Table of Contents
Family Centered Treatment®—An Alternative to Residential Placements for Adjudicated Youth: Outcomes and Cost-Effectiveness
Melonie B. Sullivan,
FamiliFirst, Inc., Great Falls, Virginia
Lori Snyder Bennear,
Duke University, Durham, North Carolina
Karen F. Honess,
FamiliFirst, Inc., Charlotte, North Carolina
William E. Painter, Jr.,
Institute for Family Centered Services, Charlotte, North Carolina
Timothy J. Wood,
FamiliFirst, Inc., Charlotte, North Carolina
Melonie B. Sullivan, Department of Research, FamiliFirst, Inc.; Lori Snyder Bennear, Department of Environmental Economics and Policy, Nicholas School of the Environment and Earth Sciences, Duke University; Karen Honess, Independent Contractor, FamiliFirst, Inc.; William E. Painter, Jr., Department of Organizational Development, Institute for Family Centered Services; Timothy J. Wood, Department of Research, FamiliFirst, Inc.
Correspondence concerning this article should be addressed to: Tim Wood, Department of Research, FamiliFirst, Inc., 313 Manning Dr., Charlotte, NC 28209; E-mail: Tim.Wood@familifirst.org
The authors gratefully acknowledge those who have made the completion of this manuscript possible: the Maryland Department of Juvenile Services, especially Dr. Lakshmi Iyengar, John Irving, and Claire Souryal-Shriver for their assistance in preparing and providing archival data for use in this study; and the Institute for Family Centered Services for their support, research funding, and advancement of Family Centered Treatment. We also thank Lauren Honess-Morreale for her comments on earlier drafts and Debbie Foster for her database assistance.
KEY WORDS: detention alternatives; court diversion alternatives; diversion programs; juvenile diversion; evidence-based programs
Nearly 100,000 adjudicated youth in the United States are placed in residential facilities (or out of home) annually, at an estimated national cost approaching $6 billion. This study compares behavioral and cost outcomes for adjudicated youth in the state of Maryland who were placed out of home with those who were diverted into the Family Centered Treatment® (FCT) program, which allowed them to remain in their homes and communities. Data were provided by the Maryland Department of Juvenile Services (DJS) and FamiliFirst, Inc. Outcomes analyzed include recidivism rates, post-treatment placement rates, and program costs. Results show that FCT provides significant, positive behavioral results based on a 2-year follow-up and reduces post-treatment placements. In addition, a cost analysis demonstrates that the FCT model is a cost-effective alternative to residential placement.
The number of adjudicated youth receiving out-of-home placement services in the United States is estimated to be more than 100,000 annually (Sedlak & McPherson, 2010). Most out-of-home placement services for adjudicated youth are provided through state-funded Departments of Juvenile Services. In 2009, each youth in out-of-home placement cost the state approximately $240.99 per day, with an annual national cost of nearly $6 billion (Petteruti, Velázquez, & Walsh, 2009).
Reductions in state budgets are increasing the need for innovative, effective programs and services for youth and families. Such programs and services should reduce the need for out-of-home placement and secure detentions while yielding therapeutic benefits, and saving money (Illinois Models for Change, 2011; Levin, 2010; National Juvenile Justice Network, 2010, 2011). Research shows that families and youth benefit when youth remain in their communities while receiving therapeutic services (Holman & Ziedenberg, 2006). In recent decades there has been a trend toward developing models for the effective treatment of at-risk youth in their homes, with Multi-Systemic Therapy (MST) and Functional Family Therapy (FFT) presenting a strong and substantial evidence base (Alexander & Sexton, 2002; Henggeler, 1999).1
A large number of practitioner-developed treatment models have been significant in filling the demand for out-of- home placement services. However, these are not represented in the peer-reviewed literature because their effectiveness has not been examined with statistical rigor. This article presents a quasi-experimental analysis of the effectiveness of one such program, the Family Centered Treatment® (FCT) program, implemented with at-risk youth in the state of Maryland. Using archival data from the Maryland Department of Juvenile Services (DJS), this study compares behavioral results and program cost-effectiveness for youth placed in residential services with those of youth in the Family Centered Treatment® (FCT) program. Youth in FCT remain at home and receive focused interventions aimed at preventing residential youth placements, reducing future contact with juvenile and adult criminal justice systems, supporting youth and families in activities of daily living, and ensuring community safety.
