Multidimensional Treatment Foster Care as a Preventive Intervention to Promote Resiliency Among Youth in the Child Welfare System

posted by Dr. James G. Hood
Wednesday, June 16, 2010

Leslie D. Leve, Philip A. Fisher, and Patricia Chamberlain
Oregon Social Learning Center and Center for Research to
Practice
ABSTRACT Demographic trends indicate that a growing segment of
families is exposed to adversity such as poverty, drug use problems, caregiver
transitions, and domestic violence. Although these risk processes
and the accompanying poor outcomes for children have been well studied,
little is known about why some children develop resilience in the face
of such adversity, particularly when it is severe enough to invoke child
welfare involvement. This paper describes a program of research involving
families in the child welfare system. Using a resiliency framework,
evidence from 4 randomized clinical trials that included components of
the Multidimensional Treatment Foster Care program is presented. Future
directions and next steps are proposed.
The number of children in the United States who experience neglect
and maltreatment has risen steadily for several decades, with an estimated
3.3 million referrals to child welfare authorities involving 6
million children during 2005 (U.S. Department of Health and
Human Services, 2007). It has been estimated that 7% of all children
and adolescents will have some involvement in the child welfare
Support for this research was provided by the following grants: MH059780,
MH060195, MH054257, MH047458, and MH076158, NIMH, NIH, U.S. PHS;
HD045894 NICHD, NIH, U.S. PHS; DA021424 and DA015208, NIDA, NIH, U.S.
PHS. The authors thank John Reid and Jerry Patterson for their contributions to the
theoretical models upon which this work is based, Matthew Rabel and Chere´ DiValerio
for editorial assistance, and the foster parents, children, and child welfare service
providers in Oregon and California for their contributions to this research.
Correspondence regarding this article should be addressed to Dr. Leslie D. Leve,
Oregon Social Learning Center, 10 Shelton McMurphey Boulevard, Eugene, OR
97401. E-mail: lesliel@oslc.org.
Journal of Personality 77:6, December 2009
r 2009, Copyright the Authors
Journal compilation r 2009 Wiley Periodicals, Inc.
DOI: 10.1111/j.1467-6494.2009.00603.x
system during their lifetime (Barth et al., 2005). The most prevalent
cause of child welfare involvement is parental neglect (64% of the
cases): inadequate child supervision; failure to attend to the child’s
physical, emotional, or educational needs; spousal abuse in the
child’s presence; parental drug or alcohol use that interferes with
parenting abilities; and inadequate medical care for the child. Other
common causes of child welfare involvement include physical abuse
(16%), sexual abuse (9%), and psychological maltreatment (7%),
with children often experiencing more than one type of maltreatment
(e.g., neglect and physical abuse; U.S. Department of Health and
Human Services, 2007).
A sizable literature details the disparities in the child welfare system
population compared to the general population on indicators of
health, mental health, and social and economic well-being (Barth,
Wildfire, & Green, 2006; Gassman-Pines & Yoshikawa, 2006; Kerman,
Wildfire, & Barth, 2002). For example, child welfare system
children and parents exhibit extremely high rates of behavioral and
emotional problems (Aarons, Brown, Hough, Garland, & Wood,
2001; Garland, Hough, Landsverk, & Brown, 2001; Klee, Kronstadt,
& Zlotnick, 1997; Landsverk & Garland, 1999; Landsverk, Garland,
& Leslie, 2001; Pilowsky, 1995). In a study with a large representative
sample of 5- to 9-year-olds, Briggs-Gowan, Horwitz, Schwab-
Stone, Leventhal, and Leaf (2000) reported that the rates of childhood
psychiatric disorders (e.g., major depression, conduct disorder,
and ADHD) increased by 2.91 times in families in which potential
child abuse was indicated: 49% of the children in such families were
diagnosed with a psychiatric disorder (vs. 16.8% of the full sample).
In addition, more than half of the children in the child welfare
system have been identified as having cognitive delays (Frankenburg,
Dodds, Archer, Shapiro, & Bresnick, 2002; Landsverk, Davis, Ganger,
Newton, & Johnson, 1996). Substance use rates are also very
high. In one study, Forrester (2000) indicated that parental substance
use was a concern in over half of the child welfare families,
with 24% of all families experiencing alcohol abuse and 16% experiencing
heroin abuse. However, despite an abundant literature that
focuses on negative outcomes, little is known about why some children
in the child welfare system show resiliency in the face of exposure
to adverse life experiences.
In this paper, we describe a program of research based on developmental
studies, randomized efficacy trials, and effectiveness stud-
1870 Leve, Fisher, & Chamberlain
ies with child welfare–involved families. We present data highlighting
resiliency processes among children and adolescents with child
welfare involvement due to a variety of life experiences, including
parental drug use, severe parenting, poverty, exposure to trauma,
caregiver transitions, and/or lack of medical care. We consider child
welfare involvement to be the extreme end of a continuum of exposure
to such adverse life experiences, with levels of exposure that are
severe enough to endanger the well-being of the child. As described
in the statistics below, many children are exposed to similar types of
adversities (severe parenting, parental drug abuse, marital conflict),
but at less extreme levels. In the following sections, we first illustrate
how a resiliency framework can provide insight into the mechanisms
whereby youth in the child welfare system show positive outcomes.
Second, we describe key components of an intervention for youth
exposed to severe early adversity: Multidimensional Treatment Foster
Care (MTFC; Chamberlain, 2003). Third, we present evidence
from four completed randomized clinical trials that incorporated
MTFC components to illustrate support for resiliency processes in
buffering children and adolescents against risks arising from early
adversity. We conclude with a discussion of directions for future research
and implications for services.
Applying Resiliency Concepts to Interventions for Youth in the
Child Welfare System
According to a recent U.S. Census Bureau (2007) report, 17.4% of
children under age 18 (nearly 13 million) live in poverty, and 11.7%
of children (8.7 million) were uninsured as of 2006. Concurrent with
these factors is widespread exposure to illicit drug use and domestic
violence. Over half of the U.S. adult population of child-bearing age
report having used illicit drugs in their lifetime (Substance Abuse
and Mental Health Services Administration, 2007), and nearly one
third (31%) of women in the United States report having been physically
or sexually abused by a husband or boyfriend at some point in
their lives (The Commonwealth Fund, 1999). Moreover, 3.3–10 million
U.S. children annually witness some form of domestic violence
(Carlson, 1984; Straus, 1992). These types of adverse life experiences
(extreme poverty, domestic violence, parental drug use) are among
the defining characteristics of experiences that necessitate child welfare
system involvement (Child Welfare Information Gateway,
2008). However, not all youth exposed to such conditions show
Resiliency in Child Welfare Families 1871
poor outcomes. In this paper, we focus on resiliency mechanisms
that may help to explain why some youth exposed to adverse experiences
have positive social, school, and/or behavioral adjustment.
As noted by Rutter (2000), understanding resilience in children
and adolescents exposed to adversity is of considerable importance
in guiding public policy aimed at the prevention of psychopathology.
