What is TFCO?

Multidimensional Treatment Foster Care

What is TFCO?

TFCO Program Overview

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TFCO treatment goals are accomplished by providing:

  • close supervision
  • fair and consistent limits
  • predictable consequences for rule breaking
  • a supportive relationship with at least one mentoring adult
  • reduced exposure to peers with similar problems

The intervention is multifaceted and occurs in multiple settings. The intervention components include:

  • behavioral parent training and support for TFCO foster parents
  • family therapy for biological parents (or other aftercare resources)
  • skills training for youth
  • supportive therapy for youth
  • school-based behavioral interventions and academic support
  • psychiatric consultation and medication management, when needed

There are three versions of TFCO, each serving specific age groups. Each version has been subjected to rigorous scientific evaluations and found to be efficacious. The programs are:

• TFCO-A for adolescents (12-17 years)
• TFCO-C for middle childhood (7-11 years)
• TFCO-P for preschool-aged children (3-6 years)

girl sitting outsideTFCO Parents. In the TFCO program, children are placed in a family setting for six to nine months. Single placements are the norm, although sibling groups are sometimes placed in one home in the TFCO-P program. Foster parents are recruited, trained, and supported to become part of the treatment team. They provide close supervision and implement a structured, individualized program for each child. The child’s program is designed by the Program Supervisor with input from the treatment team. It builds on the child’s strengths and at the same time sets clear rules, expectations, and limits to manage behavior. TFCO parents receive 12 -14 hours of pre-service training, participate in group support and assistance meetings weekly, and have access to program staff back-up and support 24 hours a day/7 days a week. In addition, TFCO parents are contacted daily (Monday through Friday) by telephone to provide the Parent Daily Report (PDR) information, which is used to relay information about the child’s behavior over the last 24 hours to the treatment team and to provide quality assurance on program implementation. TFCO parents are paid a monthly salary and a small stipend to cover extra expenses.

Program Population. A positive and predictable environment is established for children in the TFCO home via a structured behavior management system with consistent follow-through on consequences. The system is designed to encourage positive and age-appropriate behavior in the home through frequent reinforcement from the TFCO parents. The youth is closely supervised in the TFCO home, school (if applicable), and community. Behavior at school and academic progress is monitored daily in the TFCO-C and TFCO-A versions. Skill building is provided for academic and social activities. Additional program activities vary depending on the age of the child. For example, preschoolers in the TFCO-P program participate in a weekly therapeutic playgroup. Adolescents in the TFCO-A program receive individual therapy.

The Child’s Family. The birth family or other aftercare resource receives family therapy and parent training. Families learn to provide consistent discipline, to supervise and provide encouragement, and to use a modified version of the behavior management system used in the TFCO home. Therapy is provided to prepare parents for their child’s return home and to reduce conflict and increase positive relationships in the family. Family sessions and home visits during the child’s placement in TFCO provide opportunities for the parents to practice skills and receive feedback.

The Treatment Team. The TFCO treatment team is led by a program supervisor who also provides intensive support and consultation to the foster parents. The treatment team also includes a family therapist, an individual therapist, a child skills trainer, and a daily telephone contact person (PDR caller). The team meets weekly to review progress on each case, review the daily behavioral information collected by telephone, and adjust the child’s individualized treatment plan. The TFCO-P treatment team varies, see the TFCO-P Information page.

For more information on the TFCO program, see the Publications and Related Sites pages or contact Gerard Bouwman, President of TFC Consultants, Inc., or Rena Gold, Vice President of Implementations.

 

TFCO-A

Treatment Foster Care  Oregon for Adolescents™  – TFCO-A™ 

Treatment Foster Care Oregon was developed in the early 1980’s as an alternative to institutional, residential, and group care placements for boys with severe and chronic criminal behavior. Subsequently, the TFCO model has been adapted for and tested with children and adolescents with severe emotional and behavioral disorders, girls referred from juvenile justice for severe delinquency, and with youth in regular state-supported foster care. Today, TFCO serves juvenile justice as well as welfare and mental health populations.  Three additional randomized trials are currently underway that test:

  1. The effectiveness of TFCO in treating substance use and health-risking behavior for girls referred from juvenile justice,
  2. The effectiveness of applying an adaptation of TFCO to prevent placement disruption and promote family reunification in a large urban child welfare system, and
  3. The preventative effects of a version of TFCO on the development of delinquency and substance use problems for foster girls entering middle school.

