multidimensional treatment foster care mtfccosts and considerations for roll out sally burlington18 march, 2010

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3. 3 Summary

4. 4 Background � What is MTFC? MTFC is American, evidence-based model treatment programme for children who have problems with chronic antisocial behaviour, emotional and/or conduct disorders, unstable foster placement 24/7 support is provided to the child and carers Foster carers are contacted daily by the team Behaviours are logged on a daily basis and a reward system is in place Children are provided skills coaching to help overcome specific behavioural problems A typical MTFC team that consists of: Programme Manager (Social services manager with experience in fostering) Programme Supervisor (Clinical child psychologist or social worker) Foster Carer recruiter/trainer (Social worker) Birth Family Therapist (Social worker) Young Person�s Individual Therapist (Social worker or clinical psychologist) Skills Coach (Youth workers, psychology graduates) Education personnel (Qualified teacher) Psychiatrist (often accessed as required) Clinical Psychologist (usually accessed as required) This team would have a case-load of 8-10 children

5. 5 What is MTFC?

6. 6 Benefits: What is the evidence? Positive results from US and Swedish randomised control trials Research from the US suggests that MTFC can improve: Youth criminal behaviour and custody rates Youth violent offending Youth behavioural and mental health problems Disruption of placements and running away Placement recidivism Attachment to caregivers Foster parent retention and satisfaction School attendance Teenage pregnancy Cochrane Review is positive though cautious due to small samples and lack of long-term studies Cost benefit evidence from the US is very positive: �Overall, taxpayers gain approximately $21,836 in subsequent criminal justice cost savings for each program participant. Adding the benefits that accrue to crime victims increases the expected net present value to $87,622 per participant, which is equivalent to a benefit-to-cost ratio of $43.70 for every dollar spent.� The Comparative Costs and Benefits of Programs to Reduce Crime. Aos et al. Washington State Institute for Public Policy, 2001. pp. 18 ff. 2009. p. 544.

7. 7 UK Pilots Prevention programme (MTFC-P) 3-6 34 children admitted 29 children currently in foster placements 5 have completed the programme and left 2 returned home to birth parents, 1 to kinship care, 1 to adoption and 1 is remaining with the MTFC-P carers Three others are expected to remain with their MTFC-P carers on completion, one to return to father and one is shortly due to move to an adoptive placement 6 teams operating the P programme Children Programme (MTFC-C) 7-11 Seven teams have now made placements and there are currently 22 children in the programme Cambridge has made the decision to close due to lack of referrals within this age group and difficulties with foster carer recruitment.

8. 8 Positive outcomes for UK graduates

9. 9 Population Who? MTFC can be appropriate for children who demonstrate: Emotional or conduct disorders Behaviours which are known to put their placements at risk of disruption Health-risking sexual behaviour or sexual behaviour that poses a risk to others Other negative behaviours such as offending, violence, self-harm, absconding, fire-setting and alcohol and drug use There is no one, clear measure of the number of children who may be suitable for MTFC. We have therefore used a number of proxies to help build a picture of the population who may have a need including: Specialist mental health care Emotional and conduct disorders Placement instability SDQ scores Trouble with the police

10. 10 Population Breakdown by age groups Assuming that the 7% figure applies across all age groups we would be able to break down the MTFC population into the following: MTFC-Pre (3-6) 560 MTFC-Child (7-11) 875 MTFC-Adolescent (11-16) 1,406 This does not include children aged 0-2 and assumes that 30% of Adolescent children will refuse consent to the programme There is some overlap between the Child and Adolescent programmes with 11 year olds fitting into both These figures will naturally vary over time and by location Youth Justice Board estimate that there would be c. 150 young people per annum who would be appropriate for MTFC as an alternative to custody If we look at the split of this population by Local Authority we can see that only some LAs would be able to sustain an MTFC programme of 8 places based on a 7% need

11. 11 MTFC population by LA and pilot locations

12. 12 How have we calculated the benefits?