In particular, learning about the protective factors and mediating
mechanisms that promote resilience in the face of adversity is key to
the prevention of poor outcomes (Masten, 2001; Rutter, 2000, 2007).
In a recent concept paper, Luthar and Brown (2007) noted that a
primary characteristic of resiliency research is that it is applied in
nature, using scientific knowledge to maximize the well-being of
those at risk. The authors described the central mission of resiliency
research: to ‘‘illuminate processes that significantly mitigate the ill
effects of various adverse life conditions as well as those that exacerbate
these, and thus to derive specific directions for interventions
and social policies’’ (p. 931). Originating from investigations of poverty
and response to trauma (in addition to schizophrenia), resiliency
research is thus highly germane to understanding outcomes for
youth in the child welfare system, who have experienced similar adversities
(Cicchetti & Garmezy, 1993).
Masten’s (2001) review of converging findings on resiliency highlighted
a critical phenomenon: that resilience occurs through ordinary
(rather than extraordinary) processes involving the operation of basic
human adaptational systems, even in the face of severe adversity.
These adaptational systems include individual-level characteristics
(e.g., cognitive functioning, sociability, self-efficacy), family-level characteristics
(e.g., close relationships with caring adults, authoritative
parenting), and extrafamilial characteristics (e.g., social support, effective
schooling; Masten & Coatsworth, 1998). Through these adaptational
systems, interventions could therefore enhance child resilience in
several ways. First, compensatory effects could be attained if enough
positive assets are directly added to the child’s life to offset the adversity
(Garmezy, Masten, & Tellegen, 1984; Masten, 2001). Second, resilience
could be attained indirectly, through the targeting of mediating
variables that are hypothesized to relate to the desired outcome. For
example, numerous studies have indicated the mediating role of parenting
in linking early adversity with child outcomes (Masten, 2001).
Emanating from a life course developmental model that specifies
malleable, family-centered intervention targets, the MTFC interven-
1872 Leve, Fisher, & Chamberlain
tion is based on similar individual, familial, and extrafamiliar processes
as described in Masten’s (2001) conceptualization of resilience
as an ‘‘ordinary’’ set of processes. Further, it applies intervention
and policy implications as described by Rutter (2000). The MTFC
model emerges from the translation of basic theory into systematic,
effective interventions (Type 1 translational research) and the bringing
of those interventions to scale in community settings (Type 2
translational research; see Figure 1). A guiding core principle is that
intervention development is informed by empirically grounded theory
and, in particular, by theories involving resiliency processes. As
is shown in Figure 1, we conceptualize this process as an iterative
cycle, in which information from each step in the cycle informs the
next, leading full circle to the testing of more refined developmental
models that can inform intervention development and implementation
methods.
The theoretical model that guides our work evolved from research
by Patterson and colleagues (Patterson, 1974; Patterson & Cobb,
1973; Patterson & Fleischman, 1979; Patterson & Reid, 1973; Reid,
1978; Reid & Patterson, 1974). These early studies provided a foun-
Effectiveness
studies and
large-scale
implementation
Theorybased
research
Intervention
development
and efficacy
studies
Type 1 Type 2
Figure 1
Translational prevention research cycle showing Type 1 and Type 2
translation.
Resiliency in Child Welfare Families 1873
dation for coercion theory, which emphasizes the role of family interactions
as primary determinants and predictors of outcomes for
children (Patterson, 1982; Patterson, Chamberlain, & Reid, 1982;
Patterson & Reid, 1984). Those original studies and the theory have
since been replicated and validated by many other researchers (Eddy,
Reid, Stoolmiller, & Fetrow, 2003; Reid, Patterson, & Snyder, 2002;
Snyder et al., 2005). Coercion theory, in turn, has been used to identify
clear intervention targets within the parenting practices of families
with children who exhibit disruptive behavior. We have
developed and refined theory-driven interventions for parents of
children with externalizing problems referred by schools, mental
health, and juvenile justice (e.g., DeGarmo & Forgatch, 2005; Eddy
et al., 2003; Patterson & Brodsky, 1966; Patterson et al., 1982; Patterson
& Reid, 1973) and have systematically tested alternate implementation
methods for delivering such services in community
settings (Chamberlain, Brown, et al., 2008).
In the mid-1980s, we applied the coercion model theory to inform
the development of the MTFC model (a description follows). Consistent
with coercion theory and with Masten and Coatsworth’s
(1998) resiliency frame, the MTFC intervention model targets parenting
and peer interaction processes to prevent negative, coercive
interactions between caregivers and children and to enhance positive
interactions; enhances caregiver monitoring and supervision skills to
improve youths’ prosocial behavior; and reinforces youths’ positive
and prosocial behavior. The MTFC intervention has been shown to
have powerful effects on reducing delinquency (Chamberlain &
Reid, 1991; Eddy & Chamberlain, 2000). However, consistent with
this issue’s theme on adverse life experiences, it became evident that
many of the youth in these studies experienced early adversity that
predated their involvement in the intervention by many years.
Our focus, therefore, has recently broadened to include prevention
and the promotion of resiliency prior to the onset of serious
child adjustment problems. This view led to adaptation of the
MTFC intervention for foster preschoolers (MTFC-P; Fisher, Burraston,
& Pears, 2005; Fisher, Ellis, & Chamberlain, 1999), a universal
preventive intervention for foster parents of preadolescents
(Project Keep; Chamberlain, Price, Reid, & Landsverk, 2008), and
a preventive intervention for girls in foster care who are transitioning
to middle school (Chamberlain, Leve, & Smith, 2006). Throughout
our MTFC-based research, the central elements of coercion theory
1874 Leve, Fisher, & Chamberlain
remain at the core of our theoretical model (e.g., enhancing parenting
behaviors and improving child adjustment outcomes). Additionally,
consistent with research on resiliency, the model now
incorporates key positive individual and interpersonal adjustment
outcomes, such as supportive interpersonal relations, adaptive neurobiological
functioning, and adaptive social behavior.
As shown in Figure 2, our conceptual model illustrates the MTFC
intervention components that encompass the family system (foster
parent and biological parent), the individual (child or adolescent),
and the extrafamilial context (the service system). Consistent with
Masten and Coatsworth’s (1998) framework on resiliency, the intervention
focuses on direct intervention to increase the assets a child is
exposed to and also targets hypothesized mediated processes that are
expected to lead to resiliency outcomes. The panels in Figure 2 portray
a sequence of resiliency processes for children and adolescents
exposed to severe early adversity, such as child maltreatment. The
left panel of Figure 2 (described in detail in the next section) illustrates
the strength-based components of the MTFC intervention that
are intended to create experiences that lead directly to resilience. Intervention
targets include the foster parent (enhancing and support-
MTFC intervention
components
Resilience
mechanisms
Resilience
outcomes
Foster parent
• Enhanced foster
parenting skills
Biological parent
• Support and training
for after-care family
Child/adolescent
• Strength-building
• Social skills coaching
• Academic support
Service system
• Coordinated services
across home & school
Child/adolescent
• Social competence
• School success
• Behavioral adjustment
Caregiver
• Reduced stress
Supportive
interpersonal relations
• Secure attachment &
positive reinforcement
from foster parents
• Normative peer group
• Mentoring adults
• Parent social support
• Stable home context
Adaptive
neurobiological
functioning (child)
• HPA axis
• Prefrontal cortex
Figure 2
Multidimensional Treatment Foster Care as a strength-based intervention
promoting child and adolescent resiliency in youth exposed
to early adversity.
