Overview of Multidimensional Treatment Foster Care Program for Preschoolers (MTFC-P)

Multidimensional Treatment Foster Care for Preschoolers (MTFC-P) is an alternative to residential treatment for foster children 6 and under. These young children are especially vulnerable to long-term difficulties in home, school, and community settings and are at high risk for behavioral, emotional, and developmental problems.

MTFC-P is specifically tailored to the needs of 3- to 6-year-old foster children and has been shown to be effective at promoting secure attachments in foster care and facilitating successful permanent placements (e.g., reunification with birth parents and adoptions). MTFC-P capitalizes on more than 40 years of research and treatment activities that have supported the notion that families, and particularly parents who are skilled and supported, can have a powerful socializing role and positive influence on troubled youth.

MTFC-P has been in continuous operation in Eugene, Oregon, since 1996 and is a downward extension (in terms of age) of Multidimensional Treatment Foster Care, which was developed at Oregon Social Learning Center to treat chronic juvenile delinquency. MTFC-P is based upon the philosophy that, for many young children in foster care, the most effective treatment is likely to take place in a family environment in which responsive and consistent caregiving is provided. MTFC-P foster parents are in many ways the primary treatment agents for program children and have substantially influenced the program design and implementation methods over the years.

MTFC-P is delivered through a treatment team approach in which foster parents receive training and ongoing consultation/support from program staff, children receive individual skills training and therapeutic playgroup, and birth parents (or other permanent placement resources) receive family therapy. MTFC-P emphasizes the use of concrete encouragement for pro-social behavior; consistent, non-abusive limit-setting to address disruptive behavior; and close supervision of the child. In addition, the MTFC-P intervention employs a developmental framework in which the challenges of foster preschoolers are viewed from the perspective of delayed maturation (rather than strictly behavioral and emotional problems).

There are three mechanisms within the MTFC-P approach that contribute to successful outcomes for youth and their families and that are critical to activating the therapeutic potential of the foster home. These include a proactive approach to reducing problem behavior, the creation and maintenance of a consistent and reinforcing environment for participating children, and the separation and stratification of program staff roles.

A Proactive Approach to Reducing Problem Behaviors

The first mechanism within the MTFC-P model that contributes to positive outcomes is the proactive approach taken to reducing problem behaviors. Program supervisors (role is described later) carry smaller caseloads (e.g., 10-12 cases) and follow each child's progress/problems in the foster home daily.

MTFC-P foster parents are carefully recruited and are provided with extensive pre-placement training and ongoing support and supervision. Throughout the treatment process, foster parents maintain close communication with the program staff, thus serving as the eyes and ears of the program. The foster parents help to identify target behaviors and formulate treatment plans. They are strongly and repeatedly encouraged to call program staff members at any time if they are concerned or have questions about the MTFC-P child. The foster parents participate in daily data collection telephone calls regarding child problems/progress and program implementation in the previous 24 hours via the Parent Daily Report (PDR) and weekly supervision/support meetings with their program supervisor, foster parent consultant and other MTFC-P foster parents.

Foster Parent Recruitment

MTFC-P foster parents are recruited through a variety of methods including word-of-mouth and newspaper advertising which has been the most successful. Existing MTFC-P foster parents are paid $100 for recommending other families which lead to an MTFC-P placement. Newspaper ads are most successful if they include a description of the age and gender of the child to be placed and the amount of the monthly stipend that the foster parents receive. Potential MTFC-P foster parents are screened by telephone for basic eligibility (e.g., adequate space in their home and no criminal history) before an application is sent to them. Following the return of an application, the MTFC-P recruiter conducts a home visit, during which the recruiter fully describes the program and explains the training and certification requirements of the program. The purposes of the home visit are to meet the prospective family, to see whether the home atmosphere is conducive to caring for a young foster child, and to give potential foster parents more information about the program. Many families who are suitable for standard foster care may not be suitable for MTFC-P, which requires foster parents to take an active treatment perspective and to work with the program staff to implement a daily structured program for the child. Single parents and married couples with and without children of their own have been successful MTFC-P foster parents.

Training of MTFC-P Parents

MTFC-P parents participate in a minimum of 12 hours of training. During training, parents are provided an overview of the model, taught about identifying and giving information about behaviors, and taught procedures for implementing an individualized daily program. The training methods used are didactic and experiential. During the training, emphasis is on methods and techniques for reinforcing and encouraging children. Prospective MTFC-P foster parents who are resistant to the idea of giving children extra support and attention for doing what they are supposed to do are discouraged from continuing with the program. Because daily encouragement is such an important component of MTFC-P, it is important that families share (or at least do not oppose) the treatment philosophy.