FCT, the treatment intervention described in this article, is provided as part of the Maryland Department of Juvenile Service’s Non-Residential Community-Based Program. The FCT model is an innovative, family-driven therapeutic model that requires family participation in the development of strategies and goals for success, and family adherence to the goals identified. The model is practitioner developed and has been refined over a 20-year period through client response and feedback, and in concert with Stroul’s best practices of family preservation services (Lourie, Stroul, & Friedman, 1998). Certification of FCT clinicians is required and is obtained only after completing an intensive 95-hour online and field competency–based training program entitled Wheels of Change© (FCT Training, 2011). A nonprofit organization, FamiliFirst, Inc., provides program oversight, evaluation, and licensure to agencies using the FCT model.
The FCT plan is based on the desires and needs of the family and uses a strength-based model of intervention that engages youth and their families through intensive contact, commitment, and collaboration. A family system case review process is vital to identifying and describing specific family strengths. A fundamental premise of the FCT model is that change is easier for families to incorporate when treatment strategies reflect family behaviors that are working well and represent norms for other areas of functioning (Painter & Smith, 2010).
The FCT model incorporates components of eco-structural family therapy and emotionally focused therapy (Aponte, 1994; Johnson, 2002). The thinking behind an integration of these two approaches is that although some families can benefit from the behavioral change approach used in eco-structural family therapy (and used in home-based treatment models such as MST and FFT), other families have difficulty incorporating teaching or tools designed to address behavioral change alone due to long-term systemic problems or past trauma. Unlike MST and FFT, the FCT model specifically uses emotionally focused therapy when eco-structural techniques are insufficient to create change (Painter & Smith, 2010).
Treatment is provided in the home or other natural settings, with several hours of contact in multiple sessions each week, and lasting an average of 6 months. While the majority of service takes place in the family’s household, treatment does not exclusively occur in the home. When needed, family treatment can be rendered in various environments including school, at the home of a relative, in the workplace, or in other community settings.
To ensure fidelity to the FCT model, 15 adherence measures are developed for each family during the treatment process. Because these measures are specific to each phase of treatment, they are indicators of progress and quantify the degree to which the model was followed.
Structured progress through FCT follows a four-phase model with well-defined standards for success and advancement to the next phase of treatment: Joining and Assessment, Restructuring, Value Change, and Generalization. Most youth and families who complete FCT have finished all four phases of treatment (Painter & Smith, 2010). Transitional indicators demonstrate a family’s successful completion of each of phase. The transition process is guided and documented by clinicians, and success is indicated by the family’s progress and not primarily by the number of days or sessions spent in treatment (FCT Training, 2011).
The FCT engagement process is pivotal to treatment success. In the first phase, Joining and Assessment, engagement requires a delicate balance between connecting to family members and challenging their modes of operation (Lindblad-Goldberg, Dore, & Stern, 1998; Robbins & Szapocznik, 2000). Staff must disarm and join with the family to create a relationship of “allies” in treatment (Minuchin & Fishman, 2004). Family acceptance of treatment often occurs during this phase (Painter & Smith, 2010). Family cooperation is an important precondition for change during all four phases of treatment, since their acceptance establishes family centeredness and cohesion.
A fundamental premise of the FCT model, and a major departure from that of MST and FFT, is the notion that to sustain behavioral changes, youth and their families must value the changes made during treatment. Accordingly, FCT includes integrated enactments designed to determine whether behavioral changes made during treatment are made in response to external expectations, or they reflect the family’s desires and needs.2 Enactments address the ways in which the family responds to conflict, communicates, and meets the needs other family members have for affection, attention, and nurturing (Johnson, 2002).
FCT provides opportunities for families to recognize functional patterns and identify individual behaviors that can be modified. FCT enables observation of problematic interactions directly, rather than relying on stories about what happened retrospectively. When an interaction or family behavior is identified as an established pattern, the goal of FCT is to redirect the interaction to provide opportunities for the family to approach tasks and communication differently. In practice, this occurs when families display behaviors that are counter to their chosen goals, disruptive, or dysfunctional. The FCT clinician who has partnered effectively can now provide guidance for needed changes. This guided behavioral change process is formally identified as the Restructuring Phase of FCT. This phase addresses the origins of behavior of individuals and families and helps them recognize and address their underlying emotional and attachment needs. When integration of suggested behavioral changes is thwarted by emotional blockages due to previous trauma or past hurt, FCT clinicians use emotionally focused therapy (Johnson, 2002) to enable movement.