Resiliency in Child Welfare Families 1875
ing parenting skills), the biological parent (support and training for
the after-care family), the youth (skill-building, academic support for
youth), and the service system (coordination of services). The center
panels illustrate a set of interpersonal and biological processes that
might mediate the association between early adversity and resiliency
outcomes. For example, at the interpersonal level, youth exposed to
a strength-based preventive intervention are hypothesized to develop
supportive interpersonal relations (e.g., normative peer affiliations,
secure attachments to their caregivers, mentoring adults in their
lives) and to have caregivers who use positive-reinforcement parenting
practices and will secure effective social support, which in turn
will lead to resiliency outcomes, including social competence and
behavioral adjustment.
Figure 2 also shows how neurobiological functioning might serve
as a mediating mechanism between early adversity and resilience
outcomes. The inclusion of neurobiological functioning is a recent
addition to our work and to our model of resiliency (Fisher, Gunnar,
Dozier, Bruce, & Pears, 2006). The focus is on examining specified
underlying neurobiological systems that are impacted by the types of
early adversity experienced by children in the child welfare system
and that are associated with risk for negative outcomes, including
ADHD, disruptive behavior, anxiety, and affective disorders. We
have included measures of these neurobiological systems (in particular,
the prefrontal cortex and hypothalamic-pituitary-adrenal
[HPA] axis) in some more recent randomized trials to evaluate interventions
and identify resilience processes internal to the child.
Results suggest that the interventions produced positive outcomes
not only on psychosocial adjustment, but also on the functioning of
these neurobiological systems (Bruce, Martin McDermott, Fisher, &
Fox, 2009; Fisher & Stoolmiller, 2008; Fisher, Stoolmiller, Gunnar,
& Burraston, 2007).
As shown in Figure 2, the resiliency processes (neurobiological
functioning and adaptive interpersonal relations) are hypothesized
not only to benefit directly from the intervention but also to initiate a
cascade of subsequent, positive long-term effects, thereby acting as a
mediator of long-term resilience. Resilience outcomes we have examined
to date include child characteristics (social competence,
school success, and behavioral adjustment) as well as caregiver characteristics
(caregiver stress). Further, we hypothesize feedback loops
such that the resilience outcomes will positively affect the extent to
1876 Leve, Fisher, & Chamberlain
which an individual is able to form supportive interpersonal relations
and adaptive neurobiological functioning. In the sections that
follow, we describe the strength-building components of the MTFC
intervention intended to enhance resilience and present study evidence
indicating support for the intervention as leading to the resiliency
processes (center and right panels of the model) by buffering
against adversity.
The MTFC Program
The MTFC program began as a community-based alternative to
placement in group or residential care for children and adolescents
with severe emotional and behavioral problems (Chamberlain,
2003). It originated in 1983 in response to an Oregon State request
for proposals from the juvenile justice system to develop communitybased
alternatives to incarceration for adolescent placements in residential/
group care. Since then, studies have been conducted with
young children in foster care, school-aged children and adolescents
referred from the mental health and child welfare systems, and adolescents
referred from juvenile justice. In partnership with these
systems, we conducted a number of randomized trials to test the
efficacy of MTFC. Publication of these studies led to national attention
and to MTFC’s designation as a cost-effective alternative to
institutional and residential care. MTFC was selected by the Office
of Juvenile Justice and Delinquency Prevention (Elliott, 1998) as 1 of
10 evidence-based National Blueprints Programs; was selected as 1
of 9 National Exemplary Safe, Disciplined, and Drug-Free Schools
model programs; was highlighted in 2 U.S. Surgeon General reports
(U.S. Department of Health and Human Services, 2000a, 2000b),
and was designated by the Center for Substance Abuse Prevention as
an exemplary program (Chamberlain, 1998).
In terms of preventing ongoing delinquency, incarceration, and
associated behavioral problems for adolescents—outcomes that the
model was originally developed to prevent—the results from three
separate randomized trials have shown the following benefits: (a)
MTFC children (ages 9–18) leaving the Oregon State mental hospital
fared better than children receiving typical community services, with
quicker placements, lower rates of behavioral or emotional problems,
and less time in the hospital in follow-up (Chamberlain & Reid,
1991); (b) MTFC boys (ages 12–18) referred from juvenile justice
Resiliency in Child Welfare Families 1877
with 14 criminal referrals (on average) fared better than boys in
group care, with fewer official and self-reported follow-up offenses,
more time in assigned placements, being returned to their families
more often, less time incarcerated and as runaways, and fewer violent
offenses (Chamberlain & Reid, 1998; Eddy, Whaley, & Chamberlain,
2004); and (c) MTFC girls (ages 13–17) from juvenile justice
with 11 previous criminal referrals (on average) fared better than
girls in group care, with fewer incarcerations and less delinquency 1
and 2 years later (Chamberlain, Leve, & DeGarmo, 2007; Leve,
Chamberlain, & Reid, 2005).
MTFC originally aimed to reduce delinquency and related outcomes,
but more recently includes foci on prevention and the enhancement
of positive social and behavioral skills. The current MTFC
program is thus more fully conceptualized not only to help prevent
negative outcomes but also to promote resiliency among children and
adolescents exposed to a variety of adverse life experiences. This resiliency-
enhancing aspect of the model is the focus of this paper.
Key Components of the MTFC Intervention
Within the MTFC intervention, children are placed in community
foster homes where foster parents are intensively trained, supervised,
and supported to provide positive adult support and mentoring,
close supervision, and consistent limit setting. MTFC placements
typically last 6–9 months and involve coordinated interventions in
the home, with peers, in educational settings, and with the child or
adolescent’s birth parents, adoptive family, or other long-term placement
resource. Specific service components vary depending on the
child’s age and developmental level and include daily behavior management
in the foster home and at school or preschool that emphasizes
reinforcement for normative behavior and strengths,
participation in family and individual therapy, social skills training,
academic support, and case management by a program supervisor to
direct and coordinate the services. There is a strong focus on strength
building and positive reinforcement, as is illustrated in each of the
following components described below and shown in Figure 2.
