Interventions to strengthen foster family care

A systematic review and evaluation of health-related, social and health economic aspects

Certain interventions to strengthen foster family care may have positive effects for children in care. Promising results include improved mental health and attachment security, as well as reduced serious behavior problems, such as fewer days spent in locked units.

Reading time approx. 45 minutes Published: Publication type:

SBU Assessment

Presents a comprehensive, systematic assessment of available scientific evidence for effects on health, social welfare or disability. Full assessments include economic, social and ethical impact analyses. Assessment teams include professional practitioners and academics. Before publication the report is reviewed by external experts, and scientific conclusions approved by the SBU Board of Directors.

Contact SBU
Published: Report no: 408 Registration no: SBU 2023/425 ISBN: 978-91-989735-6-3 https://www.sbu.se/408e

Main message

Certain interventions to strengthen foster family care may have positive effects for children in care. Promising results include improved mental health and attachment security, as well as reduced serious behavior problems, such as fewer days spent in locked units.

Conclusions

After reviewing the scientific literature, SBU has drawn the following conclusions:

  • Attachment-focused parenting programs may reduce attachment insecurity for children in foster family care.
  • Treatment foster care for adolescents – more specifically Treatment Foster Care Oregon (TFCO) – may lead to fewer days in a locked ward, reduce substance use, and improve the mental health of adolescents with serious behavior problems.
  • The results also indicate that:
    • behavior-focused parenting programs may reduce externalizing symptoms of children in foster family care.
    • education-focused tutoring and mentoring programs may improve the reading ability of children in foster family care.
    • treatment foster care for adolescents (TFCO) may reduce deliquency of adolescents with serious behavior problems.

Aim

The purpose of this systematic review was to evaluate scientific support for interventions to strengthen foster family care. It also includes an analysis of health economic aspects.

Background

Family foster care is the dominant form of out-of-home care in Sweden, especially for younger children. Previous research has shown that children in care are a particularly vulnerable group with difficulties in several areas of life. For children with particularly extensive needs, more qualified interventions may be required where the foster families receive extra training, support, and supervision to meet children’s needs. Sometimes the children also need special support.

Method

We conducted a systematic review and reported it in accordance with the PRISMA statement. The protocol is registered in Prospero (CRD42024518998). The certainty of evidence was assessed with GRADE.

Inclusion criteria

The following two PICOs were used:

Foster family care and treatment foster care for younger children

Population: Children aged 0–17 placed in foster family care due to parental caregiving limitations, adverse home environments, or the child’s behavioral problems, with at least 70% in non-kinship foster family care
Intervention: Eligible interventions targeted children or foster parents and were delivered during foster family placements. We excluded interventions conducted in group care settings, interventions aimed at preventing placements, supporting family reunification, and at post-placement support
Control: Standard care, waitlist, or alternative intervention
Outcome: Children’s mental health (e.g., internalizing/externalizing symptoms), physical health, psychosocial functioning (e.g., education, substance use), placement stability, quality of life, or foster parents’ parenting skills or mental health

Treatment foster care for adolescents

Population: Adolescents aged 12–17 placed in treatment foster care due to their own behavioral problems
Intervention: Well-described intervention in treatment foster care
Control: Residential care
Outcome: Adolescents’ mental health (e.g., internalizing/externalizing symptoms), physical health, psychosocial functioning (e.g., education, substance use), placement stability

Study design: Prospective controlled trials, with or without randomization
Language: English or Scandinavian languages
Databases searched: MEDLINE (Ovid), PsycINFO, SocINDEX, Sociological Abstracts, and Scopus
Patient involvement: No

Result

A total of 23 interventions, evaluated in 55 articles, were identified and categorized according to their primary purpose (Flow chart). The categories are: (a) attachment-, or (b) behavior-focused parenting programs, (c) education-focused tutoring and mentoring programs, (d) treatment foster care for younger children or (e) adolescents, and (f) other psychosocial interventions. Overall, there was limited evidence available to assess the effects of the interventions, with few studies for each intervention. Many knowledge gaps were identified, for example regarding methods for assessing families who wish to become foster families, as well as interventions focusing on children’s physical health, including dental health. The conclusions presented above have low certainty. This means that the results may be accurate, but future research may change the picture.

The interventions aimed at strengthening foster care include various activities and strategies to support foster parents and children in care. The available evidence is insufficient to determine which of these components influence the effectiveness of the interventions.

A scientific publication presenting more detailed results is under preparation. A link will be provided below as soon as it has been published.

Health Economic Assessment

We included 2 health economic studies. No conclusions can be drawn about the relationship between costs and effects for interventions aimed at strengthening foster family care. The results from the two identified studies indicated that investing in TFCO is cost‑effective from a societal perspective, but this should be interpreted with caution due to major methodological limitations in the studies.

Discussion

More well‑designed research studies, for example with larger samples and clearer descriptions of the different components of the interventions, are needed to enable more reliable conclusions. There is also a need for studies on interventions aimed at improving the physical health of children in out‑of‑home care.

Conflict of Interest

In accordance with SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

Project group

Experts

  • Martin Bergström, associate professor,  PhD in social work, Faculty of Social Sciences, Lund University
  • Hilma Forsman, PhD and associate professor in social work, Department of Social Work, Stockholm University
  • Judith Lind, associate professor, Department of Thematic Studies (TEMA), Linköping University
  • Anna-Karin Åkerman, PhD and associate professor, Department of Behavioural Sciences and Learning (IBL), Linköping University

SBU

  • Annicka Hedman, project director
  • Uliana Hellberg, assistant project director until 2025-08-31 and head of unit from 2025-09-01
  • Sarah Vigerland, assistant project director from 2024-11-15
  • Álfheiður Ástvaldsdóttir, analyst from 2024-12-10
  • Carl Gornitzki, information specialist
  • Thérèse Eriksson, health economist
  • Caroline Jungner, project administrator until 2023-08-22
  • Elin Malmer, project administrator from 2023-08-23 until 2023-11-17
  • Anna Attergren Granath, project administrator from 2023-11-17 until 2024-12-18
  • Sara Fundell, project administrator from 2024-12-18
  • Sofia Carlsson, assistant project administrator from 2025-03-19
  • Sofia Tranæus, head of department until 2025-08-31

Flow chart

Flow chart.png
The selection of articles on the effects of interventions to strengthen foster family care (including treatment foster care for adolescents)

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