Program Objectives
There are two major aims of TFCO-A; to create opportunities so that youth are able to successfully live in families rather than in group or institutional settings, and to simultaneously prepare their parents, relatives, or other aftercare resources to provide youth with effective parenting so that the positive changes made while the youth are placed in TFCO-A can be sustained over the long-run. Four key elements of treatment are targeted during placement and aftercare: (1) providing youth with a consistent reinforcing environment where he or she is mentored and encouraged to develop academic and positive living skills, (2) providing daily structure with clear expectations and limits, with well-specified consequences delivered in a teaching-oriented manner, (3) providing close supervision of youth’s whereabouts, and (4) helping youth to avoid deviant peer associations while providing them with the support and assistance needed to establish pro-social peer relationships.

Program Strategies
basketball playersPlacements in TFCO-A are typically 6-9 months in length and rely on intensive, well-coordinated, multi-method interventions conducted in the TFCO-A foster home, with the youth’s aftercare family, and with the youth through individual therapy, skill training, and academic support. A program supervisor (with a caseload of 10) oversees the interventions that are implemented across multiple settings (e.g., home, school, community). Involvement of each youth’s family or aftercare resource is emphasized from the outset of treatment in an effort to maximize training and preparation for post-treatment care for youth and their families. Progress is tracked through daily phone calls with treatment foster parents where data is collected on youth behavior.

Youth in TFCO-A
Referrals are received from juvenile courts, probation officers, mental health and child welfare caseworkers. Youth referred to TFCO-A are between the ages of 12 and 17 and are in need of an out-of-home placement due to severe delinquency or antisocial behavior. Referred youth may have been involved in serious criminal offending behavior and may have complex co-morbid conditions. Most of these youth have been involved in numerous treatment efforts prior to their referral to TFCO-A, and most have experienced at least one, if not multiple, failed out-of-home placements prior to referral. Referred youth should have an IQ no less than 70 and participate exclusively in TFCO-A as the sole comprehensive treatment service. Referrals to TFCO-A programs are most appropriate after in-home family preservation programs have been tried or when youth are returning from highly restrictive institutional or group care placements. Families of the TFCO-A youth participate in the family therapy component of treatment and should be engaged in services immediately upon placement in the program. Referral information should identify the family to which the youth will reside long-term or identify independent living as the living situation upon discharge. Youth exhibiting acutely suicidal, homicidal or psychotic behavior will not be placed in the TFCO-A program. In addition, youth in need of treatment for sex offenses or substance abuse exclusively are not appropriate for TFCO-A.

Staffing
Program Supervisors are trained in the social learning treatment model and developmental psychopathology, and are responsible for coordinating all aspects of the treatment program. They serve as consultants to the foster parents, provide support and supervision in the form of weekly meetings and daily telephone contact, and are available for support, consultation, and backup 24 hours a day. Foster parents are screened, selected, and trained before they receive a placement; then are supervised and supported throughout treatment through daily telephone calls and weekly foster parent groups conducted by the Program Supervisor. Family and individual therapists, skills trainers, a foster parent recruiter/trainer and a daily telephone data collector are also employed by the program and supervised by the Program Supervisor.

Special Characteristics
Involvement of the biological family or aftercare family is emphasized throughout treatment. Families are taught parenting skills that are practiced during home visits and are provided with 24-hour backup and consultation by the family therapist and Program Supervisor.