As the family begins to experience success, there is a decrease in maladaptive functioning. FCT views this change as a performance-based progress measure, and the therapeutic process is adjusted accordingly. At this point, the Value Change phase of treatment—which provides the impetus for FCT clinicians to prompt the family to examine their intent to change and consider the purpose of their changed behaviours—guides the family in identifying changed behaviors that have long-term value (Painter & Smith, 2010). As the clinician’s role becomes less directive, the family examines changes made and gains an understanding of their role in the change process. Such understanding facilitates the family’s ownership of these changes and enables these changes to be sustained.
Families move into the final FCT phase, Generalization, when they demonstrate change independently, are able to handle difficult situations on their own, and possess the tools and skills needed to overcome their issues internally. In this stage of treatment, the family focuses on their process of addressing and resolving problems. Sustainable changes and healthy functioning are fostered as the family has a clear process to follow for problem-solving when faced with future challenges. A key indicator of the family system’s success is that they no longer identify individual family members or external factors as the cause of the initial problem(s). Instead, families note what they are doing differently to make family life work better and can identify and implement these changes without therapeutic intervention (Painter & Smith, 2010).
The FCT model emphasizes community and agency collaboration, and provides wraparound services through a plan that offers care for all family members. Like the family preservation model, FCT intensely involves all stakeholders such as a referring court counselor, psychiatrist, social worker, or individuals who may affect or be affected by the family’s actions. Furthermore, the FCT model seeks to find resources that support family stability and meet identified eco-structural needs. The overarching goals of FCT are to keep youth in their homes, ensure the safety of the community, and prevent youth from re-entering the juvenile justice system.
The typical family referred to FCT is at especially high risk of disintegration, has not responded to traditional models of treatment, and includes youth who are treatment-resistant delinquents at imminent risk of out-of-home placement. The family, as defined within the context of FCT, is a collection of individuals, whether related or unrelated, who commit to maintaining the identified client within their structural unit.
This article evaluates the post-treatment outcomes of and program expenditures for two groups of adjudicated youth and their families sharing similar risk factors that can affect treatment outcomes. These groups were 1) youth who received FCT as an alternative to residential placement and remained in their homes and communities (the treated group), and 2) those who were placed in residential services (the comparison group). We used a combination of standard and propensity-score matching to estimate the average treatment effect on the treated (SATT) youth for the following outcomes during each of the 2 years post-treatment: residential placements, pending placements, community detentions, secure detentions, offenses, and adjudications. In addition to cross-group comparisons of offending behaviors, we examined within-group changes in behaviors over time. Table 1 provides details on definitions and measurement of outcome variables. A cost-effectiveness analysis compares the direct costs of the FCT program with the costs of residential services, as explained later in this article.
Table 1. Definition of Variables*
Group homes, Therapeutic Group Homes, Therapeutic Foster Care, Residential Treatment Center, Impact Programs, Wilderness Programs, Substance Abuse Programs, and Secure Confinements
Waiting period between commitment to placement and available space
Youth remains at home with Juvenile Service supervision
Detention Center, Reformatory
Charge of violation of the law
Court decision to adjudicate youth on offense charge
|First 12 months (365 days) following discharge from FCT or Group Home|
|Months 13–24 (days 365–730) following discharge from FCT or Group Home|
According to the parameters of the Maryland DJS diversion program, all youth whose histories and data were analyzed in this study qualified for both FCT and residential placement. The decision to place the youth in FCT as opposed to a residential setting was made by case managers/probation officers, the courts, and/or the parents before this study.
