Promoting Child Well-Being
in Foster Care
Peter J. Pecora, Ph.D. School of Social Work, University of Washington.
Presentation for The Future of Foster Care: New Science to Address Old
Problems conference, Pennsylvania State University, September 24, 2019.
Conference sponsored by the Child Maltreatment Solutions Network. E-mail:
Outline
I. Safety, permanency and well-being as key outcomes for children in out-of-home care
II. Defining and promoting child and adolescent well-being for youth in out-of-home care
III. Assessing child and adolescent well-being for youth in out-of-home care
IV. What is the role of evidence-based services in achieving these outcomes and how might FFPSA be helpful?
I. SAFETY, PERMANENCE AND WELL-BEING AS KEY OUTCOMES FOR
CHILDREN IN OUT OF HOME CARE
Child Safety:
Decrease all forms of child maltreatment
Decrease recurrence of child maltreatment
Decrease child abuse and neglect fatalities
Permanence:
Minimize short-stayers (children in care for less than 30 days)
Maximize % of children placed with relatives
Minimize % of children placed in group care
Decrease entries and increase exits from out of home care
Achieve permanency for children in care for between 12-23 months
Increase the percent of children achieving permanency within 12 months for
children in care 24 months or longer
Decrease the rate of re-entry into out-of-home care
Child Well-Being:
Increase child functioning and other areas of well-being
A close look at outcome data, and interviews with birth parents and
foster care alumni reveal major problems with OOHC in the U.S.
Too many children are being placed in care, and in restrictive levels of care such as group care.
Too many children stay in OOHC for too long, including “legal orphans” – children free for adoption who are still in OOHC for years beyond TPR – termination of parental rights.
There is wide variation in CW system performance – variation way beyond what we would expect from unique community conditions.
No complex service delivery system can succeed with 25-45% staff turnover rates.
But there are innovative practices in nearly every state, and we do know more now about how to improve outcomes.
II. DEFINING AND PROMOTING CHILD AND ADOLESCENT
WELL-BEING FOR YOUTH IN OUT OF HOME CARE
Well-being is a satisfactory human condition, characterized by health, happiness and fulfillment.
Well-being is not a state of being that one achieves and then lives in for a lifetime. Defining for oneself, moving toward, and achieving well-being is a continual developmental process beginning at infancy and continuing throughout the course of life. Indeed, a better term for the process may be “well-becoming.”
Sources: Ben-Arieh & Frones (2011); Langford, Badeau & Legters (2015, p. 12).
Principles Underlying a Youth Well-Being
Framework Young People are Valuable: All young people are valuable, despite
circumstances or actions that have caused them to come to the attention of public systems. Youth-serving professionals believe, expect, and speak the best about the young people they serve.
Equity: Young people of color and other marginalized communities, including homeless, pregnant or parenting, immigrant, and LGBTQ youth, deserve equitable opportunities, experiences, and well-being outcomes. Policies and practices should demonstrate intentional efforts to effectively identify, address, and mitigate racial, cultural, linguistic, gender and other disparities among vulnerable youth.
Youth Voice and Self-Determination: What young people think and feel matters. Young people should be supported in expressing dreams and goals, defining well-being for themselves, developing decision-making skills and, in developmentally appropriate ways, exercising control over their journey to adulthood.
Source: Langford, Badeau & Legters (2015, p. 10).
Principles (Cont.)
Developmentally Appropriate: All young people have a right to
childhood and adolescence. Young people should be treated as young
people, not adults. Science related to youth and adolescent
development should drive practice and policy development.
Normalcy: All young people deserve to have access to
developmentally appropriate activities, experiences, and opportunities
even when they experience out-of-home placement through the child
welfare or youth justice systems.
A Focus on the Whole Person: Well-being requires a focus on the
whole young person (not a segment or part) and their relationship to
communities where they live, work, and learn.
Family: Every young person needs, and belongs in, a lifelong family
to love and support them.
Source: Langford, Badeau & Legters (2015, p. 10).