Comments on Implementation/Replication
TFC Consultants, Inc. was founded in 2002 and is the organization that is dedicated to the implementation of model-adherent TFCO-A programs. TFC Consultants provides consultation, training, and technical assistance to new and existing TFCO-A programs and helps service providers, policy makers and community leaders resolve issues related to the implementation of evidence-based practices. Through TFC Consultants, TFCO-A is being implemented in over 50 locations throughout the U.S. and in Canada, Sweden, Norway, the United Kingdom, the Netherlands and New Zealand.

Research Conclusions
TFCO-A has been shown to be an effective and viable method of preventing the placement of youth in institutional or residential settings. Studies have found that placement in TFCO-A can prevent escalation of delinquency and other problem behaviors such as youth violence.  Placement in TFCO-A is more economical and more effective than placement in group care in decreasing offense and incarceration rates at follow-up. Overall, TFCO-A has been shown to be effective in the treatment of boys with severe delinquency and conduct disorders (Chamberlain, & Reid, 1998), in the treatment of children and adolescents leaving a state mental hospital (Chamberlain & Reid, 1991), in the prevention of placement disruptions in regular state supported foster care (Chamberlain, Moreland & Reid, 1996), and in the treatment of girls with chronic problems with delinquency (Leve & Chamberlain, in press). In addition, specific treatment components (i.e., close supervision, fair and consistent limit setting, decreased association with delinquent peers, positive adult-youth relationship) have been shown to be factors that account for the treatment effect of TFCO-A placements (Eddy & Chamberlain, 2000).

TFCO-C

Treatment Foster Care Oregon for Middle Childhood™ – TFCO-C™

The Treatment Foster Care Oregon (TFCO) program was developed in the early 1980’s as an alternative to institutional, residential, and group care placements for adolescents with severe conduct disorders, and delinquency. Subsequently, the TFCO model has been adapted for and tested with children and adolescents with severe emotional and behavioral disorders, girls referred from juvenile justice, and with youth in regular state-supported foster care. Five additional randomized trials are currently underway that test:

  1. The effectiveness of TFCO in treating mental health, substance use and health-risking behavior for girls referred from juvenile justice,
  2. The treatment and prevention of emotional, behavioral, and attachment problems in preschool foster children,
  3. The effectiveness of applying an adaptation of TFCO to prevent placement disruption and promote family reunification in a large urban child welfare system, and
  4. The preventative effects of a version of TFCO on the development of delinquency and substance use problems for foster girls entering middle school.
  5. A state-wide implementation of TFCO in 40 sites in California

Program Objectives
Water dripping off leaves
There are two major aims of TFCO; to create opportunities so that children are able to successfully live in families rather than in group or institutional settings, and to simultaneously prepare their parents, relatives, or other aftercare resources to provide effective parenting so that the positive changes made during TFCO placements can be sustained over the long-run.  Four key elements of treatment are targeted during placement and aftercare: (1) providing the child with a consistent reinforcing environment where he or she is mentored and encouraged to develop socially, emotionally, and academically, (2) providing daily structure with clear expectations and limits, with well-specified consequences delivered in a positive, supportive, teaching-oriented manner, (3) providing close tracking of the child’s behavior and emotional adjustment in family and school settings and with peers, and (4) helping the child to develop positive attachments to adults and to peers.

Program Strategies
Placements in TFCO are typically 9 -12 months in length and rely on intensive, well-coordinated, multi-method interventions conducted in the TFCO foster home, with the child’s aftercare family, and with the child through skills coaching and academic support.  A program supervisor (with a caseload of 10) oversees and coordinates the interventions that are implemented across multiple settings (e.g., home, school, community). Involvement of each child’s family or aftercare resource is emphasized from the outset of treatment in an effort to maximize training and preparation for post-treatment care for youth and their families. Progress is tracked through daily phone calls with treatment foster parents during which data is collected on the child’s behavior.