13. 13 Costs, Benefits and the Financial Model

14. 14 Financial Model

15. 15 Cost Scenarios... Looking at the costs & savings for the A-programme (a single unit)

16. 16 Cost Scenarios...similarly for the C programme (a single unit)

17. 17 Cost Scenarios...and the P programme (a single unit)

18. 18 Cost Scenarios...How the likelihood of success affects costs (not including initial costs: a single unit)

19. 19 Cost Scenarios...optimally managing the units

20. 20 Cost Scenarios...costs of deploying

21. 21 Options for roll out

22. 22 Options for provision

23. 23 Issues and implications for roll-out

24. 24 Conclusions and Next Steps

25. 25 APPENDICES Appendix 1: MTFC Case Studies from UK pilots Appendix 2: Additional Information

26. 26 Appendix 1: MTFC Case Studies Case Studies from MTFC-P programme (3-6 years old) Child 1 Referred to MTFC aged 5 following placement breakdown in a fostering agency placement due to behavioural difficulties. Residential placements were already being considered. Has lived with Mum, then Dad, then placed in care, had 2 placement breakdowns and 2 failed returns home. Has suffered emotional abuse, physical abuse, attachment difficulties, sexual abuse by a woman � disclosures made whilst on the programme. Challenging behaviour � hitting, biting, tantrums, hyperactivity, poor attention, impulsivity, defiance, over familiarity with strangers, disinterest in peers, little imaginative play, bed wetting, clumsy, poor gross motor control. He has been on the programme for 16 months. He no longer hits or bites or has tantrums. He is good at following adults� instructions and is no more cheeky or defiant than any other 7 year old. He is much calmer and is able to focus on schoolwork. At times he can be impulsive but he responds well to adult direction and the boundaries that are put in place. He is now able to play on his own and with his peers. He no longer wets the bed. He is about to graduate from the programme and is ready to move into a long term fostering or adoption placement. Savings: Costs of previous placement with an IFA were �43,264 pa. Given the level of behaviours, the likely alternative trajectory to MTFC would be that he would be in residential school at a cost of around �200,000 p.a. � Child 2 Referred to MTFC aged 4 following placement breakdown in a foster agency placement due to behaviour problems. Further IFA placements were being considered but her behavioural problems were seen to impact on chance of adoption. She had lived with her mother, father and 2 brothers. She experienced a kinship placement breakdown and then the breakdown of the IFA placement. She had experienced sexual, physical and emotional abuse at the hands of her father, and emotional abuse, neglect and failure to protect from her mother. Challenging behaviour: screaming tantrums, hitting other children, defiance and controlling of adults, refusal to eat, sexualised behaviour to animals and self, sleep problems. Compulsive compliance. Child 2 was on the programme for 9 months. In that time, her tantrums stopped and she became able to accept cuddles and comfort when upset. She no longer hurt other children. She was able to become reliant on adults in an appropriate manner, no longer being controlling or defiant. She was able to sleep through the night and was successful in school. Now adopted and not costing anything Savings on her IFA placements have already paid back the cost of the programme with an ongoing saving of c. �36,000 pa Child 3 Referred to MTFC aged 3 following PPO She had lived with her mother, already on the revolving door of care. Within the previous 3 months, she had been rehabilitated home in Feb 08 and then came back into care on a PPO in March 08. She then joined the programme. Her behaviours were internalising rather than externalising e.g. whining and repetitive questions, but were equally challenging for her foster carer. She also had problems with peer relations. She made excellent progress and her social skills improved enormously. The MTFC team worked intensively with her mother and she was rehabilitated home in Feb 09 and is still doing well a year later. Savings: lifetime in care i.e. �20,800 pa for placement alone plus all additional support costs.

