1% Asian, and 13% reported mixed ethnic heritage. At baseline, 61% of the girls lived with single-parent families, and 32% of the girls lived with families earning less than $10,000. There were no group differences on the rates or types of prebaseline offenses or on other demographic characteristics.

      Measures: The number of criminal referrals prior to the baseline assessment were collected using state police records and circuit court data. Court records list the individual charges for each girl and the disposition of each charge. Girls reported whether they had been sexually active in the last year (Trial 1) or in the last 6 months (Trial 2). Each girl and her current caregiver were separately interviewed at baseline regarding the girl's pregnancy history; caregiver reports were used when girls' reports were missing. In Trial 1, each girl and her current caregiver were separately interviewed at 12 and 24 months post-baseline regarding pregnancies that had occurred during the study. In Trial 2, the girls reported at 6,12,18 and 24 months post-baseline on whether they had become pregnant in the past 6 months; caregivers reported the girls' past year pregnancies at 12 and 24 months post-baseline.

      Leve et al. (2013): The study collected young adult outcome measures at follow-up assessments seven years and 7.5 years after baseline. Follow-ups were mostly conducted by phone, but 20% were in person. Dichotomous measures indicated whether the respondent reported the following outcomes at either follow-up assessment:

      • Marijuana use in the past six months
      • Illicit drug use in the past six months
      • Miscarriage of a pregnancy that occurred after the follow-up two years after baseline
      • Child welfare involvement for own parenting in the prior six months

      Analysis: In Kerr et al. (2009), logistic regressions were used to predict whether rates of pregnancy across the 24 months post-baseline differed by group assignment. The maximum likelihood estimator with robust standard errors was used, and the complex sample analysis option adjusted standard errors for non-independence of girls within GC or foster care sites. Baseline age, number of criminal referrals, and dichotomous measures of sexual activity and pregnancy history were considered as potential covariates. A group x trial interaction was also examined.

      In van Ryzin & Leve (2012), the analysis involved two steps. First, it examined the effects of MTFC on outcomes at 24 months with controls for baseline levels. Second, the analysis examined the mediation of the relationships between MTFC and 24-month outcomes by delinquent peer affiliation at 12 months. Structural equation models tested for direct and mediation effects with full information maximum likelihood estimation. A test showing that data are missing at random suggests no bias in the estimates due to missing data.

      Leve et al. (2013): Though not designed to provide a sensitive or comprehensive test of the intervention on young adult outcomes, logistic regression analyses determined program effects on four young adult outcomes. Models controlled for age and pregnancies during the two years after baseline, and substance use models also included baseline substance use as a covariate. Condition assignment and analysis were conducted at the individual level. The study appears intent-to-treat, as individuals with complete predictor and outcome data were analyzed as original condition assignment.

      Outcomes

      Kerr et al. (2009)

      Fewer MTFC girls reported a pregnancy through 24 months (26.9%) than did GC girls (46.9%). Baseline number of criminal referrals, sexual activity, and history of a prior pregnancy each predicted follow-up pregnancy, whereas missingness, age, trial and the group x time interaction did not. The significant group effect supported that MTFC decreased the probability of pregnancy after baseline relative to GC.; the odds for becoming pregnant during the follow-up period were 2.44 times larger for GC than for MTFC girls. Exploratory analyses to determine mechanisms of change suggested that baseline criminal referrals predicted follow-up pregnancies among girls in GC but not among those in MTFC.

      Van Ryzin & Leve (2012)

      The intervention condition was significantly correlated (.05 level) with the mediator of delinquent peer affiliations at 12 months (r = -.20) and with the number of days in a locked setting at 24 months (r = -.18). It was significantly correlated at .10 level with number of criminal referrals (r = -.14) but not with general delinquency.

      The mediation models examined the outcomes of general delinquency and a latent construct of the number of days in a locked setting and number of criminal referrals. MTFC significantly predicted delinquent peer associations at 12 months, which in turn significantly predicted both the latent construct and self-reported delinquency. Indirect effects on both outcomes were statistically significant but small (standardized coefficient = -.04 and -.06).