Children in TFCO-C

Referrals are received from child welfare and mental health case workers. Children referred to TFCO-C are between the ages of 7-11 and are in need of an out-of-home placement due to serious emotional, behavioral or mental health problems.  Referred children may have been placed numerous times in foster care and may have complex co-morbid conditions.  Most of these children have been involved in numerous treatment efforts prior to their referral to TFCO-C, and most have experienced at least one if not multiple, failed out-of-home placements prior to referral.   The treatment plan should entail having children participate exclusively in TFCO-C as the sole comprehensive treatment service.  Referrals to TFCO-C programs are most appropriate after in-home family preservation programs or placements in regular foster care have been tried or when children are returning from highly restrictive institutional or group care placements.  Families of the TFCO-C children participate in the family therapy component of treatment and should be engaged in services immediately upon placement in the program.  Referral information should identify the family to which the child will reside long-term.

Staffing
Program Supervisors are trained in the social learning treatment model and developmental psychopathology, and are responsible for coordinating all aspects of the treatment program. They serve as consultants to the foster parents, provide support and supervision in the form of weekly meetings and daily telephone contact, and are available for support, consultation, and backup 24 hours a day. Foster parents are screened, selected, and trained before they receive a placement then are supervised and supported throughout treatment through daily telephone calls and weekly foster parent groups conducted by the Program Supervisor.  Family therapist, skills coaches, a foster parent recruiter/trainer/parent daily report caller are also employed by the program and supervised by the Program Supervisor.

Special Characteristics
Involvement of the biological family or aftercare family is emphasized throughout treatment. Families are taught parenting skills that are practiced during home visits and are provided with 24-hour backup and consultation by the family therapist and Program Supervisor.

Comments on Implementation/Replication
TFC Consultants, Inc. (http://www.tfcoregon.com) was founded in 2002 and is the organization that is dedicated to the implementation of model-adherent TFCO programs. TFC Consultants provides consultation, training, and technical assistance to new and existing TFCO programs and helps service providers, policy makers and community leaders resolve issues related to the implementation of evidence-based practices. Through TFC Consultants, TFCO is being implemented in 6 counties in California and in over 40 other locations throughout the U.S. and in Sweden, Norway, The Netherlands, and the United Kingdom.  Referrals to TFCO programs are most appropriate after in-home family preservation programs or placements in regular foster care have been tried or when youth are returning from highly restrictive institutional or group care placements.

Research Conclusions
TFCO has been shown to be an effective and viable method of preventing the placement of children and adolescents in institutional or residential settings. Studies have found that placement in TFCO can prevent escalation of placement disruptions, emotional problems, delinquency and other problem behaviors such as violence.  Cost effectiveness analyses have found that placement in TFCO is more economical and more effective than placement in group care.

TFCO-P

Treatment Foster Care Oregon for Preschoolers (TFCO-P) is an alternative to residential treatment for foster children ages 6 and under. These young children are especially vulnerable to long-term difficulties in home, school, and community settings and are at high risk for behavioral, emotional, and developmental problems.

TFCO-P is specifically tailored to the needs of 3 to 6 year-old foster children and has been shown to be effective at promoting secure attachments in foster care and facilitating successful permanent placements (e.g., reunification with birth parents and adoptions). TFCO-P capitalizes on more than 40 years of research and treatment activities that have supported the notion that families, and particularly parents who are skilled and supported, can have a powerful socializing role and positive influence on troubled youth.

boy playing soccerTFCO-P has been in continuous operation in Eugene, Oregon, since 1996 and is a downward extension (in terms of age) of  Treatment Foster Care Oregon, which was developed at Oregon Social Learning Center to treat chronic juvenile delinquency. TFCO-P is based upon the philosophy that, for many young children in foster care, the most effective treatment is likely to take place in a family environment in which responsive and consistent caregiving is provided. TFCO-P foster parents are in many ways the primary treatment agents for program children and have substantially influenced the program design and implementation methods over the years.

TFCO-P is delivered through a treatment team approach in which foster parents receive training and ongoing consultation/support from program staff, children receive individual skills training and therapeutic playgroup, and birth parents (or other permanent placement resources) receive family therapy. TFCO-P emphasizes the use of concrete encouragement for pro-social behavior; consistent, non-abusive limit-setting to address disruptive behavior; and close supervision of the child. In addition, the TFCO-P intervention employs a developmental framework in which the challenges of foster preschoolers are viewed from the perspective of delayed maturation (rather than strictly behavioral and emotional problems).

