Not Reinventing the Wheel: Adapting Treatment Foster Care Oregon to Public Mental Health

This case illustrates the complexity and severity of problems that children in the public mental health system can exhibit as well as the lack of improvement in child mental health despite intensive and lengthy residential interventions. Additionally, this case highlights the often insurmountable challenges that families with seriously emotionally disturbed children face. A focused intervention, Treatment Foster Care Oregon (TFCO), targets multiple problem behaviors of children at risk for residential placement in multiple public systems and is the topic of this column.

In the United States, 49.5% of children and adolescents have a lifetime prevalence of any mental disorder; of these, 22.2% have a severe impairment that substantially interferes with functioning in multiple life domains (1). The prevalence of mental disorders and service needs among children and adolescents in Michigan mirrors these national data (2).

TFCO is one promising intervention for children with serious emotional disturbances who meet psychiatric hospitalization criteria (3). Typical behaviors and conditions among these youths include animal cruelty, aggressive or violent defiance, destructiveness, anxiety, depression, encopresis, tantrums, arguing, back talking, hyperactivity, and school problems. For adolescents, this behavior escalates to drug use or drinking, sexual activity, involvement with the law, running away, and truancy. Although, to date, TFCO has been implemented in child welfare and juvenile justice settings, the Behavioral Health and Developmental Disabilities Administration within the Michigan Department of Health and Human Services (referred to hereinafter as the State), in collaboration with Wayne State University, recognized that adaptations can be made to existing evidence-based practices rather than designing a new mental health service from scratch. The collaboration to bring TFCO to Michigan’s public mental health system began in 2016, building on previous successful collaborations.

Intervention

The primary goal of TFCO is to interrupt the cycle of negative reinforcement and reactivity between parent and child in order to promote family adaptation and prevent family dissolution. Family stability resulting from improved parental management of dysfunctional behavior is one key mechanism of TFCO success.

Results from randomized controlled trials in the child welfare and criminal justice systems have indicated that TFCO improves psychological outcomes and decreases delinquency rates, arrests, violent offense referrals, incarceration, substance use, and pregnancies (3). As a team-based and time-limited intervention, it utilizes concrete encouragement for positive behavior and clear limit setting for problem behavior. The child is temporarily placed with trained foster parents (called therapeutic parents in Michigan) who give daily telephone reports on specific behaviors and receive ongoing support and consultation supplemented by weekly treatment support groups and 24/7 on-call staff. Additionally, the child receives services from his or her own individual therapist and from a skills coach up to five times per week, depending on need. The therapist supports problem solving, and the skills coach focuses on practicing target skills in community settings such as libraries and parks (3). The family or caregivers (called the aftercare family) receive instructions and skill training in effective parenting and incorporating the child into the family. The members of the aftercare family also practice these skills during therapeutic visits with the child under the guidance and support of a separate family therapist.

Adaptation

Traditional intervention adaptations expand evidence-based practices to populations that may differ in geographic or demographic factors from the original population (3, 4). TFCO adaptation across systems expands intervention options without the delay and expense of developing an intervention while maintaining the basic tenets and theoretical underpinnings of the intervention. This column discusses the process and challenges that we encountered in this adaptation.

Implementation Process: Ground Work and Pilot Project

To build capacity within the public mental health system, funding for 2 years was included for preparation work before TFCO clinical services began. The implementation approach involved the full transfer of the clinical model for sites to conduct the program independently. To align with the Michigan public mental health system, a community development team (CDT) approach (5) was utilized for problem solving and overcoming barriers.

The CDT approach included systems- and agency-level adaptations. (A table outlining these adaptations is available in an online supplement to this article.) Systems-level work began with designing collaborative structures and decision-making processes and with the identification of key system representatives to participate at meetings (discussed in more detail below). Agency-level work began with an organizational assessment to determine feasibility. This assessment was also intended to build rapport between the partners and the agencies by clarifying expectations. TFCO implementation required engaging agencies to work collaboratively with the State and university to build a program template, beyond simply delivering the service at their agency. Activities at the agency level included establishing TFCO staffing structures, clinical coordination with other services provided, group training and orientation, fidelity in reporting requirements, and screening and referral processes for potential therapeutic parents and eligible families with children who would benefit from this service.