Foster Parent: Enhancing Parenting Skills via Foster Parent
Groups. Foster parents meet weekly (for 90 min) in small groups
(7–10 participants) with a program supervisor for the duration of the
1878 Leve, Fisher, & Chamberlain
child’s foster placement. The parents are provided support and instruction
during these meetings and are encouraged to share experiences
of positive parenting strategies. The program supervisor
coaches the group to consistently and regularly reinforce positive
and normative child behaviors by using incentives such as providing
small rewards or allowing the children to accumulate points for
complying with routine expectations (e.g., getting up on time, doing
household chores, and attending classes). In addition, nondegrading
definitions of problem behaviors are developed, and the foster parents
are instructed to deduct points for problem behaviors rather
than engage in lecturing or angry interactions. As such, negative
behaviors or problems are not the primary focal point of the intervention;
rather, the emphasis is on developing children’s positive
behaviors and emotions. For example, the foster parents are coached
on the ‘‘four-to-one rule’’: There should be at least four positive interactions
for every one correction. For families with adolescents,
incentive systems are organized into a point-and-level system in
which the youths earn points each day and acceptable behaviors are
reinforced by earned privileges (e.g., additional time with friends,
computer game time, and attendance at a special event or show).
Points are reviewed daily, emphasizing the adolescent’s strengths
and accomplishments and minimizing problems (e.g., ‘‘You lost 1
point for arguing at breakfast but earned 5 points for having a positive
attitude in the afternoon.’’). For families with younger children,
a similar incentive point system is used, with the privileges typically
being smaller, tangible items such as stickers, small toys, or family
activities. For youth of all ages, the program supervisor encourages
foster parents to work together with the youth in advance to select
incentives that are attainable, appropriate in magnitude or cost, and
of sufficient interest to the child or adolescent to be motivating. Occasionally
a youth will change caregiving environments during the
course of treatment (e.g., move to a different foster home or a kinship
family). Whenever possible, intervention services are continued
within the new caregiving environment and with the new caregivers(
s).
Biological Parent: Support and Training for after-care Family via
Family Therapy. Simultaneously with the foster parent group
meetings, a family therapist works with the birth parents, relatives,
or other long-term after-care resources to improve their reinforce-
Resiliency in Child Welfare Families 1879
ment, relational, supervision, and limit-setting skills and behaviors.
These caregivers are taught to use the same incentives or point systems
employed in the foster home to provide positive feedback and
brief, nonemotional consequences for problem behavior. For example,
the family therapist works with the caregivers to practice avoiding
debates and discussions during discipline situations. For many
caregivers, this is a fresh approach that frees them to invest more
emotional energy and time to positive interactions with their youth.
The family therapist coaches the parents to practice and adhere to
these methods to help recalibrate the parent’s executive role in the
family. Regular home visits are scheduled throughout the youth’s
foster care placement so that after-care parents can practice the skills
with the support and feedback of the family therapist before the
youth returns home.
Youth: Strength Building via Individual Therapy. Adolescent-aged
youth are assigned an individual therapist to help them identify and
build on their strengths and assets, to find solutions to problems at
school, and to have adaptive relationships with their foster parents
and after-care parents. Topics for individual therapy are selected
based on data from the daily point system in the foster home, at
school, and during home visits. The individual therapist’s role is to
motivate and encourage the adolescent to find and practice alternatives
to problem behaviors and negative emotions that appear to be
having a destructive impact on their short- and long-term goals. For
example, if an adolescent experiences rejection or conflict with peers
at school, the therapist would likely role-play ways for the adolescent
to react to perceived provocations from peers or learn ways to initiate
friendship-oriented interactions. Psychiatric consultation is
used as needed.
Youth: Social Skills Coaching. To help generalize developing skills
to community settings and with peers, a skills coach is assigned to
each youth. The coach is typically a recent college graduate who
helps the youth to identify and participate in community activities
that interest them, and addresses their development of specific social
skills through practice and feedback in real-world settings. The skills
coach works with the program supervisor to determine specific behavioral
targets and role-play options for reacting and behaving in
both hypothetical situations and real-world settings. In vivo treat-
1880 Leve, Fisher, & Chamberlain
ment in community settings allows the skills coach to practice particular
situations that are particularly challenging for the child. A
variety of behavioral treatment strategies, including preteaching and
direct positive reinforcement are employed to strengthen skills. The
skills coach is trained and supervised to emphasize skills and actions
rather than spend limited time discussing past behaviors or problematic
situations.
Youth: Academic support. Each MTFC youth attends public
schools. The foster parents and program supervisor work together
to carefully monitor youth adjustment in the classroom and with
peers and to build an individualized network of services that supports
academic and social success. For adolescents, this involves
earning daily incentives for attendance, attitude, and homework
completion tracked on a school card that teachers initial following
each class. Positive involvement in school also is rewarded, and tutoring
is provided when needed. For young children, school readiness
is emphasized via a therapeutic playgroup that children attend
on a weekly basis. The playgroup uses the same preteaching and direct
positive reinforcement strategies as used by the social skills
coach to focus on two key elements of school readiness: early literacy
and social emotional skills. For example, children practice sitting in
a circle and raising their hand when they have a question, and staff
provide positive reinforcement to children actively practicing this
activity. A high staff-to-child ratio ensures that the playgroup is
highly structured and that the children receive extensive reinforcement
for prosocial behavior (for more details about the playgroup,
see Pears, Fisher, & Bronz, 2007).
Service System: Coordinated Services via the Program Supervisor.
The program supervisor directs, coordinates, and monitors
all of the youth and family services. To direct and coordinate, the
supervisor conducts weekly group foster parent meetings (described
previously) to discuss the youth’s gains and problems and reviews
and revises the daily behavior management charts and school cards
to reflect progress and emerging problems. The program supervisor
conducts a second weekly meeting with clinical staff (the family and
individual therapists and skills coaches) to formulate the treatment
plan and supervise their efforts. The youth’s gains and foster parent
stress levels are monitored by the supervisor through the Parent
Resiliency in Child Welfare Families 1881
Daily Report telephone interview (PDR; Chamberlain & Reid,
1987), in which foster parents report on the occurrence or nonoccurrence
of specific behaviors within the past 24 hr and indicate the level
of stress they experienced as a result: 0 (not stressful) to 3 (very stressful).
In addition, specific point gains and losses are recorded. The PDR
data are also used to monitor the balance between the foster parents’
use of encouragement or reinforcement and discipline.
The key components previously described are generally delivered as
an integrated set of services to each MTFC youth and family; however,
variations occur depending on the developmental needs of the youth,
the skill level of the foster and after-care parents, and the specific
strengths and challenges inherent in the youth. In addition, one study
has tested the implementation of only the foster parent groups (Project
Keep; Chamberlain, Price et al., 2006). Notably, although the MTFC
intervention is multicomponent and requires multiple staffing positions,
the benefits of the program have been shown to greatly outweigh
the costs. A series of independent cost-benefit analyses from the Washington
State Public Policy group reported a $32,915 cost savings in
2006 to taxpayers for each juvenile justice youth placed in MTFC
versus regular group care (Aos, Miller, & Drake, 2006; Aos, Phipps,
Barnoski, & Lieb, 1999, 2001).