There are three mechanisms within the TFCO-P approach that contribute to successful outcomes for youth and their families and that are critical to activating the therapeutic potential of the foster home. These include a proactive approach to reducing problem behavior, the creation and maintenance of a consistent and reinforcing environment for participating children, and the separation and stratification of program staff roles.

A Proactive Approach to Reducing Problem Behaviors
The first mechanism within the TFCO-P model that contributes to positive outcomes is the proactive approach taken to reducing problem behaviors. Program Supervisors (role is described later) carry smaller caseloads (e.g., 10-12 cases) and follow each child’s progress/problems in the foster home daily.

TFCO-P foster parents are carefully recruited and are provided with extensive pre-placement training and ongoing support and supervision. Throughout the treatment process, foster parents maintain close communication with the program staff, thus serving as the eyes and ears of the program. The foster parents help to identify target behaviors and formulate treatment plans. They are strongly and repeatedly encouraged to call program staff members at any time if they are concerned or have questions about the TFCO-P child. The foster parents participate in daily data collection telephone calls regarding child problems/progress and program implementation in the previous 24 hours via the Parent Daily Report (PDR) and weekly supervision/support meetings with their program supervisor, foster parent consultant and other TFCO-P foster parents.

Foster Parent Recruitment
TFCO-P foster parents are recruited through a variety of methods including word-of-mouth and newspaper advertising which has been the most successful. Existing TFCO-P foster parents are paid $100 for recommending other families which lead to an TFCO-P placement. Newspaper ads are most successful if they include a description of the age and gender of the child to be placed and the amount of the monthly stipend that the foster parents receive. Potential TFCO-P foster parents are screened by telephone for basic eligibility (e.g., adequate space in their home and no criminal history) before an application is sent to them. Following the return of an application, the TFCO-P recruiter conducts a home visit, during which the recruiter fully describes the program and explains the training and certification requirements of the program. The purposes of the home visit are to meet the prospective family, to see whether the home atmosphere is conducive to caring for a young foster child, and to give potential foster parents more information about the program. Many families who are suitable for standard foster care may not be suitable for TFCO-P, which requires foster parents to take an active treatment perspective and to work with the program staff to implement a daily structured program for the child. Single parents and married couples with and without children of their own have been successful TFCO-P foster parents.

Training of TFCO-P Parents
TFCO-P parents participate in a minimum of 12 hours of training. During training, parents are provided an overview of the model, taught about identifying and giving information about behaviors, and taught procedures for implementing an individualized daily program. The training methods used are didactic and experiential. During the training, emphasis is on methods and techniques for reinforcing and encouraging children. Prospective TFCO-P foster parents who are resistant to the idea of giving children extra support and attention for doing what they are supposed to do are discouraged from continuing with the program. Because daily encouragement is such an important component of TFCO-P, it is important that families share (or at least do not oppose) the treatment philosophy.

Ongoing Consultation, Support, and Supervision
Following the training, a match is made between prospective TFCO-P foster parents and children. Foster parents are provided with all information known to the TFCO-P program, so that they are fully informed about the child’s history and can make an informed decision about accepting the child into their home. Once a match is made, the Program Supervisor and foster parent(s) develop the child’s individualized daily program.

Throughout the placement, foster parents receive continued support in addressing new problems via weekly meeting, daily “Parent Daily Report” (PDR) telephone calls, and home visits from TFCO-P staff. In addition, staff members are always on call to support the foster parents and will visit the home if the problem cannot be managed over the telephone.

Parent Daily Report (PDR) is a critical component of the treatment program which allows frequent and reliable tracking and measurement of behaviors in children. PDR is conducted in a 5-10 minute phone call between the foster parent and the TFCO-P PDR caller. Data on approximately 40 behaviors is gathered every day and includes the occurrence of the behavior and if the foster parent found that behavior to be stressful. By looking at the PDR information, the program supervisor can gain insights into the effectiveness of the treatment plan. Adjustments in the treatment interventions can then be individualized to the behaviors of each child. Patterns in behavior are also evident when reviewing several weeks of PDR data at a time. Patterns can highlight slow changes in behavior that may not otherwise be noticed as well as identifying events or situations that are regularly impacting behavior.