Ongoing Consultation, Support, and Supervision

Following the training, a match is made between prospective MTFC-P foster parents and children. Foster parents are provided with all information known to the MTFC-P program, so that they are fully informed about the child's history and can make an informed decision about accepting the child into their home. Once a match is made, the Program Supervisor and foster parent(s) develop the child's individualized daily program.

Throughout the placement, foster parents receive continued support in addressing new problems via weekly meeting, daily "Parent Daily Report" (PDR) telephone calls, and home visits from MTFC-P staff. In addition, staff members are always on call to support the foster parents and will visit the home if the problem cannot be managed over the telephone.

Parent Daily Report (PDR) is a critical component of the treatment program which allows frequent and reliable tracking and measurement of behaviors in children. PDR is conducted in a 5-10 minute phone call between the foster parent and the MTFC-P PDR caller. Data on approximately 40 behaviors is gathered every day and includes the occurrence of the behavior and if the foster parent found that behavior to be stressful. By looking at the PDR information, the program supervisor can gain insights into the effectiveness of the treatment plan. Adjustments in the treatment interventions can then be individualized to the behaviors of each child. Patterns in behavior are also evident when reviewing several weeks of PDR data at a time. Patterns can highlight slow changes in behavior that may not otherwise be noticed as well as identifying events or situations that are regularly impacting behavior.

The Creation and Maintenance of a Responsive, Consistent, and Reinforcing Environment

The second mechanism within the MTFC-P model that contributes to positive outcomes is the implementation of an individualized, detailed behavior management program within the foster home. The goal of the behavior management program is to give foster parents a vehicle for providing the child with frequent positive reinforcement for normative and pro-social behavior and to give the child a clear message about their progress.

This program is implemented in the MTFC-P home and involves concrete encouragement for positive behavior. Most commonly this consists of "kid bucks" (which are exchanged for larger items) or edible rewards. In addition, foster parents are instructed in the use of effective limit setting techniques for this age group, including time out and redirection. MTFC-P foster parents are trained to set limits in a matter-of-fact or slightly sympathetic way. They are specifically taught to refrain from lecturing or arguing and to disengage if the child initiates an argument.

Separation and Stratification of Staff Roles

The third mechanism within MTFC-P that contributes to positive outcomes involves the separation and stratification of staff roles. In many youth treatment programs, staff members are assigned a "generalist" role. We have found this model to be insufficient when working with children in foster care. Various factors, including the complexity of the MTFC-P services and the likelihood that biological families will be involved with multiple other service providers, can require generalist staff members to continuously balance the opposing needs of different constituencies. Within this context, it is challenging to develop and maintain a trusting relationship with any of the parties involved in treatment.

A distinguishing characteristic of MTFC-P is its utilization of a treatment team (in which roles are clearly defined) to carry out the treatment plan for each youth. As is discussed below, the treatment team includes a program supervisor, a foster parent consultant/recruiter/trainer, a family therapist, a child skills trainer, a PDR caller, and consulting psychiatrists. There is little overlap in the responsibilities of team members, which helps to reduce confusion about who should carry out specific tasks. Staff members advocate the needs of those with whom they work. This insures that the child, foster parents, birth parents, and other service providers have a voice in the treatment process.

Staff Roles

Program supervisor. The program supervisor organizes all aspects of the MTFC-P treatment, leads the treatment team, and is the primary liaison with the child welfare system and other treatment providers in the community. Given the disparate roles of the team members, a key role of the program supervisor is to oversee and integrate team activities. The program supervisor works to ensure that team members are following the same treatment protocol, that team members are informed about each other's activities, and that the needs and concerns of all parties - child, foster parents, biological/adoptive families, and the child welfare system social worker - are being heard. Although the treatment team might not maintain a strict hierarchy, the program supervisor is the team leader. Therefore, this individual ultimately articulates the treatment plan, resolves disputes among team members, and sets the tone for the treatment process. The program supervisor also runs the weekly foster parent support groups and the weekly clinical meetings.

Given the multidisciplinary nature of the team, effective communication is essential for treatment to proceed smoothly. This communication occurs through team meetings, through email, and through informal conversations among team members. There is a strong emphasis on maintaining a high level of information sharing so that the treatment is consistent across team members. Although this approach might appear to be labor and personnel intensive, the long-term benefits provide justification for the utilization of these resources. In addition, because of the clarity in which roles are defined and the ability of staff to focus intensively on the needs of the child and adults involved in treatment, the turnover rate for staff is low and morale is high.

