Approximately 2,000 adolescents are annually placed in residential care in Sweden due to their behavior problems. Those adolescents also have substantially increased risks of mental and physiological problems at time of care entry, while in care and in adulthood. An alternative to residential care is Treatment Foster Care Oregon, TFCO (previously called Multidimensional Treatment Foster Care). TFCO has been available in Sweden since the beginning of the 2000s. This report reviews and synthesizes the evidence regarding TFCO for seriously delinquent adolescents.
There is moderate certainty of evidence that placing seriously delinquent adolescents in TFCO reduces the risk for future criminal behaviour and consequently lowers the number of days in locked settings compared to when adolescents are placed in residential care. TFCO may also reduce the risk of delinquent peer associations and drug use, while improving the individuals’ psychological health compared to individuals receiving residential care.
TFCO costs are lower when compared to the fees set by secure residential care, but slightly higher than the rates of residential homes, assuming that the care times for the different settings are the same. Considering the long-term effects, TFCO is more cost-effective than both types of residential care mentioned above.
Approximately 30–40 adolescents in Sweden annually receive TFCO. If more people are to receive this treatment, additional TFCO teams need to be established, which would require increase in funding that would allow for more efficient training and certification.
The alternative to TFCO is institutional care, normally supplemented with various interventions. The evidence of their benefits and harm is inadequate because of lack of effectiveness trials. From an ethical point of view, it is important to have reliable knowledge of the pros and cons of all other supplementary treatments used.
Background and purpose
Seriously delinquent adolescents have an increased risk for criminal behaviour, substance abuse, physical and mental illness and premature death. The traditional care for these individuals has been residential care – either secure residential care or residential homes. The purpose of this report is to review and synthesize the scientific evidence for family homes with enhanced support, the so-called Treatment Foster Care, compared to residential care and residential homes. After an evaluation of the results of the literature search only one version of Treatment Foster Care for the target group, Treatment Foster Care Oregon (TFCO), was considered valid to be used in this report.
The systematic literature review was conducted in accordance with SBU’s methodology (www.sbu.se/en/method). Included studies are controlled trials with high or medium quality, published between 1990 and 2007. The control group should consist of residential care and the follow-up time from inclusion had to be at least 12 months. Trials were excluded if the comparison group consisted of foster care and if children were younger than 12 years of age or older than 17. The systematic review also includes economic aspects. Furthermore, the report contains an inventory of the interventions used in residential care in Sweden and expressed experiences by some young people that have received TFCO or residential care. Ethical aspects are discussed based on the results.
Effects of TFCO
A total of 5,893 abstracts were reviewed, and of these, 18 articles from eight studies matched the inclusion and exclusion criteria. Of the eight studies, five were from the United States, two from the UK and one from Sweden. Meta-analysis indicates that TFCO probably reduces future criminality according to police or court records (d=0.393), self-report (d=0.242) and days in locked settings (d=0.665) compared to when adolescents are placed in residential care. It is also possible that TFCO leads to less delinquent peer associations (d=0.415), less drug use (d=0.472) and increased mental health when compared with residential care (d=0.348). The evidence was considered insufficient to evaluate the effect of alcohol use, psychotic symptoms, sexual risk behavior and teenage pregnancies. No studies were identified that included measures on physical health, quality of life, occupational employment or possible harmful or unwanted effects of the care received.
A total of 314 abstracts were examined and one, a Danish report, met the criteria for relevance and quality. The report presented a model-based cost-income analysis that shows that TFCO is cost-saving compared to residential care with nearly SEK 900,000 per youth in a lifetime perspective. A compilation of Swedish costs for placements shows that TFCO is less expensive than costs incurred in secure residential care but slightly more expensive than residential homes when care times are of the same length.
Interventions used in residential care
Since institutional care often include some type of treatment program, it was deemed important to identify those. A random sample of residential institutions for adolescents with behavioral problems were contacted (answers from 53/67). Altogether, 33 branded treatment programs were used and eight more theoretical approaches. Only for two of them was there strong evidence of its efficacy for the target group. The results also indicate problems in addition to the lack of effectiveness trials. For example, one in four institutions state that they used specific treatment programs although the staff lacked adequate training, and in most cases the staff worked without continual supervision. The institutions used 18 standard assessment methods, four of which are particularly relevant to the target group.
Perspectives from young people that have experienced TFCO and residential care
Fifteen individuals that have received either TFCO or residential care had similar views on what they considered important while in care: close adult relationships, treatment for the family of origin, and reduced contact with other delinquent adolescents. However, only those that had received TFCO acknowledged receiving those components while in care.
When society takes responsibility for the custody of adolescents, there is an obligation to act in their best interests. It is an ethical problem that treatment methods used in institutional care do not incorporate high standards concerning evidence of their effectiveness. Thus, it is unclear whether institutional care benefits adolescents and meets basic ethical requirements for social responsibility. TFCO has been used in Sweden since the beginning of the 2000s. The observation that only few adolescents receive this treatment annually may be considered an ethical shortcoming.
presents a comprehensive, systematic assessment of available scientific evidence. The certainty of the evidence for each finding is systematically reviewed and graded. Full assessments include economic, social, and ethical impact analyses.
SBU assessments are performed by a team of leading professional practitioners and academics, patient/user representatives and SBU staff. Prior to approval and publication, assessments are reviewed by independent experts, SBU’s Scientific Advisory Committees and Board of Directors.