The Creation and Maintenance of a Responsive, Consistent, and Reinforcing Environment
The second mechanism within the TFCO-P model that contributes to positive outcomes is the implementation of an individualized, detailed behavior management program within the foster home. The goal of the behavior management program is to give foster parents a vehicle for providing the child with frequent positive reinforcement for normative and pro-social behavior and to give the child a clear message about their progress.

girl playing guitarThis program is implemented in the TFCO-P home and involves concrete encouragement for positive behavior. Most commonly this consists of “kid bucks” (which are exchanged for larger items) or edible rewards. In addition, foster parents are instructed in the use of effective limit setting techniques for this age group, including time out and redirection. TFCO-P foster parents are trained to set limits in a matter-of-fact or slightly sympathetic way. They are specifically taught to refrain from lecturing or arguing and to disengage if the child initiates an argument.

Separation and Stratification of Staff Roles
The third mechanism within TFCO-P that contributes to positive outcomes involves the separation and stratification of staff roles. In many youth treatment programs, staff members are assigned a “generalist” role. We have found this model to be insufficient when working with children in foster care. Various factors, including the complexity of the TFCO-P services and the likelihood that biological families will be involved with multiple other service providers, can require generalist staff members to continuously balance the opposing needs of different constituencies. Within this context, it is challenging to develop and maintain a trusting relationship with any of the parties involved in treatment.

A distinguishing characteristic of TFCO-P is its utilization of a treatment team (in which roles are clearly defined) to carry out the treatment plan for each youth. As is discussed below, the treatment team includes a program supervisor, a foster parent consultant/recruiter/trainer, a family therapist, a child skills trainer, a PDR caller, and consulting psychiatrist. There is little overlap in the responsibilities of team members, which helps to reduce confusion about who should carry out specific tasks. Staff members advocate the needs of those with whom they work. This insures that the child, foster parents, birth parents, and other service providers have a voice in the treatment process.

Staff Roles
Program Supervisor. The program supervisor organizes all aspects of the TFCO-P treatment, leads the treatment team, and is the primary liaison with the child welfare system and other treatment providers in the community. Given the disparate roles of the team members, a key role of the program supervisor is to oversee and integrate team activities. The program supervisor works to ensure that team members are following the same treatment protocol, that team members are informed about each other’s activities, and that the needs and concerns of all parties – child, foster parents, biological/adoptive families, and the child welfare system social worker – are being heard. Although the treatment team might not maintain a strict hierarchy, the program supervisor is the team leader. Therefore, this individual ultimately articulates the treatment plan, resolves disputes among team members, and sets the tone for the treatment process. The program supervisor also runs the weekly foster parent support groups and the weekly clinical meetings.

Given the multidisciplinary nature of the team, effective communication is essential for treatment to proceed smoothly. This communication occurs through team meetings, through email, and through informal conversations among team members. There is a strong emphasis on maintaining a high level of information sharing so that the treatment is consistent across team members. Although this approach might appear to be labor and personnel intensive, the long-term benefits provide justification for the utilization of these resources. In addition, because of the clarity in which roles are defined and the ability of staff to focus intensively on the needs of the child and adults involved in treatment, the turnover rate for staff is low and morale is high.

Foster Parent Consultant/Recruiter/Trainer. The foster parent consultant/recruiter/trainer is the primary support person for foster parents in the TFCO-P program structure. This individual is responsible for working with prospective foster parents from the time of initial contact with the program, through the certification and training process, and for the duration of the foster placement. This individual advocates for foster parents and serves as their voice in the program. The consultant/recruiter/trainer conducts home visits, is available by phone on an as-needed basis, and co-leads the weekly foster parent meeting. This individual might facilitate the implementation of treatment strategies and gather information about the status of interventions being employed in the foster home; however, it is the role of the program supervisor to design interventions for specific children.