The sample of youth in the treated group was drawn from the set of all youth discharged from FCT during the first 4½ years of FCT field implementation in Maryland (between July 2003 and December 2007). The sample of youth in the comparison group was drawn from the set of all youth discharged during the same timeframe from group homes, therapeutic group homes, and other residential placements offering similar types of services. Because data from the adult criminal justice system were unavailable, and because youth age into the adult system at age 18, those who turned 18 during the follow-up period were not included in our analysis. Accordingly, in the first year post-treatment, we analyzed outcomes data for 447 youth in the treated group and 888 youth in the comparison group. For the second-year follow-up, we retained more than half of the first-year sample (57% of the treated group and 54% of the comparison group). Data measuring the engagement rates of youth in both the treated and comparison groups across the entire study period were unavailable.
We obtained data on demographics, offenses, and placement history for youth in both groups through the Maryland DJS. Study data contained a record of each placement, offense, and adjudication event beginning with the youth’s first referral to the juvenile justice system. Each placement record contained data on program type and dates of service. Each offense record contained data on offense date, offense category (seriousness of offense), adjudication date (if applicable), and adjudicated offense.
We obtained cost data from resource coordinators at the Maryland DJS and the Institute for Family Centered Services, Inc., the FCT service provider. Cost data consisted of average daily costs for each youth in the treated group during 2006 and the average daily costs of placement in Group homes or Therapeutic Group Homes for those in the comparison group during the same year.
Selection bias may occur when group assignment is not random. Therefore, to control for potential selection bias, we used a combination of standard matching and propensity-score matching to estimate the average treatment effect on those in the treated (SATT) group for each outcome. Matching controls for all observable differences between groups, and propensity-score matching, equalizes the overall likelihood of individuals receiving either treatment or placement. The use of matching methods and, particularly, propensity-score matching enables researchers to replicate findings from random assignments, including studies in which substantial differences exist in mean outcomes and covariates between the unmatched control and intervention groups (Dehejia & Wahba, 1999; Heckman, Ichimura, & Todd, 1997; Lee and Thompson, 2008). Exact matching in areas of service provided by the Institute for Family Centered Services allowed us to control for exogenous geographic influences. We implemented matching in Stata using the nearest-neighbor matching code developed by Abadie and Imbens (2004, 2008) by using the four closest matches for each youth receiving FCT. We chose four matches to reduce variance of the SATT estimator without increasing the bias that might result from poor matches. We corrected the estimates for bias that can result from imperfect matches, and calculated robust standard errors (Abadie et al., 2004, 2008).
The SATT statistic takes the average of the differences in outcomes across every matched pair. For a dichotomous outcome variable, the SATT interprets directly as the percentage difference between the treated and the comparison, or control groups (i.e., the effect size). For continuous outcome variables, dividing the SATT by the control group mean gave the percentage effect size. Effect sizes are reported as percentage differences and by Cohen’s d statistic for outcomes found significant by classical criteria. Cohen’s standards for small, medium, or large effects are noted (Cohen, 1988). See Sullivan, Bennear, and Honess (2011) for a more detailed exposition of the matching procedure. We conducted cross-group comparisons of demographics for the matched groups using the Welch t-test for unequal variances. We conducted within-group comparisons of pre- and post-treatment behaviors by comparing means across the matched groups. For reporting purposes, youth receiving FCT are referred to as the FCT group, and youth who received out-of-home services are referred to as the Placed group.
Explanatory variables in the propensity score equation included youth demographic characteristics and variables from each youth’s history within the DJS system. The explanatory variables represented a risk profile for each youth, which we believed helped those in the Maryland DJS influence decisions as to whether a youth was placed into treatment and whether treatment was successful.
Cross-group Comparison of Demographics
Table 2 illustrates the effect of the matching procedures on the demographic makeup of the two groups. The resulting matched groups were well balanced with respect to both demographics and pre-treatment variables, as both groups looked the same with respect to variables believed to affect both selection into groups and treatment effectiveness.