      Leve et al. (2013)

      The study found no significant intervention effect for the four young adult outcomes (marijuana use, illicit drug use, miscarrying a new pregnancy, and child welfare involvement). The study also found no significant moderated program effect for individuals who had a pregnancy in the two years following baseline.

      Though a mediation analysis was not conducted, other results in the models indicated that the program may influence young adult outcomes through teen pregnancy. A previous article (Kerr et al., 2009) reported a program effect on pregnancy across the two years after baseline, and this article showed that having had a pregnancy in these two years was associated with increased risk of illicit drug use (OR=1.89), miscarrying a new pregnancy (OR=3.87), and child welfare involvement (OR=1.81).

      Rhoades et al., 2014
      Using latent growth curve models, girls randomly assigned to MTFC when they were 13-17 years old reported significant decreases in drug use over a 2-year period in young adulthood (7-9 years after the study began), while those assigned to treatment as usual did not report significant decreases in drug use during this time.

      Preschooler Evaluation
      Fisher, P.A. & Kim, H.K. (2007). Intervention effects on foster preschoolers' attachment-related behaviors from a randomized trial. Prevention Science, 8, 161-170.

      Evaluation Methodology

      This publication reports on evaluation of a version of MTFC adapted for use with pre-schoolers. Following a team approach, services designed to meet children's developmental and social-emotional needs were delivered to children, foster parents, and permanent placement resources (birth parents and adoptive relatives or non-relatives). Children attended weekly therapeutic playgroup sessions to facilitate school readiness and were also visited by behavior specialists in the home and at preschool or daycare. Foster parent consultants provided 12 hours of intensive training to foster parents, along with support and supervision through daily phone calls, weekly parent support group meetings, and 24-hour on-call availability. The goal was to help foster parents to create a positive, responsive, consistent environment through use of limit setting for problem behavior and encouragement for positive behaviors. Family therapists also worked with birth parents or adoptive parents, when possible, to familiarize them with the parenting skills taught to foster parents and facilitate consistency between the two settings. Services were delivered for approximately 9 to 12 months, including the period of transition to permanent placement or, if the child was to be in foster care long-term, until behavior stabilized.

      Design: Foster children of preschool age (3 to 5 years) who were entering into foster care placement through the Lane County Branch of the Oregon Department of Human Services were targeted for program participation. These children were eligible if their placement was expected to last for at least three months. Recruitment occurred continuously over a 3.5 year period and randomization occurred prior to recruitment. Potential participants were randomly assigned to either the MTFC-P condition or to a regular foster care (RFC) comparison condition, after which caseworkers were contacted for consent to participate and foster parents were contacted for recruitment. All research staff members were blind to study condition.

      In total, 137 eligible children were randomized (64 MTFC-P and 73 RFC), while consent was obtained for 57 MTFC-P children (89%) and 60 RFC children (82%; overall retention rate 85.4%). Refusal rates for each group were not significantly different from one another. Data was collected at each of five 3-month intervals, including baseline, 3 months, 6 months, 9 months, and 12 months.

      Sample Characteristics: MTFC-P children were 49% male and, on average, 4.54 years of age. RFC children were 58% male and, on average, 4.34 years of age. Across groups, children were 89% European American, 5% Latino, 5% Native American, and 1% African-American. They had spent an average of 171 days in foster care prior to baseline assessment.

      Measures: Attachment-related measures were measured with the Parent Attachment Diary, originally developed for parent-reports of infant and toddler attachment. The PAD requires the parent to indicate how the child responds to being physically hurt or frightened (14 items) and to being separated (13 items). Responses for those items were coded for the following attachment-related behaviors: secure (proximity seeking, contact maintenance), avoidant (ignoring, moving away from caregiver), or resistant (displaying angry behaviors towards caregivers).

      Analysis: Latent growth curve modeling was used to analyze data from T1 to T5 (baseline to 12-months). Complete data from all five assessment points was unavailable for 30.8% of the sample. 14.5% of participants were missing data at three or more time points. Therefore, models were estimated using the full information maximum likelihood estimator in Mplus, which allows for inclusion of participants with only partial data on dependent variables. Finally, in order to examine individual variations in developmental patterns of attachment-related behaviors, a linear spline model was fitted to the data.