Foster parent consultant/recruiter/trainer. The foster parent consultant/recruiter/trainer is the primary support person for foster parents in the MTFC-P program structure. This individual is responsible for working with prospective foster parents from the time of initial contact with the program, through the certification and training process, and for the duration of the foster placement. This individual advocates for foster parents and serves as their voice in the program. The consultant/recruiter/trainer conducts home visits, is available by phone on an as-needed basis, and co-leads the weekly foster parent meeting. This individual might facilitate the implementation of treatment strategies and gather information about the status of interventions being employed in the foster home; however, it is the role of the program supervisor to design interventions for specific children.

Skills trainers/playgroup staff members. These staff members teach pro-social behavior and problem solving skills to the child through intensive one-on-one interaction and skill practice in the community. Skills trainers are trained to use applied behavior analysis as a way of examining potential antecedents to, and reinforcers for, problem behavior in the child's environment. They are also instructed in the use of shaping procedures to teach new behaviors. The implementation of skills trainer interventions is based often on behavioral contracting with the child.

Skills trainers also serve as playgroup staff members. In particular, one skills trainer serves as the playgroup leader, and two others serve as assistants. The playgroup staff members work together, under the supervision of the program supervisor, to implement the playgroup curriculum.

Family therapist. A key component to the success of the MTFC-P program is the degree to which the youth can generalize gains made during treatment to post-treatment environments. Parents (or other adult guardians) are the primary social agents who determine the quality and consistency of this generalization. Participation in the program does not fundamentally change the child and without continued support and socialization, gains do not remain. Therefore, teaching birth and adoptive parents how to effectively supervise, discipline, and encourage their child is a major task undertaken in MTFC-P.

In MTFC-P, family therapy includes the establishment of a consulting role with the child's parents. Many of the families have received services with multiple providers and social service agencies. Those experiences tend to range from neutral to poor and have involved blame, confrontation, avoidance, and other negative events. Thus, it is important for the family therapist to develop an alliance with the family and to establish a relationship that is supportive and constructive prior to introducing parent management training techniques in family therapy.

The family therapist works with parents to plan and implement strategies that increase reinforcement for positive/appropriate behavior. Parents are instructed in procedures for following through on negative behavior and providing consistent discipline. MTFC-P emphasizes the in-home practice of skills discussed in treatment sessions. As the parent learns particular skills, supervised visits with the child at the treatment center are initiated. As multiple skills are learned, the visits lengthen and then transition to the family's home. Parents have specific practice assignments which they implement during the home visits. Ultimately, home visits extend to overnights and then weekends. Provided that this process occurs without further maltreatment of the child, family reunification occurs. The family therapist maintains contact with the family during this transition and for 1 to 3 months following reunification.

A similar set of procedures occurs when children are being adopted due to termination of parental rights. Given that adoptive parents enter the picture closer to the end of treatment and require less intensive services, the timeframe of working with adoptive parents is shorter.

PDR caller. Because a high level of contact with foster parents is critical to the success of treatment, MTFC-P employs a staff member to contact foster families each day via telephone for the Parent Daily Report (PDR) calls. The PDR consists of a list of 40 problem behaviors exhibited by disruptive children. Foster parents are asked to indicate if each of the behaviors occurred in the past 24 hours. The checklist takes approximately 5 minutes to complete. The information gathered is viewed by the Program Supervisor on a daily basis and provides a thumbnail sketch of the youth's functioning which is used to track progress, identify patterns of problematic behavior, and monitor foster parent stress. Because the PDR interview is highly structured, it is possible to recruit and hire PDR callers with solid interpersonal skills but relatively limited clinical experience.

Consulting psychiatrist. Some MTFC-P youth enter the program with multiple diagnoses that include disruptive behavior disorders (e.g., conduct disorder and attention deficit disorder), posttraumatic stress disorder, and other anxiety disorders. Although children frequently respond to the treatment regimen of MTFC-P despite these problems, psychiatric consultation is sometimes required. Although it is possible to refer these youth to providers in the community for medication evaluations, the ability to consult directly with a psychiatrist who is familiar with the program elements is extremely useful. It allows for careful examination of the diagnoses and clarification of the specific medications judged most effective for addressing particular symptoms. Working together, the psychiatrist and program staff members are able to evaluate the impact of medication changes on the child's functioning. Consequently, once the child has stabilized in the foster home, it is often possible to greatly reduce the number and dosage of medications.

"Multidimensional Treatment Foster Care for Preschoolers" and "MTFC-P" are registered service marks of OSLC Community Programs, Inc.