Evidence for Resiliency: Outcomes of Four Completed MTFC
Trials
When considered together, the set of randomized clinical trials based
on the MTFC intervention model provides evidence that the intervention
leads to the development of resiliency mechanisms, including
improved interpersonal relations and adaptive neurobiological functioning.
In addition, the MTFC intervention leads directly to child
and caregiver resiliency outcomes, including social-behavior adjustment
and reduced caregiver stress (see Figure 2). Evidence from four
completed independent studies that lend support for this resilience
model is described below (Table 1 provides a brief overview of the
four studies). In the first study (Chamberlain & Reid, 1998), referred
to as ‘‘Juvenile Justice Boys,’’ 79 adolescent boys with chronic and
severe delinquency who were referred for out-of-home care were
randomly assigned to MTFC or to services as usual (typically group
care facilities). The second study (Leve et al., 2005) was modeled
after the Juvenile Justice Boys study and included 81 adolescent girls
1882 Leve, Fisher, & Chamberlain
who were referred for out-of-home care by a juvenile court judge due
to problems with chronic delinquency. After a determination by the
judge that the girls were appropriate for placement in communitybased,
out-of-home care, the girls were randomly assigned to MTFC
or to services as usual (typically group care). We refer to this study as
‘‘Juvenile Justice Girls.’’ The third study (Fisher & Kim, 2007) is a
downward extension of the MTFC model that adapts the basic
model to include components for preschool-aged children centered
on their developmental needs and risks. This study, referred to as
‘‘Multidimentional Treatment Foster Care for Preschoolers’’
(MTFC-P), consists of 57 foster children who were randomly assigned
to MTFC-P, 60 children who were randomly assigned to
regular foster care, and 60 low-income children living in their biological
homes with no child welfare system involvement. The fourth
study (Chamberlain, Price et al., 2006), referred to as ‘‘Project
Keep,’’ is an effectiveness trial of child welfare–involved families
who were randomly assigned to receive the MTFC foster parent
groups or services as usual. Project Keep consists of 700 families
with children between the ages of 5 and 12 years from diverse ethnic
backgrounds.
As shown in Table 1, study youth were typically referred to outof-
home care and to the MTFC program due either to chronic delinquency
(and typically an accompanying history of child welfare
involvement) or to caregiver neglect and emotional abuse. However,
a wide range of prior maltreatment experiences characterized the
youth. Although the analyses described below focus on outcomes
within study sample (rather than by maltreatment type), a recent
paper by Bruce, Fisher, Pears, and Levine (2009) using the MTFC-P
sample examined the association between maltreatment type and
outcomes, finding associations between specific maltreatment experiences
and foster children’s morning cortisol levels: Foster children
with low morning cortisol levels experienced more severe physical
neglect than the other foster children. In contrast, foster children
with high morning cortisol levels experienced more severe emotional
maltreatment.
Supportive Interpersonal Relationships
A key aspect of resilience is the ability to develop supportive interpersonal
relationships and to mobilize support resources. MTFC
Resiliency in Child Welfare Families 1883
Table 1
Overview of the Four Completed Studies That Utilized One or More of the Key Multidimensional Treatment Foster
Care (MTFC) Intervention Components
Project Title Project Description
Primary Reason for
Placement in Care
Research
Type Intervention Target
1. Juvenile
Justice Boys
Randomized intervention trial of MTFC
with 79 adolescent boys in the juvenile justice
system who had been referred for out-ofhome
care due to chronic delinquency.
Chronic delinquency
(often accompanied by a
history of child welfare
involvement)
Type 1
efficacy trial
Foster parent,
biological parent,
adolescent, service
system
2. Juvenile
Justice Girls
Randomized intervention trial of MTFC
with 81 adolescent girls in the juvenile justice
system who had been referred for out-ofhome
care due to chronic delinquency.
Chronic delinquency
(often accompanied by a
history of child welfare
involvement)
Type 1
efficacy trial
Foster parent,
biological parent,
adolescent, service
system
3. MTFC for
Preschoolers
(MTFC-P)
Randomized prevention trial of MTFC-P
with 177 preschool-aged children: 117 foster
children randomly assigned to MTFC-P
treatment or regular foster care conditions
and 60 low-income, nonmaltreated
community children.
Caregiver neglect or
emotional abuse (subset
also experienced physical
or sexual abuse, or both)
Type 1
efficacy trial
Foster parent,
biological parent,
child, service system
4. Project Keep Randomized prevention trial of MTFC with
700 foster and kin parents in San Diego
county child welfare system. Child age5
5–12 years. Sample is 74% minority.
Intervention included foster parents only.
Caregiver neglect or
emotional abuse (subset
also experienced physical
or sexual abuse, or both)
Type 2
effectiveness
trial
Foster parent
studies provide evidence that the intervention increases the likelihood
that youths and their caregivers will show more supportive interpersonal
relationships relative to the control condition in five areas: parenting
and attachment relations, peer group process, mentoring adults,
social support, and the stability of the home context.
Parenting and Attachment. The primary, significant relationship for
young children is with their parent(s) or caregiver(s), regardless of
whether they are the biological caregiver or not. By definition, youth
in the child welfare system have had adverse life experiences connected
to this relationship. Thus, it is critical to examine resiliency processes
in relation to parenting for youth who have experienced caregiverbased
adversity. Three MTFC studies have examined how the intervention
can impact the parenting relationship. First, Fisher and Kim
(2007) used the MTFC-P sample to study the attachment relationships
of preschool-aged children. The children’s attachment-related
behavior toward their foster parents was assessed at five 3-month intervals
beginning on entry into the study using a Parent Attachment
Diary (PAD; Stovall-McClough & Dozier, 2000). The PAD measures
secure, resistant, and avoidant attachment-related behaviors by asking
the caregiver to indicate how the child responds to situations in which
he or she was frightened, hurt, or separated from the caregiver; it has
obtained attachment patterns consistent with the Strange Situation
attachment classifications. The results from the Fisher and Kim study
indicated that children in the MTFC-P condition showed significant
increases in secure behavior and significant decreases in avoidant behavior
relative to children assigned to foster care services as usual,
suggesting the ability of theMTFC intervention to promote resiliency
in young children’s abilities to form secure relationships with caregiving
adults.
In Project Keep, the specific parenting practices of caregivers with a
school-aged foster child were examined to see whether an MTFCbased
intervention predicted improvements in parenting practices.
The intervention goal was to reduce child problem behaviors by
strengthening foster parents’ skills. Chamberlain, Price, et al. (2008)
measured positive reinforcement in foster and kinhip parents at baseline
and 5 months later. Path models indicated that, relative to foster
parents in the control condition, foster parents in the intervention
condition used a greater level of positive reinforcement relative to
their disciplinary parenting behaviors 5 months after study entry,
Resiliency in Child Welfare Families 1885
suggesting that the intervention was successful in increasing caregivers’
positive parenting interactions with the child. This pattern of improvements
in positive, effective parenting practices extends a pattern
found with the Juvenile Justice Boys sample. In that study (Chamberlain
& Reid, 1998), caregivers’ discipline and supervision practices
were examined across groups. Caregivers in this study were foster
parents for the MTFC youth and group home staff for the control
youth. The results of an assessment conducted when the boys had
been in their treatment placement approximately 3 months indicated
that, relative to caregivers in the control condition, caregivers in the
MTFC condition reported higher levels of supervision and more appropriate,
fair, and positively reinforcing discipline. Further, these
caregiving variables partially mediated the association between
MTFC intervention effects and later delinquency outcomes, suggesting
the importance of positive parenting relations relative to later adjustment.