Principles (Cont.)
Fairness and Second Chances: All young people deserve opportunities to heal from trauma. Policies and practices should be fundamentally fair. Balanced and restorative approaches to justice, which reduce or eliminate collateral consequences, should be the norm when systems respond to adolescent behaviors or needs. Use of harmful practices such as incarceration should be reduced and ultimately eliminated.
Youth Workers and Volunteers: The people who serve youth and young adults are valuable, and they need adequate resources, training, and ongoing support to do their work effectively.
Science-Based: Evidence generated from research, practice, communities, and experience should inform and improve implementation of this framework.
Communities: Communities (and community safety) are improved when young people have opportunities to thrive and contribute as community members.
Source: Langford, Badeau & Legters (2015, p. 10).
Well-Being Life Domains
1. Cognitive Development: All young people should have the opportunity and supports —through family, community, and public systems — to maximize their individual growth and development.
2. Social and Emotional Well-Being: All young people should have the opportunity and social supports — from family, community, and public systems — to cultivate a strong and resilient self-identity as well as supportive and nurturing relationships.
3. Mental Health and Wellness: All young people should have the opportunity and supports — through family, community, and public systems — to manage their mental health and wellness.
4. Physical Health: All young people should have the opportunity and supports — through family, community, and public systems — to maximize physical health, strength, and functioning.
5. Safety: All young people should have the opportunity and supports — through family, community, and public systems — to be physically and psychologically safe and free from violence, abuse, and neglect.
6. Economic Well-Being: All young people should have the opportunity, necessary education, and supports — through families, community, and public systems — to obtain and retain steady employment that provides a living wage, a career path, and housing that is safe, stable, and affordable. Source: Langford, Badeau & Legters (2015, p. 12).
A Framework for Well-Being Source: Langford, Badeau & Legters (2015, p. 13).
Tables 1, 2 and 3 present a framework for
well-being for vulnerable youth transitioning
to adulthood by drilling down into conditions
and capacities by environment: youth,
families, communities, and the public
environment.
Source: Langford, Badeau & Legters (2015, pp. 15-17).
National Academies of Sciences, Engineering,
and Medicine. (2019). Fostering Healthy Mental,
Emotional, and Behavioral Development in
Children and Youth: A National Agenda.
Child welfare section is on pages 257-293.
Future Research Funding Should Support• Studies that enact holistic approaches to understanding adolescent outcomes
characterized by the consideration of achievement, health, and other outcome
domains simultaneously;
• Studies that demonstrate the specific social conditions and supports inked
to epigenetic mechanisms that activate processes related to resilience
and positive outcomes for young people, despite challenging circumstances;
• Studies that identify, substantiate, and implement interventions that build
locus of control and agency in adolescents and that promote resilience,
for example by delivering specified curricula to youth and their caregivers, as
was done in the Strong African American Families study (see Brody et al.,
2017); and
• Studies specifically designed to test optimal timing of interventions, posing
questions such as “What are the trajectories of true developmental change in
connectivity within and between neural networks implicated in cognitive control
and emotional processing? Are these trajectories of change steeper or quicker
during some periods than others potentially providing key windows for input and
intervention?” (Fuligni et al., 2018, p. 151).
Understanding how the social and environmental context (and factors
within that context) can offer opportunities for flourishing outcomes or
for worsened outcomes for youth and emerging adults is critical. Focus on:
Understanding the impact of laws and policies that improve
or impede adolescent health, well-being, safety, and security;
Ascertaining what social and economic policies may
improve opportunities for youth to thrive and test whether
their effectiveness differs by race/ethnicity or context; and
Identifying what interventions might ameliorate and (or) enrich
the outcomes of youth who have experienced childhood
deprivation, oppression, or other negative experiences (such as
poverty, trauma, separation, or displacement).