Recognizing that the introduction of such an intensive and expensive intervention needed to proceed in stages once the first step after the ground work was completed, we undertook a pilot TFCO project in two community mental health agencies, as opposed to all agencies, in different regions of the state. This approach minimized geographic exceptionalism influencing the implementation. The pilot implementation was guided by consultation with TFC Consultants, Inc., the organization responsible for the development and implementation of the intervention both nationally and internationally.

Implementation Process: Communication

To start the implementation, the State officials contracted with a university to facilitate the project. The university established a multidisciplinary work group consisting of members representing psychiatry, psychology, epidemiology, social work, and finance. A full-time project manager with experience in both administration and direct clinical care was hired and trained in TFCO. The project manager serves as the liaison between the State, the university work group, and TFC Consultants (collectively referred to as the partnership) and clinical agencies. Other responsibilities of the project manager include coordination of all aspects of clinical implementation, facilitation of TFCO-related infrastructure (e.g., funding streams and eligibility criteria), and oversight of fidelity. Weekly meetings are used to monitor implementation progress, and programmatic decisions were initially made in monthly partnership meetings; the partnership meetings decreased in frequency to quarterly as implementation progressed. The structure of the work group and partnership is nonhierarchical to foster collaboration. The project manager continuously liaises between the partnership and agencies. Urgent items are brought to the partnership for immediate feedback and resolution.

The implementation process encountered some programmatic challenges. The problem-solving approach to each challenge built on the relationships established in the beginning stages and relied heavily on a collaborative approach for resolution. One agency discovered during the implementation that its vision differed from that of TFCO. Specifically, the agency wanted to fit the program into an already existing program as opposed to creating a new structure that TFCO requires. The agency decided to stop implementation, and another agency was recruited to replace it for the pilot phase. Solutions to these and other challenges were identified through a process of discussion and group meetings, which prompted the development of a Michigan-specific agency feasibility assessment to assist with agency selection. Challenges encountered had three major themes: regulations, system cultures, and funding. These challenges and the proposed solutions are described as follows.

Challenge: Regulations

The first and most obvious challenge was that the public mental health system has regulations that differ from those of either the child welfare system or the juvenile justice system. Service reimbursement and funding structures, staffing credentials, and organizational designations all differ across these various systems. Thus, to implement TFCO in the public mental health system, the first step was to translate staffing and departmental oversight at the State level through an evaluation of the different credentials and licenses needed by agencies and their staff to implement the intervention. Additionally, new language was needed and approved by the state that maintained the rigorous child welfare licensing standards while designating TFCO homes as distinct from foster homes.

Less obvious were other regulations that required addressing the difference between a child being a ward of the court, such as in child welfare and juvenile justice systems, and parents remaining legal guardians in the public mental health system. This difference had implications for eligibility, the role of guardians in treatment and oversight, and education.

The solution to these challenges was to specify that eligibility for TFCO in Michigan depends solely on the mental health treatment needs of the youth rather than removal from his or her home due to substantiated abuse or neglect or criminal activity (as done in child welfare implementation). Consistent with this, legal guardians are not mandated to initiate treatment, but once enrolled in treatment, they are required to actively participate in it as a condition of eligibility for their child to receive TFCO. Documents were created that delineated the role of legal guardians retaining responsibility for the child’s academic and medical decisions and physical guardianship when therapeutic parents were unavailable (e.g., because of illness). Written releases and consent packages explicitly emphasized the intervention’s voluntary nature. Parameters for therapeutic parents to administer medications and access emergency medical care as necessary were included.

TFCO strongly recommends a change in school environment through enrollment at a new school. However, in Michigan, public school enrollment is assigned on the basis of the physical address of the legal guardian. For TFCO implementation, we therefore utilized a U.S. Department of Education “suitable housing” statute, which mandates that the school district of the therapeutic parents accept enrollment of the child while the child is receiving TFCO treatment in their home.