27. 27 Appendix 1: MTFC Case Studies Child 4 Referred to MTFC aged almost 3. He was on an ICO and had been in a kinship placement for 10 months on a trajectory to a full time care career out of the extended family. He had significant global developmental delay with an IQ below assessable levels. He made huge progress on the programme and caught up in all domains so that he is functioning as a normal child of his age. The team worked with his mother and he returned home in September 09. He is doing well and his mother is still in touch with his MTFC carer. Savings: lifetime in care i.e. �20,800 pa for placement alone plus all additional support costs. From the MTFC-C programme (7-11 years old) Child 5 Referred August 09, aged 9. One of three siblings with significant abuse and neglect. The two older brothers are in residential accommodation at a joint cost of �395,200 pa. Extremely disturbed behaviours in all aspects of life with significant global delay, night terrors, continuous disruptive behaviours at school, impulse control difficulties and generally on a trajectory to early residential accommodation since, as he has become more secure, his behaviour has become more disruptive Now making significant progress but still likely to need special schooling. However, he can remain with his carer. Savings: his brothers are both in residential care costing �145,600 and �249,600 pa respectively Child 6 Referred in June 2009, aged 9 Significant verbal and physical aggression at home and school. Refusing to eat meals, and instead helped himself to snacks when he was hungry (e.g. a 10 pack of crisps). He did not have any bedtime/morning routine, and only fell asleep in the early hours. His mother reported feeling unable to care for him safely, and thus he required an emergency foster placement. He was initially placed with IFA carers over summer 2009. However, his challenging behaviour continued and his carers reported feeling unable to continue caring for him. Options on offer for him were either a residential care home or an MTFC-C placement. In terms of education, his level of violence resulted in him having a reduced school timetable, so that he was only attending a mainstream primary school for one hour a day. It was initially decided that he would need specialist education provision. He has made significant improvements in his behaviour within a mainstream primary school so it is unlikely he will be transferred to specialist education provision. He has recently been attending 4 mornings and 2 full days a week. Savings: Cost of IFA at �50, 648 pa; next placement would have been a specialist IFA placement at between �62,400 and �93,600 pa. Now likely placement costs will be either mainstream foster plus or rehab home at a minimum saving of c. �26,000 pa �

28. 28 Appendix 1: MTFC Case Studies Child 7 Came into MTFC aged 9. Had experienced significant and long term sexual, physical and emotional abuse from his stepfather and mother, and also neglect. Referred whilst on an IFA placement, and described as very �closed down�, e.g. not demonstrating any emotions the majority of the time. Approximately once a month he was verbally aggressive towards his carer, and destructive towards property. Not progressing academically, and a fair way behind his peers with learning. Frequently having outbursts at school where he would be verbally aggressive, slam doors, overturn tables, hit the other students (particularly one less able student in the class), and be destructive towards school property. A tendency to being over-controlling, e.g. wanting to control what activities were undertaken and how they were done. Presented as being a very unhappy child. Made huge SEN progress, so now at same academic stage as peers. He is very popular with other children and happy. There have been no aggressive outbursts since the first week of this term and he is able to take himself away to calm down. He is trusting of adults and has made disclosures about his past. No aggressive outbursts at foster carers for four months. Carer has applied to adopt him. Savings: costs would have been continuing IFA at �44,200 pa or Residential Care at a minimum of �52,000 pa as opposed to an enhanced adoption allowance for 2 yrs at �18,200 pa Child 8 Came into MTFC following breakdown of IFA placement. Was needing two escorts to transport him to school in a taxi following refusal of County Transport to transport him on H&S grounds. School problems, significant behaviour problems. In all settings, running away, kicking, biting, sexualized behaviour and oppositional defiance. In MTFC his behaviour was sufficiently challenging to threaten the placement and without the support of the team would almost inevitably have broken down. He is now stabilizing and has had 10 days without incident. Savings: with this behaviour, the alternative to MTFC would have been residential care costing �52,000 pa.

29. 29 Appendix 2: Additional Information

30. 30 Cost Scenarios...figures around optimal management

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33. 33 Case studies of LAC costs

34. 34 Case studies of LAC costs

35. 35 Evidence: Cochrane Review Meta-analysis �Although the numbers of studies are relatively few, diverse and small scale, the evidence suggests that [M]TFC is a promising social intervention for children and young people at risk of placement in settings that restrict their liberty and who are at risk of a range of adverse outcomes. This holds for a range of children and youth with behavioural and emotional disorders, but particularly those with conduct disorders and delinquency.� Treatment Foster Care for improving outcomes in children and young people (Review). The Cochrane Collaboration. p. 38. However, �Whilst the findings are in keeping with earlier studies and reviews, they also highlight the tendency of the perceived effectiveness of popular interventions to outstrip their evidence base. The results of individual studies generally indicate that [M]TFC is a promising intervention for children and youth experiencing mental health problems, behavioural problems or problems of delinquency, but the evidence base is less robust than that usually reported.� ibid.