Studies should also focus on:
Discrimination and marginalization, with a focus on both
neurobiological consequences as well as structural strategies
(school, community, state policies and practices) that reduce the
conditions in which discrimination and marginalization are prevalent,
and that buffer individuals from such experiences;
Youth who historically have been underrepresented, or who are most
vulnerable (e.g., youth of color; immigrants; sexual and gender
minorities; religious minorities; out-of-home youth or hose experiencing
homelessness, foster care, or unstable housing);
Ways in which intersecting axes of oppression shape youth
development, particularly against a backdrop of social
stratification and oppression, where relationships between identity,
experience, and behavior may not operate the same way for all youth.
III. ASSESSING CHILD AND ADOLESCENT WELL-BEING
FOR YOUTH IN OUT OF HOME CARE FOR SERVICE
PLANNING AND PERFORMANCE MEASUREMENT
As CW moves to engage more with public health, behavioral
health, public assistance, and other systems we need to
improve how we match needs and services for children and
families.
With the Family First Prevention and Services Act (FFPSA),
for services like group care, a standardized third party
assessment is required.
For all areas of CW, use trauma-informed multi-dimensional
assessments consistently across each state. (See Figure 1.)
Social Determinants of Health
Source: Retrieved from https://www.promedica.org/socialdeterminants/pages/default.aspx
Source: National Research Council and the Institute of Medicine. (2009). Preventing mental, emotional and behavioral disorders among young people: Progress
and possibilities. Washington, D.C.: National Research Council and the Institute of Medicine of the National Academies.
http://www.nap.edu/catalog.php?record_id=12480
Figure 1. Key Child and Youth Assessment Domains in Child and
Family Social Services (in addition to medical, dental & vision)
Overall Child Profile and
Sense of Self
Family/Fictive Kin Family
Functioning and Networks
Resiliency and Other Strengths
Protective Factors
Race/Ethnicity, Sexual
Orientation and Spiritual
Identification
Dangerous Behaviors
Toward Self and Others
Emotional and
Behavioral Functioning
Source: Adapted from Pecora, P.J. (2015). Assessment: Ensuring That Children Receive the Right Services at
the Right Time From High Quality Providers. Presentation for the National Association for Children’s Behavioral
Health conference, Baltimore, July 16, 2015.
Child Assessment Tools to Consider Achenbach System of Empirically Based Assessment (e.g., ABC, CBCL, YSR, TRF)
Ages and Stages Questionnaire- Social-Emotional (ASQ-SE) for children ages 0-4.
Casey Life Skills Assessment
Brief Infant Toddler Social and Emotional Assessment (BITSEA)
Child and Adolescent Functional Assessment Scale (CAFAS)
Child and Adolescent Needs and Strengths Scale (CANS)
Child and Adolescent Service Intensity Instrument (CASII and ECASII)
Children’s Global Assessment Scale (C-GAS)
Devereux Early Childhood Assessment Scale (DECA)
Early Childhood Child and Adolescent Needs and Strengths (EC-CANS)
Ohio Scales - Ohio Youth Problems, Functional and Satisfaction
Pediatric Symptom Checklist (PSC)
Strengths and Difficulties Questionnaire (SDQ)
Trauma Symptoms Checklist (TSC) and the Treatment Outcomes Package (TOP)
Sample Parent and Family Assessment Measures
Parent:
Adult-Adolescent Parenting Inventory (AAPI)
Conflict Tactics Scale (CTS)
Milardo Social Support Inventory
Parental Stress Inventory (PSI)
Parent Assessment of Protective Factors (PAPF)
Protective Factors Scale-2 (PFS-2)
Family:
ACTION for Child Protection: Family Functioning Assessment
Family Assessment Form (FAF from LA Children’s Bureau)
North Carolina Family Assessment Scales (NCFAS and NCFAS-R, NCFAS-G and NCFASG+R)
SDM Strengths and Needs Assessment
Key Criteria for Selecting a Measure
Completeness: does the measure cover all the key
areas to be assessed?