Taken together, this set of MTFC studies on parenting
suggests that strength-based interventions targeting parenting practices
not only have effects on the quality of positive parenting but also
can affect relationship processes such as the parent–child attachment
relationship, thus serving as mechanisms of resiliency.
Peer Group Process. A second facet of a youth’s relationship base is
peers. Despite residence in contexts such as juvenile detention, in
which the proximity and prevalence of antisocial peers is extremely
high, some youth avoid associating with antisocial peers and select
more normative peers. Two studies have provided evidence that adolescents
placed in MTFC become more successful in avoiding relationships
with antisocial peers and in forming relationship with
normative peers than adolescents placed in group care. In the first
study, Eddy and Chamberlain (2000) used the Juvenile Justice Boys
sample to examine whether chronically delinquent boys’ peer preferences
were a causal factor in explaining why boys in the MTFC
condition had lower subsequent arrest rates than boys in the control
condition. After the boys had been in their respective treatment settings
for approximately 3 months, they were asked about the kinds
of friends they spent time with. Caregivers were also asked about the
boys’ friendship preferences. This peer factor was a significant mediator
of the MTFC intervention effects on delinquency, with
MTFC boys having peer relations that were 2 SD above those of
the control boys, and with this peer-preference variable significantly
1886 Leve, Fisher, & Chamberlain
mediating the association between intervention condition and delinquency
outcomes. This effect was replicated and extended in a second
study that included the Juvenile Justice Girls sample. In that study,
MTFC youth showed significantly more adaptive peer relations during
treatment and at a 12-month follow-up, and peer relations during the
treatment setting mediated the MTFC intervention effects on delinquent
peer association (Leve & Chamberlain, 2005). In both studies, the
adolescents had histories of affiliating with delinquent peers and had
recently been in juvenile detention facilities where they were surrounded
by other antisocial youth. However, despite these adverse experiences,
the MTFC treatment program was significantly more effective in enabling
such youth to separate from this context and to form affiliations
with more normative peers, and this qualitative change in the kinds of
friendships they were able to develop mediated the association between
intervention condition and reductions in delinquency.
Mentoring Adults. There is some evidence to suggest that relationships
with mentoring adults can help offset early adversity and facilitate
resiliency (Tierney, Grossman, & Resch, 1995). Using the
Juvenile Justice Boys sample, we examined whether MTFC improved
the quality of the youth-adult relationship and whether this
positive youth-adult relationship accounted for some of the variance
in MTFC intervention effects on delinquency outcomes. In this
study, Eddy and Chamberlain (2000) asked caregivers, boys, and
interviewers about the quality of the youth-adult relationship, including
how much they liked one another and how nice they were to
one another. As such, this variable was intended to be distinct from
‘‘parenting,’’ focusing instead only on the positive, mentoring components
of the youth-adult relationship, regardless of whether the
current caregiver was a foster parent, biological parent, or group
home staff member. The results indicated that MTFC boys had
higher mentoring scores 3 months into treatment than boys in the
control condition. Further, together with the parenting and peer
variables described for the above sample, this set of variables partially
mediated the effects of the intervention on 12-month delinquency
outcomes, accounting for over 30% of the variation in
delinquency. Though in need of replication, this study not only suggests
that the MTFC program increased mentoring within relationships
but also that mentoring was a mediating mechanism associated
with greater well-being and adjustment later in development.
Resiliency in Child Welfare Families 1887
Social Support. A fourth domain of supportive interpersonal functioning
is the caregivers’ ability to seek and create social contexts in
which they are engaged and receive appropriate social support. The
ability of caregivers to effectively receive and participate in supportive
social contexts might be especially important in contexts when
the family has experienced adversity, ultimately leading to better
adjustment in the youth. For foster parents, interpersonal challenges
might result indirectly from providing care for a child who has experienced
adversity, posing additional parenting challenges because
of the oft found behavioral, cognitive, and emotional deficits in foster
children (Aarons et al., 2001; Clausen, Landsverk, Ganger, Chadwick,
& Litrownik, 1998; Pilowsky, 1995). In light of the potential
social support benefits of participating in a group-based parenting
intervention, we examined caregiver engagement (e.g., participation,
homework completion, openness to ideas, and apparent satisfaction)
among foster and kin parents using Project Keep data. The groupbased
intervention was delivered in 16 weekly sessions. Multilevel
modeling was employed for the intervention-only cases: 337 caregivers
nested within 59 groups. The results indicated that the level of
caregiver engagement moderated the effects of early adversity (measured
by the number of prior home placements) on child behavior
problems and moderated the risk of negative placement disruption
for Hispanic children (DeGarmo et al., 2009). Together, these findings
suggest that a caregiver who actively engages in and attains
support in group settings helps to buffer his or her child against the
negative outcomes often associated with early adversity, promoting
child resiliency.
Stable Home Context. Stability in safe, nurturing family settings
affords children opportunities to develop positive and supportive
relationships, especially with caregivers and other significant adults
(e.g., teachers); this, in turn, facilitates normative development
(Cicchetti & Valentino, 2006; Sroufe, Duggal, Weinfield, & Carlson,
2000; Thompson, Flood, & Goodwin, 2006). A stable home context
also leads to stability in school settings, peer networks, health care
providers, and access to community resources and activities. A stable
home context that promotes well-being might thus ameliorate some
of the consequences of early adversity and alter poor developmental
trajectories (Harden, 2004). Two studies have examined whether an
MTFC-based intervention can impact the stability of the home en-
1888 Leve, Fisher, & Chamberlain
vironment for foster children. In the first study, Fisher et al. (2005)
found that, compared to the children in regular foster care, the
MTFC-P children had fewer failed permanent placements 2 years
later. Further, MTFC-P mitigated the risk of early adversity (as
measured by the number of prior placements) such that the significant
relationship between early adversity and placement failures was
present only for children in regular foster care.
The second study utilized the Project Keep data and focused on a
narrower time frame. Consistent with the MTFC-P effects, the
Project Keep results indicated that early adversity (as measured by
the number of prior placements) was predictive of foster placement
disruptions up to 4 months later. Importantly, however, the foster
parent training intervention increased the likelihood of a successful
reunification with the biological parents. It also mitigated the
negative risk-enhancing effect of multiple placements, similar to
the MTFC-P finding. More specifically, children in the Project
Keep intervention condition were nearly twice as likely as the
children in the control group to be successfully reunified with their
biological parents by the end of the intervention period (Price et al.,
2008). Together, the MTFC-P and Project Keep findings provide evidence
that the effects of early adversity on the stability of the home
context can be ameliorated through MTFC-based interventions.
