1. Multidimensional Treatment Foster Care – an alternative to institutional placement Euromet Symposium 2013 Annika W Jonsson, psychologist Sara Lindstein, psychologist SiS ungdomshem Hässleholm

2. Background Information  OSLC, where MTFC was developed, was started in the 1970’s by Gerald Patterson and John Reid in Eugene, Oregon, USA  The MTFC program is based on Social Learning Theory and Coercion Theory  MTFC is evidence- and manualbased

3. How is MTFC different?  MTFC places one child with a family at a time  Placement in MTFC is approx. one year  MTFC uses a team approach to treatment  Foster Parents are members of the team  For one of the foster parents, MTFC is a full-time job  Programs are individualized for each youth  Support for foster parents is available 24 hours a day, 7 days a week  Foster parents meet regularly with their supervisor and other foster parents in the program to learn from and support each other

4. Main purpose of MTFC Youth returning to a permanent living with his/her family. For all treatment components of MTFC, this is focus from day one.

5. MTFC Key stones  Reinforcement of pro-social behaviors  Close supervision  Fair, consistent and predictable limits and consequences  Supportive relationships  Minimize association with peers who may be a bad influence

6. Who is served by MTFC?  Children and youth in need of out-of-home placement due to serious behavioral and emotional problems and their families  MTFC-P serves children 3 – 6 years old  MTFC-C serves children 7 – 11 years old  MTFC-A serves youth 12 – 17 years old  Those who may have failed in prior placements or treatments  Can be used as step-down from institutional placements  Can be used as diversion from institutional placements

7. Exclusionary criteria  Absence of serious behavior problems  Substance abuse is the only problem behavior  Sex offending/acting out is the only problem behavior  Active suicidal/homicidal  Psychosis  Schizophrenia  Bi-polar disorder with psychotic features

8. The MTFC Universe School Foster parents Social services Youth therapist Biological family Family therapist Youth Program supervisor Skills coach

9. Core Components for MTFC Parents  Conducts daily behavior management point and level system  Daily telephone contact and data collection  Weekly support and training meetings  24-hour, 7-day on-call program supervisor

10. Core Components for Youth  Daily mentoring by MTFC parents  Daily structure and support via a point and level system  Daily school card  Weekly contact with parents and frequent home visits  Weekly individual therapy  Weekly skill building and advocacy  Close supervision of whereabouts and associations  Psychiatric consultation

11. Point chart Name Date Points Things to Do to Earned Points Earned Bonus Total  5 UP ON TIME  5 READY IN MORNING  5MORNING CLEANUP  5GO TO SCHOOL, CARRY SCHOOL CARD  10ON TIME FOR CLASS  10BEHAVIOR IN CLASS  10 READ AND STUDY  5 ATTEND THERAPIES & SKILLS TRAINING  5ATTEND LEISURE ACTIVITY  10BEING ON TIME  5 CHORE  5 DINNER WITH FOSTER FAMILY  5 ENGAGE IN FAMILY ACTIVITIES  0-10 PRO-SOCIAL PEER CONTACT  5ATTITUDE  5 BED ON TIME  5CELL PHONE TO FOSTER PARENTS DAILY TOTAL (115)

12. Point and Level System  Three levels  Opportunities to earn points for compliance, prosocial behavior  Points are lost for rule violations, misbehavior  Provides a framework within which interaction can occur without engagement in conflict

13. Level 1 During Level 1, the youth settles into the MTFC family home and begins to build relationships. In Level 1, there is very close supervision and immediate reinforcement.  The youth earns points for routine daily activities.  The youth is supervised at all times.  No homevisits, no time with friends, no cell phone  The youth should be able to earn approx. 100 points a day.  It takes 2,100 points or about 3 weeks to move out of Level 1.

14. Level 2 Level 2 will be individualized according to what was learned during level 1.  Youths can earn 805 points a week.  Bonuspoints earned in one week are used to buy privileges for the next week.  They learn to delay gratification, plan ahead, and work toward a goal.  The amount and quality of privileges increases.  They can be demoted to level 1 for low point days.  It takes 110 days to earn enough points to move to level 3.

15. Level 3 Level 3 is a maintenance phase. The youth is allowed more free time and a higher quality of privileges in level 3.  The youth must earn 90 points a day.  Youth and foster parents/family are more independent in relation to the program supervisor  Activities must be approved in advance.  Serious violations can result in a demotion to level 1.

16. Core Components for Families  Weekly family counseling focusing on Parent Management Training: teaching parents to use clear and consistent discipline, be warm and supportive and to supervise their children closely  Instruction in behavior management methods  Home visits with crisis back-up  24-hour, 7-day on call to program supervisor

17. Research results – Swedish 2-year-follow-up Comparison MTFC-group (n = 20) and TAU-group (treatment as usual)(n = 20)  MTFC had significantly reduced all self-reported problem symptoms (internalized and externalized) for youths and mothers.  TAU had significantly reduced some self-reported problem symtoms  MTFC had reduced all self-reported problem symtoms with at least 30% Pia Kyhle Westermark, 2009, IMS & Socialhögskolan, Lunds universitet

18. Swedish 3-year-follow-up Comparison SiS assessment + MTFC-treatment (n = 19) vs SiS assessment +TAU (n = 27)  Violent crime during the three-year follow-up period 0 % in the MTFC-group vs 41 % in the TAU group  Days in locked wards during the follow up period: MTFC average 23 days vs TAU average 87 days  Third year – significantly lower frequency of criminality in the MTFC-group On going study, Bergström & Höjman, Lund university/SiS

19. Aftercare  Aftercare helps to prevent old patterns of problem behavior to return. Without it, problem behaviors most often reoccur. Support is needed for a long time.  The youth level of functioning after the termination of the MTFC-program is more dependent on the situation at home then it is on the level of functioning during the MTFC-placement.  Multidimensional work is necessary also in the phase of aftercare; family, school, friends and leisure activities.