Ease of completion (clarity of instructions, clarity of
items and time to complete)
Training and coaching requirements
Knowledge of client requirements: if a person in a
related system like behavioral health will be
completing the measure for a CW caseworker, will
the behavioral health worker have sufficient
knowledge of the child or family to accurately
complete the measure?
Criteria for Selecting a Measure (Cont.)
Does it capture the: Youth’s perspective? Parent’s perspective? Teacher’s perspective? Foster parent’s perspective?
Cost to use the measure?
Able to be used for the age, gender, ethnic or other cultural groups that are served?
Are different versions used for different age groups?
If used for measuring treatment progress, is it clinically sensitive? I.e., can it measure change over time?
Ease of scoring?
Criteria for Selecting a Measure (Cont.)
How practical are the scores in terms of using them for
assessment, case planning and performance
measurement?
Are norms available for the population of interest?
Compatibility with the agency management information
system, including accessing total and sub-scale scores
for case planning and evaluation?
How well does the measure perform in terms of construct
validity, “face validity”, concurrent validity, criterion
validity, discriminant validity, inter-rater reliability, and
predictive validity?
IV. WHAT IS THE ROLE OF EVIDENCE-BASED SERVICES IN
ACHIEVING KEY OUTCOMES? HOW MIGHT THE FAMILY
FIRST PREVENTION AND SERVICES ACT BE HELPFUL?
EBPs and interventions supported by Practice-Based Evidence
are not the total answer for what ails CW.
We need to also pay attention to fundamentals:
Careful child and family assessments
Identifying and addressing the root causes of various child
maltreatment situations such as social isolation, lack of
resources, and behavioral health issues
Addressing concrete service needs, including housing,
employment, transportation, and health care
Establishing healthy organizational environments for staff
Family First Prevention and Services Act (FFPSA)
Family First offers new opportunities for states and some Tribal Nations to get federal reimbursement for evidence-based prevention services in priority areas of
Substance Abuse Treatment and Prevention
Mental Health services for children and parents/caregivers
In-Home Parenting Skills
New funding will cover all eligible children and parents with a 50% reimbursement. In 2026, federal funding will increase to the State’s Federal Medical Assistance Percentage (FMAP) rate.
It covers evidence-based kinship navigator programs.
It will cover 12-months of a child’s placement with their parent in a residential treatment program for substance abuse.
FFPSA Clearinghouse Reviewed Intervention and Rating
*Promising, ** Supported, ***Well-supported +Does not currently
meet criteria
Mental Health:
• Functional Family Therapy (FFT)***
• Multisystemic Therapy (MST) for Child Abuse and
Neglect+
• Multisystemic Therapy (MST)***
• Parent-Child Interaction Therapy (PCIT)***
• Trauma Focused-Cognitive Behavioral Therapy (TF-
CBT)*
FFPSA Clearinghouse Reviewed Intervention and Rating
*Promising, ** Supported, ***Well-supported +Does not currently
meet criteria
Substance Abuse
• Families Facing the Future**
• Multisystemic Therapy (MST)***
In-Home Parent Skill-Based:
• Nurse-Family Partnership***
• Parents as Teachers***
Kinship Navigator Programs:
• Children’s Home Inc. Kinship Interdisciplinary Navigation Technologically-Advanced Model (KIN-Tech)+
• Children’s Home Society of New Jersey Kinship Navigator Model+
What the FFPSA Clearinghouse is Reviewing:
Mental Health:
Attachment and Bio-behavioral Catch-Up [also listed under in-home parent skill-based]
Brief Strategic Family Therapy [also listed under substance abuse and in-home parent-skill based]
Child Parent Psychotherapy
Incredible Years
Interpersonal Psychotherapy
Multidimensional Family Therapy [also listed under substance abuse and in-home parent-skill based
Solution-Based Casework
Triple P – Positive Parenting Program
What the FFPSA Clearinghouse is Reviewing (Cont.)