Table 2. Participant Demographics*
|Average Age at First Offense||12.85||12.86|
|Mean Age at Intake||15.20||15.19|
|First Offense was Serious Category 1 or 2 Crime||18%||16%|
|From Urban or Mixed Geographical Area||78%||78%|
Estimates of the average treatment effect on the FCT group for post-treatment placement outcomes are reported in Table 3. Because actual placement with a residential provider can be significantly delayed while waiting for space, we included pending placements as an outcome of interest. As detailed in Table 1, four types of potential placement options were studied: residential, community detention, secure detention, and pending.3
Table 3. Placement Outcomes
|Year 1 Post-treatment||Year 2 Post-treatment|
|Effect Size % Difference (Cohen's d)||Mean
|Proportion with Pending Placements||.29 (.45)||.33 (.47)||–.04 (.252)||.19 (.39)||.16 (.36)||.041 (.254)|
|Frequency||.40 (.73)||.47 (.76)||–.065 (.244)||.24 (.56)||.21 (.54)||.043 (.450)|
|Duration||14.62 (35.74)||24.38 (47.87)||–9.46 (.010)||–39% (.23)*||10.39 (26.23)||9.67 (31.56)||1.23 (.629)|
|Conditional Duration||50.67 (51.09)||72.90 (57.59)||–19.32 (.004)||–27% (.41)**||48.02 (39.48)||54.84 (59.63)||–12.02 (.33)|
|Proportion with Residential Placements||.38 (.49)||.50 (.50)||–.118 (.002)||–24% (.24)*||.23 (.42)||19 (.39)||. .045 (.288)|
|Frequency||.50 (.74)||.63 (.70)||–.123 (.03)||–20% (.18)*||.26 (.51)||.23 (.53)||.027 (.648)|
|Duration||63.75 (100.14)||90.84 (114.56)||–26.85 (.002)||–30% (25)*||52.68 (95.42)||52.83 (89.53)||2.24 (.825)|
|Conditional Duration||169.88 (93.18)||184.51 (96.80)||–14.80 (.215)||150.12 (97.85)||133.55 (87.36)||17.13 (.405)|
|Proportion with Community Detentions||.32 (.47)||.29 (.45)||.034 (.293)||.21 (.41)||.18 (.39)||.036 (.381)|
|Frequency||44 (.74)||. .42 (.76)||.02 (.742)||.30 (.67)||.22 (.53)||.082 (.128)|
|Duration||14.19 (27.67)||15.52 (29.65)||–1.20 (.568)||10.17 (23.29)||9.48 (25.66)||.97 (.656)|
|Conditional Duration||44.57 (32.45)||54.12 (31.23)||–12.42 (.007)||–23% (.30)*||47.08 (29.40)||49.68 (39.38)||–3.17 (.722)|
|Proportion with Secure Detentions||34 (.50)||. .48 (.50)||.041 (.299)||.33 (.47)||.30 (.46)||.046 (.345)|
|Frequency||.69 (.98)||.69 (.88)||.005 (.939)||.57 (.92)||.43 (.82)||.15 (.091)|
|Duration||12.56 (24.47)||13.70 (23.41)||–.184 (.606)||9.34 (18.90)||8.35 (18.90)||1.16 (.574)|
|Conditional Duration||28.93 (30.12)||28.61 (26.81)||–.192 (.946)||27.84 (23.81)||27.54 (26.01)||–1.12 (.796)|
A brief discussion of our findings among these options for years 1 and 2 post-treatment follows.
Year 1 Post-treatment: The proportion of FCT youth with post-treatment residential placements in the first year following treatment was 38%, compared with 50% of Placed youth; i.e., 24% fewer FCT youth than Placed youth experienced residential placement during this timeframe (effect size 24%, p = 0.002). The frequency of residential placements was significantly lower for FCT youth relative to Placed youth (0.50 for FCT youth compared with 0.63 for Placed youth); (effect size 20%, p = .03). In addition, the average FCT youth spent 30% fewer days in residential housing than Placed youth, with an average of 64 days for FCT youth compared with an average of 91 days for Placed youth (effect size 30%, p = 0.002).
Year 2 Post-treatment: We found no significant differences between the groups on residential variables. Youth in both groups experienced a decline in all measures following the first year post-treatment (see Table 2).
Year 1 Post-treatment: Time that youth spent in community detention, conditional on placement, was significantly lower (23%) for FCT youth, averaging 44.5 days compared with 54 days for Placed youth (effect size 23%, p = 0.007). There were no significant differences in the groups regarding the proportion or frequency of youth who served community detentions.
Year 2 Post-treatment: We found no significant differences between the groups for community detention measurements, but we noted declines in community detention for both groups.
Year 1 Post-treatment: Youth in both groups had the same frequency of secure detention (0.69). The proportion of youth placed in secure detention was lower for FCT youth than for Placed youth (0.34 vs. 0.48), but the difference was not statistically significant.