Skills Trainers/Playgroup Staff Members. These staff members teach pro-social behavior and problem solving skills to the child through intensive one-on-one interaction and skill practice in the community. Skills trainers are trained to use applied behavior analysis as a way of examining potential antecedents to, and reinforcers for, problem behavior in the child’s environment. They are also instructed in the use of shaping procedures to teach new behaviors. The implementation of skills trainer interventions is based often on behavioral contracting with the child.

Skills trainers also serve as playgroup staff members. In particular, one skills trainer serves as the playgroup leader, and two others serve as assistants. The playgroup staff members work together, under the supervision of the program supervisor, to implement the playgroup curriculum.

Family Therapist. A key component to the success of the TFCO-P program is the degree to which the youth can generalize gains made during treatment to post-treatment environments. Parents (or other adult guardians) are the primary social agents who determine the quality and consistency of this generalization. Participation in the program does not fundamentally change the child and without continued support and socialization, gains do not remain. Therefore, teaching birth and adoptive parents how to effectively supervise, discipline, and encourage their child is a major task undertaken in TFCO-P.

In TFCO-P, family therapy includes the establishment of a consulting role with the child’s parents. Many of the families have received services with multiple providers and social service agencies. Those experiences tend to range from neutral to poor and have involved blame, confrontation, avoidance, and other negative events. Thus, it is important for the family therapist to develop an alliance with the family and to establish a relationship that is supportive and constructive prior to introducing parent management training techniques in family therapy.

The family therapist works with parents to plan and implement strategies that increase reinforcement for positive/appropriate behavior. Parents are instructed in procedures for following through on negative behavior and providing consistent discipline. TFCO-P emphasizes the in-home practice of skills discussed in treatment sessions. As the parent learns particular skills, supervised visits with the child at the treatment center are initiated. As multiple skills are learned, the visits lengthen and then transition to the family’s home. Parents have specific practice assignments which they implement during the home visits. Ultimately, home visits extend to overnights and then weekends. Provided that this process occurs without further maltreatment of the child, family reunification occurs. The family therapist maintains contact with the family during this transition and for 1 to 3 months following reunification.

A similar set of procedures occurs when children are being adopted due to termination of parental rights. Given that adoptive parents enter the picture closer to the end of treatment and require less intensive services, the timeframe of working with adoptive parents is shorter.

PDR Caller. Because a high level of contact with foster parents is critical to the success of treatment, TFCO-P employs a staff member to contact foster families each day via telephone for the Parent Daily Report (PDR) calls. The PDR consists of a list of 40 problem behaviors exhibited by disruptive children. Foster parents are asked to indicate if each of the behaviors occurred in the past 24 hours. The checklist takes approximately 5 minutes to complete. The information gathered is viewed by the Program Supervisor on a daily basis and provides a thumbnail sketch of the youth’s functioning which is used to track progress, identify patterns of problematic behavior, and monitor foster parent stress. Because the PDR interview is highly structured, it is possible to recruit and hire PDR callers with solid interpersonal skills but relatively limited clinical experience.

Consulting Psychiatrist. Some TFCO-P youth enter the program with multiple diagnoses that include disruptive behavior disorders (e.g., conduct disorder and attention deficit disorder), post-traumatic stress disorder, and other anxiety disorders. Although children frequently respond to the treatment regimen of TFCO-P despite these problems, psychiatric consultation is sometimes required. Although it is possible to refer these youth to providers in the community for medication evaluations, the ability to consult directly with a psychiatrist who is familiar with the program elements is extremely useful. It allows for careful examination of the diagnoses and clarification of the specific medications judged most effective for addressing particular symptoms. Working together, the psychiatrist and program staff members are able to evaluate the impact of medication changes on the child’s functioning. Consequently, once the child has stabilized in the foster home, it is often possible to greatly reduce the number and dosage of medications.

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