Implementing the MTFC adolescents programme in England: issues in programme transfer

1. Implementing the MTFC adolescents programme in England: issues in programme transfer Nina Biehal and Jo Dixon Department of Social Policy and Social Work University of York

2. English evaluation of MTFC-A • MTFC developed and positively evaluated in the USA • Adolescents programme (MTFC-A) in USA mainly targeted at young offenders • Independent English evaluation of MTFC-A by Universities of York (Biehal, Dixon, Parry, Sinclair) and Manchester (Green, Kay et al): MTFC-A for children age 11-16 years who: • were already in family foster care or residential care (‘looked after children’) • had serious emotional and behavioural difficulties • In an unstable placement/at risk of placement breakdown

3. English evaluation of MTFC-A MTFC-A for looked after children age 11-16 years • 219 children at 18 sites across England • Quasi-experimental study (n=219) • RCT also attempted but recruitment unsuccessful (n=34) • Sample • 106 children placed in MTFC, 113 in ‘Usual Care’ (UC) • UC = ordinary foster (34%) or residential care (58%) • UC group: young people who met criteria for MTFC • MTFC children slightly older and more likely to be in residential care at baseline (analysis took account of this) • Data collection at baseline and 1 year follow-up

4. The children in the study • Over 93% had experienced abuse or neglect • Many had entered care late • 78% at age 5 or over, 44% at age10-15 years • Long exposure to adversity in family • History of placement instability • Average of 5 previous placements

5. Behavioural and emotional difficulties • Per cent with clinically significant scores on SDQ • Total score 64% • Conduct problems 68% • Emotional problems 37% • Involvement in crime • 26-30% convicted in the last 6 months

6. Outcomes at 1-year follow-up: global functioning • Primary outcome measure: the C-GAS (Children’s Global Assessment Scale) • Blind ratings of all data at baseline and follow-up • MTFC group as a whole did no better than UC group • But those who were disruptive/anti-social at baseline did better in MTFC than in usual care • MTFC originally designed for those with behaviour problems • Those who were not anti-social did better in the usual care placements than in MTFC

7. One-year follow-up: placement outcomes • MTFC placements • 26% disrupted (21% for control group) • Aim: move to a long-term foster family after 9-12 months in MTFC • But ½ still in MTFC placements at follow-up • Hard to find follow-on foster placements • Of those who had left MTFC • Only 25% moved to new foster placements • 50% moved to residential care (2/3 of those who had been in residential care pre-MTFC placement)

8. One-year follow-up: offending outcomes • No overall difference in involvement in offending over follow up between MTFC and UC group • But those previously involved in crime were less likely to offend if they received MTFC • MTFC group were less likely to offend if stayed in MTFC placement for 3+ months

9. One-year follow-up: education outcomes Intensive educational support provided but • Engagement in education no better for MTFC-A group than for UC group • More of MTFC group excluded from school • No improvement in school attendance

10. MTFC-A: interviews and case studies • Engagement • MTFC worked better if child was willing to ‘buy in’ to the highly structured nature of the programme • Parents sometimes undermined the programme • Importance of relationship with foster carer • Could make reluctant children more willing to accept the structured behaviour management • Displacement of discipline onto programme & clinical team helpful to foster carers • Might have helped to keep relationships positive? • Post-MTFC environment important • Did it reinforce any changes or undermine them?

11. Why were our findings less positive than in the US studies? • Evidence-based programmes found to be effective when tested by their developers in tightly controlled settings • What affects programme effectiveness when transferred to other settings?

12. Targeting & evaluation of programme • Different populations, different outcomes measured • US studies of MTFC-A • Mainly seriously delinquent youth/chronic juvenile offenders • Most were living at home prior to MTFC placement • Aim of MTFC-A: reduce re-offending and return child home • Primary outcome: various measures of recorded re-offending • Independent English evaluation • < 1/3 had recent criminal convictions • 93% had histories of abuse and neglect • Were already in care and unlikely to return home • Aim of MTFC-A: address d behavioural and emotional problems and then move child to long-term foster placement • Primary outcome: measure of children’s global functioning (C-GAS)

13. Treatment fidelity in real world settings • Difficult to ensure fidelity to MTFC model across multiple sites despite: • National programme co-ordinators/teams • Distance supervision by programme developers • Fidelity consistently rated as high for only 1/3 of MTFC-A sites • Varied between sites and within sites over time • Affected by changing staff and staff vacancies

14. The wider context • Lack of key provision by other agencies • Hard to find new schools when young people moved to MTFC and when they left it • undermined work with young people in placement and after return home • National shortage of foster carers • Hard to find follow-on foster placements after programme completed, so many returned to residential care

15. Importance of what happens after the placement ends • Effects of the new environment • Behavioural change may not last beyond the placement • those who left MTFC-A did worse than those in still in placement • this was not related to time in placement • Similar findings for companion study of MTFC-A for young offenders (Intensive Fostering) • Reduced re-offending while in placement • No difference 1 year after leaving placement

16. Conclusions: issues in programme transfer Programme effectiveness may be found to vary due to: • Variation in the population served • Is the programme delivered to a similar group of children? • The outcomes of interest • Re-offending versus global functioning • The local service context • e.g. availability of education provision • Quality and effectiveness of the control condition • Is UC of similar quality in USA and England? • The wider policy and resource context, which determines • Who enters care and in what circumstances • The nature, quality and availability of services

17. Publications • Biehal, N., Dixon, J., Parry, E., Sinclair, I., Green, J., et al (2012) The Care Placements Evaluation (CaPE). Evaluation of Multi-dimensional Treatment Foster Care for Adolescents (MTFC-A). Department for Education. https://www.education.gov.uk/publications/eOrderingDownload/DFE-RB194.pdf (summary). • Green, J.M., Biehal, N., Roberts, C., Dixon, J., Kay, C., Parry, E., Rothwell, J., Roby, A., Kapadia, D., Scott, S. and Sinclair, I. (2014) ‘Multidimensional Treatment Foster Care for Adolescents in English care: randomised trial and observational cohort evaluation,’ British Journal of Psychiatry 204: 214-221 • Dixon, J., Biehal, N., Green, J., Sinclair, I., Kay, C. and Parry, E. ‘Trials and tribulations: challenges and prospects for randomised controlled trials of social work with children’. British Journal of Social Work. Advance access doi:10.1093/bjsw/bct035 March 4th 2013. • Biehal, N., Ellison, S. and Sinclair, I. (2011) ‘Intensive fostering: an independent evaluation of MTFC in an English setting,’ Children and Youth Services Review 33: 2043-2049 (other MTFC-A study).