Adaptive Neurobiological Functioning
Within the resiliency framework, the MTFC model emphasizes
the impact of early adversity on underlying neurobiological
systems, the associations between alterations in these systems and
many of the psychosocial outcomes observed in the foster care
population (e.g., disruptive behavior disorders, drug abuse, and
affective and anxiety disorders), and the potential for interventions
to enhance functioning in these systems (see Fisher et al.,
2006). As such, measures of these systems serve as indicators of
short-term intervention effects and as mediators of long-term psychosocial
outcomes.
HPA Axis. Our research to date has focused primarily on two neurobiological
systems, the HPA axis and the prefrontal cortex. In the
case of the HPA axis, there is extensive evidence from animal and
human studies (see Gunnar, Fisher, & the Early Experience, Stress,
Resiliency in Child Welfare Families 1889
and Prevention Network, 2006) that early life stress, and particularly
disruptions in early caregiving, are associated with alterations in HPA
axis functioning, as measured by levels of cortisol (corticosterone in
rodents; the glucocorticoid hormone which is the end product of activity
in this system). Similarly, we have observed alterations in the
HPA axis among children in foster care, with atypical diurnal cortisol
levels being especially prevalent among children who have experienced
caregiver neglect ( Bruce, Fisher, et al., 2009). On the positive side, the
randomized efficacy trial of the MTFC-P intervention provided evidence
that the intervention is associated with increased regulation of
the HPA axis relative to children in regular foster care (Fisher et al.,
2007). Moreover, intervention effects on the children’s HPA axis
functioning were significantly associated over time (i.e., as a timevarying
covariate) with intervention effects on caregiver self-reported
stress levels (Fisher & Stoolmiller, 2008). This association is noteworthy
because it indicates that qualities of the caregiving environment
have an effect on a key neural regulatory system and that interventions
have the potential to affect this system. This is one of the first
documented associations that has been reported between caregiver
behavior and children’s neurobiology in the literature.
Prefrontal Cortex. More recently, we have begun to examine prefrontal
cortex activity in our samples of foster children because of the
link between particular executive functions that are known to emanate
from the prefrontal cortex (e.g., inhibitory control, attention,
and working memory) and problems such as attention deficit/hyperactivity
disorder, disruptive behavior, and drug abuse. Similar to the
HPA axis studies, our work has documented that problems with executive
functioning are more common in foster children than in the
general population (Pears, Kim, & Fisher, 2008). In addition, these
problems appear to be particularly common in foster children who
have experienced frequent caregiver transitions (e.g., failed foster
placements). However, in a pilot study using event-related potentials,
we observed that MTFC-P children showed significantly more brain
activity in the prefrontal cortex than regular foster children in response
to performance feedback on a task designed to measure executive
functioning (Bruce, Martin McMermott, et al., 2008).
Although these data are preliminary because they did not include a
preintervention measure and assessed only a subsample of children in
the MTFC-P efficacy trial, they provide further evidence of the plas-
1890 Leve, Fisher, & Chamberlain
ticity of key underlying neurobiological systems in response to
strength-based environmental interventions.
Resilience Outcomes
As shown in Figure 2, the end point of our conceptual model is
positive youth outcomes and reduced caregiver stress. It is hypothesized
that the MTFC intervention will lead directly and indirectly
(via supportive interpersonal relationships and adaptive neurobiological
functioning, as described above) to positive adjustment outcomes
across settings. To the extent that the evidence supports this
model, the strength-based intervention components can be considered
underlying mechanisms to promote resiliency among children
and adolescents in the child welfare system who have been exposed
to early adversity. We have examined positive adjustment outcomes
in three areas within our child welfare samples: social competence,
school success, and behavioral adjustment.
Child: Social Competence. When children enter formal educational
settings, they are expected to possess competencies that enable them
to respond to the demands of the school environment. Children who
lack basic social skills and fail to develop successful peer relations
during school entry are at greater risk for conduct problems, peer
rejection, and academic failure throughout childhood and adolescence
(Brendgen, Vitaro, Bukowski, Doyle, & Markiewicz, 2001;
Dishion, 1990; Snyder et al., 2005). Children who have experienced
early life adversity may be at particular risk for failing to develop
effective social skills. To examine the effects of early adversity on
social skills, we assessed social competence in our MTFC-P sample.
The MTFC-P and regular foster care groups were combined in the
analyses and were considered to have experienced more extreme levels
of early adversity than the biologically reared comparison group.
Self- and teacher-reported social competence was assessed at school
entry via questionnaires that included items such as ‘‘compromises
with peers when situations call for it,’’ ‘‘invites peers to play or share
activities,’’ ‘‘resolves problems with friends/siblings,’’ and ‘‘shares
things with others.’’ Controlling for prior level of behavior problems
prior to school entry, results from a multigroup SEM analysis suggested
a significant relationship between group (foster care vs. biologically
reared) on social competence at school entry for girls only.
Resiliency in Child Welfare Families 1891
Specifically, early adversity had a detrimental effect on social competence
for foster girls, but not for foster boys (Leve, Fisher, &
DeGarmo, 2007). Because this study did not examine the buffering
effects of MTFC on these social competence outcomes, the specific
mechanisms that buffer children against the ill effects of early adversity
have not yet been identified. However, the results suggest an important
link between early adversity and social competence that
might be specific to girls. Such group-specific processes are further
discussed later in this article.
Adolescent: School Success. Involvement in the child welfare system
has been shown to increase risk for low academic performance
and school failure (Lenssen, Doreleijers, van Dijk, & Hartman,
2000), with maltreated children exhibiting severe impairments on
standardized tests of language in middle childhood and adolescence
(Dale, Kendall, & Schultz, 1999). Similarly, Trickett’s (1997) review
suggested that sexual abuse is linked to developmental delays, lower
academic performance, and learning problems. This impacts later
academic functioning and puts children at risk for later academic
failure and placement in special education classes. Guided by resiliency
research, we sought to investigate whether the potential consequences
of early adversity on school success could be ameliorated
with the MTFC intervention. In this set of analyses, we used the
Juvenile Justice Girls study data to examine homework completion
and school attendance, which are hypothesized to be fundamental to
school success. Path modeling results suggested that MTFC was
more effective than group care in increasing girls’ school attendance
and homework completion while in treatment and at 12 months
postbaseline. In addition, the previously reported effect of MTFC on
reducing girls’ days in locked settings was mediated by homework
completion while in treatment (Leve & Chamberlain, 2007). That is,
doing homework while in treatment accounted for the positive
effects of the intervention on reducing later problem behaviors.
This set of analyses suggests that MTFC can assist in buffering the
effects of early adversity to promote adaptive school engagement
behaviors.