Year 2 Post-treatment: We found reductions in secure detention for youth in both groups, with 33% of FCT youth and 30% of Placed youth having experienced secure detention. While both groups reduced their frequency of secure detentions in year 2 (0.57 for FCT youth and 0.43 for Placed youth), the between-group difference was not significant at classical levels of significance.
Year 1 Post-treatment: FCT youth spent 14.6 days pending placement, significantly lower than the 24.3 days for Placed youth (effect size 39%, p = 0.01). FCT youth spent 21 fewer days (51 versus 72) pending placement than did Placed youth (effect size 27%, p = 0.004).
Year 2 Post-treatment: For both groups, the number of youth with pending placements decreased 19% for FCT youth and 16% for Placed youth; the frequency of pending placements decreased to 0.24 for FCT youth and 0.21 for Placed youth. No significant differences were found between the two groups.
Mean frequencies and proportions of recidivism are reported in Table 4, along with within-group tests of differences in means over time. For cross-group comparisons (Table 5), the year-to-year change in frequency is reported for each youth, as are the changes in proportions for each group.
Table 4. Within Group Comparisons of Pre- and Post-treatment Offense Behaviors
|Mean (Standard Deviation) [Percentage Change]||p-values: Differences in Means|
|1 Year Pre-treatment||1 Year Post-treatment||2 Years Post-treatment||Change in Year 1 Compared with Pre-treatment||Change in Year 2 Compared with Year 1|
|Family Centered Treatment®|
|Offense Frequency||4.38 (5.12)||2 (2.74) [–54%]||1.72 (3.41) [–14%]||0.000||.24|
|Proportion Offending||.87 (.336)||.60 (.491) [–31%]||.41 (.493) [–32%]||0.000||.0.000|
|Adjudications Frequency||1.69 (1.94)||.69 (1.48) [–59%]||.65 (1.84) [–6%]||0.000||.75|
|Proportion Adjudicated||50.67 (51.09)||.32 (.466) [–59%]||.21 (.41) [–34%]||0.000||0.000|
|Offense Frequency||4.5 (5.62)||1.79 (2.39) [–60%]||1.67 (3.09) [–0.7%]||0.000||.25|
|Proportion Offending||.89 (.317)||.61 (.489) [–31%]||.44 (.497) [–23%]||0.000||0.000|
|Adjudications Frequency||1.66 (1.89)||.44 (.99) [–73%]||.75 (2.42) [+70%]||0.000||0.000|
|Proportion Adjudicated||.80 (.399)||.26 (.437) [–68%]||.24 (.42) [–0.8%]||0.000||.24|
Table 5. Cross Group Recidivism Outcomes Measured by Differences in Frequencies/Proportions Between Years for Each Youth
|FCT Mean¹ (Standard Deviation)||Placed Mean (Standard Deviation)||SATT||p-value||Effect Size % Difference (Cohen’s d)|
|Change in Frequency of Offenses|
|Year 1 Relative to Pre-treatment Baseline||–2.38 (.26)||–2.71 (.13)||.26||.50|
|Year 2 Relative to Year 1 Baseline||–.44 (.28)||–.11 (.10)||–.39||.28|
|Change in Proportion of Youth Committing Offenses|
|Year 1 Relative to Pre-treatment Baseline||–.27 (.027)||–.28 (.013)||.009||.831|
|Year 2 Relative to Year 1 Baseline||–.20 (.04)||–.14 (.02)||–.068||.29|
|Change in Frequency of Adjudications|
|Year 1 Relative to Pre-treatment Baseline||–1.0 (.11)||–1.22 (.05)||.19||.19|
|Year 2 Relative to Year 1 Baseline||–.17 (.25)||.22 (.065)||–.43||.08|
|Change in Proportion of Youth with Adjudications|
|Year 1 Relative to Pre-treatment Baseline||–.47 (.028)||–.54 (.013)||.07||.09|
|Year 2 Relative to Year 1 Baseline||–.13 (.036)||–.008 (.017)||–.13||.02||>100% (4.3***)|
Within-Group Offense Recidivism Outcomes: Table 4 shows that in the first year following treatment, both groups experienced significant reductions in recidivism compared with 1 year before treatment on all variables. The average frequency of offenses fell by more than 50% for both groups, while the proportion of the sample that committed alleged offenses fell by 31% for both groups. Moreover, the proportion of youth offending in the second year fell again by approximately 30% for both groups, although the average frequency of offenses remained static. In the second year following treatment, the frequency of adjudications rose significantly for youth in the Placed group compared with adjudications the year before; however, the proportion of youth adjudicated remained static between years 1 and 2. Conversely, FCT youth experienced a large and significant drop in the proportion of offenses and adjudications, but the average frequency of their offenses remained static compared with the previous year.