Substance Abuse:
Brief Strategic Family Therapy [also listed under mental health and in-home parent skill-based]
Family Behavior Therapy
Methadone Maintenance Therapy
Motivational Interviewing
Multidimensional Family Therapy [also listed under mental health and in-home parent skill-based]
Seeking Safety
The Seven Challenges
Kinship Navigator:
Ohio's Kinship Supports Intervention/ProtectOHIO
YMCA Kinship Support Services, YMCA Youth and Family Services of San Diego County
What the FFPSA Clearinghouse is Reviewing (Cont.)
In-Home Parent Skill-based:
Attachment and Biobehavioral Catch-Up [also listed under
mental health]
Brief Strategic Family Therapy [also listed under mental health
and substance abuse]
Healthy Families America
Homebuilders
Multidimensional Family Therapy [also listed under mental
health and substance abuse]
Nurturing Parenting
SafeCare
State Technical Evidence Reviews
Until the Clearinghouse issues a rating for an intervention, the state can do a technical review of that EBP.
If approved by the ACYF Regional Office/Central Office/OPRE team, the state can then seek reimbursement for that service until one quarter after the Clearinghouse review if the rating is lower than the state rating it is seeking reimbursement under.
Or continue to get reimbursed if the Clearinghouse rating matches the state rating.
Selecting EBPs and Interventions Established through
Practice-Based Evidence and Observational Data
Practice-Based Evidence
The practice-based evidence (PBE) movement is an effort to draw attention
to the value of cultural knowledge as a cornerstone of healing and recovery.
Practice-based evidence is also referred to as community-defined evidence
(CDE).
Fundamental to PBE or CDE are the following:
• Knowledge of the function of cultural help-seeking patterns
• Understanding the cultural context of problem identification
• Use of culturally-informed therapeutic intervention(s)
• Provision of therapeutic interventions and supports in a manner that
consistently recognize the value of the cultural self to wellness and
recovery
• Engaging the local community and/or cultural resources to achieve and
sustain the long-term positive effects from the intervention. (Echo-Hawk,
2018, p. 2)
Evidence Basis for Validity of the Tribal
Practice: Historical/Cultural Connections
Longevity of the Practice in Indian Country
Teachings on which the Practice is based
Values incorporated in the Practice
Principles incorporated in the Practice
Elder’s approval of the Practice
Community feedback and evaluation of the Practice
Cruz (2010), p. 1.
V. References
Ben-Arieh, A., & Frønes, I. (2011). Taxonomy for child well-being indicators: A framework for the analysis of the well-being of children. Childhood, 18(4), pp.460–476.
Casey Family Programs. (2018). Interventions with Special Relevance for the Family First Prevention and Services Act (FFPSA). (Second Edition) Seattle: Author. Retrieved from https://www.casey.org/evidence-to-action/
CFSR Child Welfare Outcomes Report for 2016: https://www.acf.hhs.gov/cb/resource/cwo-2016
Cruz, Carolyn. (2010). Oregon Addictions & Mental Health Division Evidence-Based Programs Tribal Practice Approval Form, Mk V. Warm Springs, OR: Confederated Tribes of Warm Springs, Health and Human Services. Also see a completed form for an intervention here: https://www.oregon.gov/oha/HSD/AMH/EBP/Healthy%20Relationship%20Curriculum.pdf
Echo-Hawk, Holly (2018). Family First Prevention Services Act of 2018 Background: Culturally Based and Emerging Evidence-Based Practice. Paper prepared for Casey Family Programs. Seattle, WA. E-mail: [email protected]
National Academies of Sciences, Engineering, and Medicine. (2019). Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press. Retrieved from: https://doi.org/10.17226/25201
Pecora, P.J., Whittaker, J.K., Barth, R.P., Borja, S., & Vesneski, W. (2019). The child welfare challenge. (Fourth Edition.) New York City: Taylor and Francis.
Roberts, Y.H., O’Brien, K., & Pecora, P.J. (2017). Supporting Lifelong Families Ensuring Long-Lasting Permanency and Well-Being. Seattle: Casey Family Programs. https://www.casey.org/supporting-lifelong-families/