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38. 38 MTFC Population Using a range of proxies, it seems the LAC population who may be suitable for MTFC programmes ranges from c. 4-40% of the LAC population. The lower end of the range of particularly high-need LAC making up c. 4-6% (2500-3500) of the population (those with emotional AND conduct disorders or who have been in trouble with the police more than 3 times or who move directly into residential care from foster care). The mid point of the range is c. 8-14% (5000-8000) of the population who are particularly unstable in placements, have a mental disorder and are in trouble with the police, or require specialist mental health services. The highest end of the range, c. 20-40% (12-24000) is made up of all children with any form of emotional or conduct disorder. The lower and mid ranges are more common in the proxy measures so an estimate of the LAC population for whom MTFC may be appropriate would be between 6% and 8%. For the purposes of our modelling, we have assumed that 7% of the LAC population would be suitable for MTFC treatment However, MTFC is only suitable for children aged between 3 and 16 years old, roughly 75% of the LAC population. We also know that approximately 30% of adolescent children who are referred to the programme refuse consent to be part of the MTFC programme.

39. 39 Sample LAs If we use a figure of 7% of LAC being suitable for MTFC we can look at the current LAC populations in some different LAs of different sizes: Birmingham � 146 Hammersmith and Fulham � 20 Lambeth � 38 Wokingham � 5 Shropshire � 14

40. 40 MTFC Population The total numbers of children who may use MTFC are not the full story as MTFC has 3 programmes based on the age of the children For example, if we take the previous LAs we can see that the number of LAC breaks down into age groups

41. 41 Roll out � Risks, Constraints, Barriers?

42. 42 MTFC Workforce Requirements MTFC-A Staffing Requirements Programme Manager Programme Supervisor Foster Carer recruiter/trainer Birth Family Therapist Young Person�s Individual Therapist Skills Coach Education personnel e.g. teacher Psychiatrist (1-2 sessions) Clinical Psychologist (if not appointed as PS or IT then 1-2 sessions for assessment) MTFC-P Staffing Requirements Programme Manager Programme Supervisor Foster Carer recruiter/supervisor Birth Family Therapist Children�s Group Lead Teacher/Skills Coach Skills Coach

43. 43 Workforce Supply: Clinical Psychologists The September 2008 NHS Information Centre (IC) census recorded 7,523 headcount and 6,056 FTE clinical psychologists � an FTE to headcount ratio of 0.80. This census figure for, �clinical psychology� includes all types of applied psychologists, some psychology assistants and trainees, and possibly counsellors and some psychotherapists. The Sainsbury Centre (2006) produced a report which attempted to estimate the demand for mental health professionals required to deliver the Mental Health National Service Framework (NSF). This demand estimate is for only one of the NSFs and excludes demand for staff for children services, older people�s services, learning difficulties, health promotion and physical health services. The report estimates that 10,200 clinical psychologists will be required, which exceeds the number in the IC census. Source: Migration Advisory Committee Shortage Report Clinical Psychologists, September 2009 http://www.wrt.nhs.uk/index.php/component/docman/doc_download/396-clinical-psychology-mac-inclusion

44. 44 Workforce Supply: Social Workers There are c. 80,000 registered social workers c. 30,000 social workers in LA children�s social work c. 11% vacancy rate in LAs for children�s social workers Social Work Task Force has recommended a National supply strategy but this is not expected for some time

45. 45 Workforce Strategy It is recommended that the workforce strategy address: Supply By professional group Existing qualifications & development Skills Individual Group/team Integration Existing workers and team around the child Development of existing social workers and those who would refer Impact On other programmes and employers Stakeholders How to manage workforce changes and create buy-in

46. 46 National Implementation Team National Implementation Team Staff Executive Director �Stephen Scott, Professor in Child Health & Behaviour, Consultant Child & Adolescent Psychiatrist Project Director - Rosemarie Roberts, Consultant Systemic Therapist Site Consultants North Team- Central Manchester& Manchester South Team - Maudsley Hospital, London Children�s University Hospitals NHS Trust Project Manager � Dawn Walker � Consultant Systemic Therapist (f/t) Cath Connolly � Systemic Therapist (p/t) Colin Waterman � Systemic Therapist (f/t) Brigitte Wilkinson � Clinical Psychologist (p/t) Kate Friedmann � Clinical Psychologist (p/t) Megan Jones � Clinical Psychologist (f/t) Vacant post Alison Nash � Senior Administrator (f/t) Joyce Self � Team Administrator (p/t) Zarina Abbas � Assistant Psychologist (f/t)