Child: Behavioral Adjustment. A third outcome that has been examined
in MTFC studies is behavioral adjustment. It is widely recognized
that children exposed to early adversity exhibit psychosocial
1892 Leve, Fisher, & Chamberlain
problems at a significantly higher rate than the general population
(Clausen et al., 1998; Pilowsky, 1995). We used Project Keep data to
test whether the MTFC-based intervention could lead children in the
intervention condition to exhibit more normative behavioral adjustment.
Using the PDR interview, we asked parents about the occurrence
or nonoccurrence within the past 24 hr of specific child
behaviors that pose parenting challenges (e.g., whining and ignoring).
The behaviors were tallied each day to compute a sum of behaviors
per day. Prior work with the PDR has indicated that it is
normative for children to have several behaviors every day; however,
when rates of behaviors increase beyond the sum of 6, the risk for
problems increases dramatically. For example, children with 6 or
fewer behaviors per day were found to be at low risk for subsequent
disruption; in contrast, the risk for disruption increased by 17% for
every child problem behavior reported over 6 (Chamberlain, Price,
et al., 2006). Therefore, a goal of Project Keep was to enhance parenting
practices to reduce the number of child behaviors. The results
of SEM analyses indicated that intervention children had fewer behaviors
than control children at the termination of the intervention.
Specifically, the intervention children showed an average of 5.9 behaviors
at the start of the study and 4.4 behaviors at the termination
assessment, a reduction of 1.5 behaviors per day (Chamberlain,
Price, et al., 2008). In comparison, children in the control condition
only showed a 0.3 behavior per day reduction. These results suggest
that the intervention was successful in buffering the risk of early
adversity and facilitating more normative behavioral adjustment.
Caregiver: Caregiver Stress. The evidence described earlier suggests
that therapeutic interventions for foster children can affect
HPA axis activity. However, the specific intervention components
responsible for change have not been fully explicated. The association
between HPA axis activity, the MTFC intervention, and caregiver
stress were investigated using the MTFC-P sample to examine
whether diurnal cortisol activity was associated with caregiver selfreported
stress in response to child problem behavior (Fisher &
Stoolmiller, 2008). Reduced caregiver stress was considered to reflect
resilience processes in the adult caregivers who participated in the
MTFC intervention. Results showed immediate reductions in caregiver
stress that were sustained through 12 months postbaseline in
the intervention condition. In contrast, caregivers in the regular fos-
Resiliency in Child Welfare Families 1893
ter care condition showed higher rates of stress across time and increased
stress sensitivity to child problem behaviors. In addition,
among caregivers in regular foster care, higher self-reported stress
was associated with lower morning cortisol levels and more blunted
diurnal cortisol activity. These results provide evidence that interventions
can simultaneously impact caregiver stress and buffer children
from the negative impacts of caregiver stress on HPA axis
regulation.
Future Directions
Resiliency experts contend that it is important to measure children’s
resiliency across multiple contexts, including school, peers, and family
(Richmond & Beardslee, 1988). The study results described above
provide preliminary evidence to support the proposed resiliency
model, with the resiliency-enhancing outcomes of the MTFC intervention
noted across studies and across multiple outcome domains.
Specifically, known links between early adversity and poor outcomes
were reduced in the context of the MTFC intervention. Further,
converging evidence from this set of MTFC studies indicates direct
resiliency effects at two levels: hypothesized mechanisms (interpersonal
relations and adaptive neurobiological functioning) and resilience
outcomes (social competence, school success, behavioral
adjustment, and reduced caregiver stress). This has important implications
for social service provision. Given the increased risk for
social service involvement and dependence for youth exposed to
early adversity, effective preventive intervention services that buffer
children from the risks associated with early adversity can reduce
costs at individual, familial, and societal levels.
Despite solid evidence in support of the study’s resiliency model,
not all of the pathways from Figure 2 have been tested within the
context of the MTFC intervention model. With the exception of the
Fisher and Stoolmiller (2008) examination of the association between
MTFC-P, HPA axis functioning, and caregiver stress, the
pathways between the resilience mechanisms and the resilience outcomes
shown in Figure 2 have not been thoroughly examined. In
addition, long-term follow-up is needed to understand the persisting
effects of strength-based preventive interventions and to see whether
effects persist into young adulthood, thereby serving to foster the
intergenerational transmission of resilience. Also needed are studies
1894 Leve, Fisher, & Chamberlain
that expand upon the gender and ethnic differences in resiliency
processes noted here (DeGarmo et al., 2009; Leve, Fisher, et al.,
2007) to provide a more comprehensive picture of how resiliency
processes differ across subgroups.
Several additional directions for future research are suggested
from our research findings. First, we have made the assumption that
the underlying processes and mediational pathways described here
would be similar for youth exposed to similar types of adversity, but
at milder levels. A test of this extension to other populations, including
those with exposure to adversities such as parental drug use,
caregiver transitions, and poverty—but without involvement in the
child welfare system—is needed to provide validating and convergent
support for the proposed model.
Second, with the exception of Project Keep, analyses examining
the outcomes of the randomized trials considered the full set of
MTFC intervention components together and grouped all early adversity
experiences. Perhaps some types of early adversity are more
readily offset by one or more specific components of the MTFC
model. An examination of Adversity  Intervention Component
interactions would provide more specific delineation of the pathways
to resilience and could indicate a more efficient and cost-effective
means of preventing poor youth outcomes.
Third, positive parenting and positive reinforcement were measured
via interviewer- and self-report in the work described above.
Although observational methods and constructs have been well validated
for studying negative parenting processes and child behavioral
problems (e.g., Stoolmiller, Eddy, & Reid, 2000), little has been
done to facilitate the development of theoretically driven contingent
coding systems to reliably tap positive reinforcement interactions
between parents and children.
Fourth, additional research on the underlying biological mechanisms
that are affected by early adversity and that can be modified by
strength-building interventions would increase our understanding of
the basic processes whereby environmental process affect biological
systems. Such work will benefit from the burgeoning technology allowing
for noninvasive investigations of hormonal systems and from
the advances in electroencephalogram and neuroimaging technology
that have made it possible to assess children at younger ages. We will
continue to include measures of underlying neural systems in our prevention
trial protocols, both as measures of immediate intervention
Resiliency in Child Welfare Families 1895
effects and as mediators of long-term outcomes. As advances in technology
are made, we expect to be better able to measure and modify
neurobiological systems that effect resiliency processes.
A second focus of our ongoing work on underlying biological systems
is to better understand the role that genetic characteristics play in
resiliency processes. To this end, we have begun a prospective adoption
study with 360 sets of adoptive parents, their adopted child, and
the child’s birth parent(s) (Leve, Neiderhiser, et al., 2007). This work,
which includes in-home assessments of infant behavior and continued
follow-up through first grade, has the potential to inform resiliency
research in two ways: by detailing specific environmental processes in
early childhood that could offset genetic risk and lead to resilient adjustment
in children and by detailing specific genetically influenced
characteristics (e.g., sociability, persistence) that could increase resilience
even in the face of early adversity. Together, work in these expanded
directions will provide greater specificity to the understanding
of mediating and moderating processes that promote positive longterm
adjustment in youth exposed to early adversity.
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