      Outcomes

      Baseline Equivalence and Attrition:
      Groups were not significantly different at baseline on child's age, gender, ethnicity, average time spent in foster care prior to study participation, type of current foster placement, number of permanent placements that occurred during the study period, or on outcome measures. Attrition was 6.1% for RFC at 3-months, 11.7% at 6-months, 16.7% at 9-months, and 30% at 12-months. There was no MTFC-P attrition at T2 or T3, but 7% were lost at T4 and 14% were lost at T5. At 12-months, then, overall attrition was 33.6% from randomization. Attrition was significantly lower for the MTFC-P, compared to RFC, at T2, T3, and T5, though there was no evidence of differential attrition by outcome measures.

      Results:
      While intervention condition did not significantly predict mean levels of secure, avoidant, or resistant behaviors at the final assessment point, intervention status significantly predicted change over time, such that MTFC-P children showed significantly more positive change over time than controls on both secure and avoidant behaviors. There were no overall effects on trajectories of resistant behaviors. Accounting for the interaction between intervention status and age at first foster placement, MTFC-P children who were older when first placed made the greatest increases in secure behavior. However, those placed when older were also more likely to show resistant behaviors. RFC youth who were younger when first placed, on the other hand, were the ones who made the largest increases in secure behavior. There were no age-effects for avoidant behaviors.

      Generalizability: Effects are generalizable to preschool aged children in the foster care system. Effects were not examined by gender or by race/ethnicity. It should be noted that the sample evaluated here is predominantly White.

      Limitations: Attrition is relatively high from the point of randomization, which occurred prior to recruitment, and program children and families were significantly more likely to be retained in the study sample than RFC comparison children.

      Westermark, PK, Hansson, K. & Olsson, M. (2011). Multidimensional treatment foster care (MFTC): Results from an independent replication. Journal of Family Therapy, 33: 20-41.

      This study is the first independent, randomized control study of Multidimensional Treatment Foster Care (MDFC) outside the USA.

      Evaluation Methodology

      Design: This evaluation of Multidimensional Treatment Foster Care (MTFC) focused on 35 Swedish antisocial youths and presents outcomes at 24-months post-baseline. A total of 35 Swedish youth (20 treatment, 15 control) participated in the evaluation. Data were collected at baseline, 6-months, 12-months and 24-months post-baseline, but results are only presented from 24-months. Multiple sources of information were used, including self-reports and mother reports.

      The treatment condition consisted of MTFC, and the control condition was 'treatment as usual' but included some intervention from the local child welfare authority. A total of 38 participants were referred by Swedish social agencies, but 3 declined to participate. Participants were referred for intervention due to serious behavioral problems. Criteria for inclusion include (a) diagnosis of a conduct disorder according to the DSM-IV and (b) were at risk of immediate out-of-home placement. Individuals were excluded from the study if they met one of the following criteria: (1) ongoing treatment by another provider (2) substance abuse without another antisocial behavior (3) sexual offending (4) acute psychosis (5) imminent risk of suicide (6) placement of the individual in a foster home that would cause a serious threat to the safety of the foster family.

      Attrition: Overall treatment attrition rate was 11%. A total of 2 participants were lost from the treatment group and 2 from the control group. However, following an intent-to-treat model, these youth were included in the final analysis.

      Sample: The sample included 35 Swedish youths (17 girls and 18 boys) with a mean age of 15.4 years. Almost half the sample had a history of previous interventions.

      Measures: A number of measures were used including the Youth Self-Report (YSR), Child Behavior Checklist (CBCL) and the Symptom Checklist-90 (SCL-90).