Cross-Group Comparisons of Recidivism Trends
Year 1 Post-treatment: While both groups experienced declines in all categories relative to their pre-treatment status, we found no significant differences between the groups in terms of the proportion of offending youth, offense frequency, adjudication frequency, or the proportion of youth with adjudications.
Year 2 Post-treatment: During this period, both groups showed declines in the proportion of youth offending but no change in the frequency of offending, with no significant difference between groups. Youth in the Placed group showed a large increase in the frequency of adjudications, and no significant decrease in the proportion of youth with adjudications. There was a greater decline in adjudication frequency for youth in the FCT group, who had a significantly lower proportion of adjudications (p = 0.02, effect size 1600%).
Discussion of Offense Findings
Taken together, the within- and across-group results indicate both groups exhibited significant reductions in offenses that were sustained through the second year. Indeed, during the second year, the proportion of youth offending fell even further for both groups. The fact that the average frequency of offenses remained static in the second year, however, means the recidivists must have committed offenses at an increased rate. For these outcomes, both FCT and Group Home care seem to have produced the same results. But if adjudicated offenses are examined as the measure of recidivism, the results are quite different.
In the first year following treatment, both groups showed a decline in the frequency of adjudications and the proportion of youth adjudicated. However, those in the FCT group showed a 13% smaller decline in the proportion of youth with adjudications. However, this result is more than offset in the second year by adjudications in the placed group. While the FCT group showed a decline in the proportion of adjudications and no change in their frequency (consistent with the offense results and therefore consistent with a constant rate of adjudications per offense), the Placed group showed no change in proportion and a large increase in the frequency of adjudications. Taken together with the offense results, this suggests that not only were Placed recidivists committing offenses at a higher rate than those in the FTC group, but the offenses of Placed recidivists were adjudicated at a higher rate.
The cost analysis depicted in Table 6 shows costs for treatment periods limited to 368 days of service for all categories. Because this study analyzed a diversion program, the cost calculation follows the parameters of the program by assuming all youth would have been placed in a residential service had FCT not been an alternative. Therefore, we determined costs by assuming that youth receiving FCT would have been placed in a Group Home or Therapeutic Group Home. For all Placed youth in this sample, 87.5% were placed in Group Homes and 12.5% in Therapeutic Group Homes; therefore, this placement ratio is assumed for FCT youth in the counterfactual calculation of costs (Sullivan et al., 2011).
Table 6. Cost Benefit: Truncated Length of Service
|FCT||Group Home||Therapeutic Group Home|
|Cost per Day in 2006 Dollars||$80||$198||$233|
|Number of Youth||446||777||111|
|Average Length of Service (Range)||151 days (16–368 days)||185 days (16–368 days)||156 days (16–368 days)|
|Average Program Cost for One Youth||$12,080||$36,630||$36,348|
|Average Daily Cost/All Youth||$35,680||$153,846||$25,863|
|Program Cost for All Youth during Time Frame||$5,387,680||$28,461,510||$4,034,628|
|Total Program Cost||$5,387, 680||$32,496,138|
|Total Counterfactual Cost [.875 (446 × 36,630) +.125 (446 × 36,348) = $16,321,259]||–$16,321,259|
|Total Program Savings||$10,933,579|
|Savings per Dollar Spent: FCT vs. Placement||$2.03|
The average program cost for each youth in FCT was $12,080. The average program cost for each youth was $36,630 in Group Homes and $36,348 in Therapeutic Group Homes—both more than three times the cost of FCT. Had FCT been unavailable, all youth would have been placed in Group or Therapeutic Group Homes, and the cost for serving those youth would have been $16.3 million. Every $1.00 spent on the FCT program saved the state of Maryland between $2.03 and $2.29, for a total estimated savings of $10.9 million to $12.3 million over 4½ years.