These solutions required specialized training to preserve the core concepts and competencies of TFCO and reflect implementation in the public mental health system. The training encompassed clinical staff, administrators, and therapeutic parents. A manual was developed to detail the inclusion of all concepts and competencies as well as their origin (i.e., TFCO or the public mental health system).

Challenge: System Cultures

While addressing the initial obvious regulatory differences among systems, we became aware of differences in organizational culture across agencies and partners. For the purposes of this column, we define organizational culture as agency definitions of achievement and success, attitudes toward risk taking and employee development, structures for decision making, staff oversight, and the structure and style of leadership (6).

One culture-based system difference was that the TFCO vocabulary was developed using language from child welfare. The same terminology can mean something different in another system. To remedy this potential for confusion, a glossary of terms was developed for trainers, clinical staff, administrators, and evaluators. For example, the initiation of the intervention in our adaptation was termed beginning treatment as opposed to starting a placement, to highlight that placement in the therapeutic parents’ home differs from entry into a traditional foster care home. Documents and training were structured to reflect a patient-centered approach as opposed to a child welfare or public safety approach. As with any new intervention, staff expectations and roles differed among the systems. Training provided by TFCO was explicitly reviewed and modified to reflect the public mental health system.

Another cultural difference we encountered was the shift in treatment focus that TFCO requires for clinicians. Some clinicians preferred using psychodynamic treatment modalities rather than utilizing the behaviorally focused approach required by TFCO. The clinical supervision and quarterly reviews conducted by TFC Consultants revealed this problem. TFC Consultants offered additional training sessions and clinical consultations with clinicians and their supervisors to address this challenge.

Challenges: Funding and Resources

Maximizing sustainability and effectiveness while also minimizing staff and therapeutic parents’ attrition were programmatic concerns. Michigan hopes to leverage Medicaid reimbursement for ongoing sustainability, which requires ongoing data collection, monitoring of reimbursement parity, and analyzing funding gaps. Additionally, the model certification requirement of select staff to be dedicated full time to TFCO was burdensome, given the resources available at each agency. Creative role and job sharing devised by the agency and discussed at partners’ meetings effectively minimized this problem.

Conclusions

In this column, we present the promises and challenges of translating an intervention across different child-serving sectors with different foci of service. Although challenging, the adaptation of an existing evidence-based intervention is feasible and faster than creating and validating a newly created intervention. Differing regulations, organizational cultures, and funding resources were identified as challenges to the adaptation of TFCO, an evidence-based treatment originally used in child welfare and juvenile justice systems, for the public mental health system in Michigan. Some of the solutions involved clarification of mandatory and voluntary participation in the TFCO treatment program, modification of language to reflect the public mental health system, ensuring school enrollment in the therapeutic parents’ school district, and working toward long-term financial sustainability.

Modifications and their effects on the TFCO clinical intervention are being assessed by quarterly reviews conducted by TFC Consultants. All reviews completed during the first five quarters of program implementation indicated that Michigan’s TFCO adaptations have met model adherence typically seen during child welfare and juvenile justice implementation.

Returning to our example case, Jenny graduated and continues to live with her family. At the time of this column, 10 children have entered the TFCO program; seven have completed it, and three are currently enrolled. Although data analysis is ongoing, preliminary clinical outcomes have indicated that most early enrollees successfully completed the TFCO treatment, returned to their aftercare families, and maintained treatment gains for at least 6 months without needing hospitalization (estimated to cost Michigan $1,500 per day). These findings emphasize the positive clinical and potential financial effects of using a time-limited, intensive, community-based model. To date, four TFCO sites in Michigan are engaged in the implementation project, with the potential to serve 50 children and their families in community-based settings annually.

With limited resources and differing eligibility criteria, the field of children’s mental health would benefit from creative and flexible adaptations of evidence-based practices from other child-serving systems. The process of adapting an evidence-based practice to a new setting or population allows for a greater clinical reach of the intervention and for more intervention choices.