      • The YSR is a self-report measure completed by participants. The YSR contains 119 items that explores youths' behavior over the previous six months. Alpha coefficients for the YSR range from .71 - .95.
      • The CBCL was completed by participants' mothers and included 113 items that describe the behavior of their child over the last six months. The CBCL includes both internalizing and externalizing subscales and has alpha coefficients between .78 - .97.
      • The SCL-90 is a self-report rating scale for measuring psychiatric symptoms. Subscales of this measure were also used to measure mother's depression and anxiety. Alpha coefficients for the SCL-90 were between .81 - .91.

      Analysis: The study followed a 2 X 2 condition (treatment versus control X baseline versus post-test). ANOVA was used to examine the effects of MTFC on youth's behavior problems. A general linear model (GLM) was used to analyze the variation within groups at two different periods (baseline and post-baseline) and the statistical interaction effect between groups.

      Researchers measured the clinical significance of MTFC in two ways:

      1. Reduction in standard deviation: This is a change in an individual's symptoms compared to the normative level of the symptom. If the change was (at least) as large as one standard deviation from pre- to post-intervention in a positive direction, researchers considered this clinically significant.
      2. Minimum 30% reduction: A symptom reduction was also estimated if at least a 30% improvement (in a positive direction) was noted between baseline and post-test.

      Outcomes

      Implementation fidelity: There were no measures of implementation fidelity.

      Baseline equivalence and Differential Attrition: There were no significant differences between treatment and control groups at baseline. Participants who dropped out of either the treatment or control group (n = 4) were entered in the intent-to-treat analysis. The missing value was imputed by last observation carried forward.

      Post-test (24-Months)

      Externalizing: There was a significant difference between treatment and control conditions (favoring treatment) in the YSR externalizing subscale. This significant difference was noted in an ANOVA and in both clinical markers (reduction in standard deviation and minimum 30% reduction). There was also a significant difference between treatment and control conditions in the CBCL externalizing subscale, as measured by a minimum 30% reduction.

      Internalizing: There was a significant difference between treatment and control conditions in the CBCL internalizing subscale, as measured by a reduction in standard deviation as well as a minimum 30% reduction. There was no significant reduction in the internalizing subscale of the YSR.

      Psychiatric symptoms: There were no significant differences between treatment and control conditions in clinical reduction of psychiatric symptoms, as measured by the SCL-90. However, the ANOVA showed differences favoring MTFC for Depression and for the Global Severity Index.

      Outcomes - Brief Bullets

      • There was a significant difference between treatment and control conditions in externalizing, as measured by the YSR and CBCL.
      • There was a significant difference between treatment and control conditions in internalizing, as measured by the CBCL, but not the YSR.
      • There were no significant differences between treatment and control conditions in psychiatric symptoms, as measured by the SCL-90.

      Generalizability: This evaluation was performed on a small sample (n = 35) of Swedish youth, so the ability to generalize to other populations is unknown.

      Limitations

      • Small sample size (n = 35).
      • Significant outcomes for internalizing were not consistent across different scales (YSR and CBCL).
      • Less problematic, there are no tests for differential attrition of the 4 subjects (11%) lost to attrition. Since these subjects are included in the analysis by imputing missing outcomes with the last available observation, this likely is not serious.

      Rhoades, K. A., Chamberlain, P., Roberts, R., & Leve, L. D. (2013). MTFC for high-risk adolescent girls: A comparison of outcomes in England and the United States. Journal of Child & Adolescent Substance Use, 22 (5), 435-449.

      This study used a pre/posttest design to look at outcomes of MTFC participants in England. The sample consisted of 58 girls who were 12 to 16 years old. A full write-up is not included because the study did not use a comparison group and thus cannot identify program effects. However, paired sample t-tests of baseline and posttest (12 months after baseline) outcomes provide preliminary support that MTFC may be generalizable to European cultures. Results showed that the English girls had significantly improved rates of offending, violence, risky sexual behavior, self-harm, and school activities at posttest, but substance use did not change. Though the study also compared effect sizes of the pre/posttest differences for the England sample to those of pre/posttest differences for MTFC participants in Oregon (described in Study 7), these comparisons are unable to indicate program effectiveness, especially given that the two groups differed in sampling criteria, sample composition, outcome measures, program timing, and program components.