These findings build on and support financial savings reported by other home-based therapeutic diversion programs, including MST and FFT (Aos et al., 2011; Illinois Models for Change, 2011; National Juvenile Justice Network, 2011). Indeed, the cost benefits of FCT to the state of Maryland reflect reported direct cost reductions in states using diversion programs for adjudicated youth throughout the United States (Levin, 2010; Office of Program Policy Analysis & Government Accountability, 2010; Petteruti et al., 2009; Tyler, Ziedenberg, & Lotke, 2006).
For this sample of youth, we were unable to draw a distinction between FCT youth who were engaged in treatment and those who were not. Therefore, all youth were included in the study, regardless of whether they actually received the full treatment or were discharged early for noncompliance, refusal of services, and the like. Assuming engagement is not an issue for Group Homes (in the sense that refusing services is not an option), this may have resulted in an estimate of the effectiveness of FCT that was biased downward.
Similarly, we were unable to observe attrition rates, since we used archival data from the Maryland DJS. Any attrition from that database was due to relocation, death, or the transition youths make into the adult system. There is no reason to hypothesize that any systematic relationship existed among youth in our study who died or relocated that would have affected study results. There might have been systematic differences among older youth who transitioned into the adult system that would have influenced these findings. Therefore, outcomes from this study cannot be extrapolated to an older juvenile population.
The lack of adult system data resulted in a sample size loss that had a negative impact on the study in other ways. The loss of statistical power precluded a multisite analysis of FCT in the five geographically distinct FCT service areas in Maryland. It also prevented analyses of other covariates of interest, such as gender and race. The program is ongoing, and additional data will be available to expand the analysis of FCT.
In a rigorous initial analysis of aggregate outcomes across five provider sites and a heterogeneous population with respect to risk factors/demographics, this study reveals a promising model new to this literature. FCT works at least as well as restrictive residential placements at reducing offense behaviors, and better at reducing new placements, at a substantially reduced cost. The model is effective with females and males, African Americans, Hispanics, and Caucasians. Components of the model that probably account for this success include the manner in which the model engages the participants, the breadth of family inclusion and the structure of the supervision, and an approach that allows fidelity to all of the components of the model while creating awareness of and accommodating gender and cultural needs.
The FCT model is currently being replicated in other states, and preliminary evidence regarding outcomes and costs are encouraging. As additional data become available, future research efforts will focus on cross-site comparisons of effectiveness, as well as examinations of youth/family-specific covariates of success (i.e., for whom does this program demonstrate effectiveness?).
In this long-term follow-up study of adjudicated youth in the state of Maryland, FCT is shown to be a promising and cost-effective alternative to residential placements. In the first year following treatment, we found that youth receiving FCT significantly reduced the frequency of their offenses and adjudications, and that the proportion of youth with offenses and adjudications was also significantly reduced. These findings were sustained 2 years post-treatment. The results were consistent across groups in the first year following treatment. In the second year following treatment, however, FCT youth exhibited a much greater decline than the Placed group in both the average frequency of adjudications and the proportion of youth with adjudicated offenses. Moreover, in the first year following treatment, we found that the effect of FCT reduced the average frequency of residential placements, days in pending placements, and days in community detentions relative to those of the comparison group. These outcomes were achieved at substantial cost savings: every $1.00 spent on the FCT program saved the state of Maryland between $2.03 and $2.29, for a total estimated savings of $10.9 million to $12.3 million over 4½ years.
About the Authors
Melonie B. Sullivan, Ph.D., is Research Director, Department of Research, FamiliFirst, Inc., Great Falls, Virginia.
Lori Snyder Bennear, Ph.D., is Assistant Professor of Environmental Economics and Policy, Nicholas School of the Environment and Earth Sciences, Duke University, Durham, North Carolina.
Karen F. Honess, B.S., is an Independent Contractor, FamiliFirst, Inc., Charlotte, North Carolina.
William E. Painter, Jr., M.S., is Senior Director of Organizational Development, Institute for Family Centered Services, Charlotte, North Carolina.
Timothy J. Wood, M.S., L.P.C., is Executive Director, FamiliFirst, Inc., Charlotte, North Carolina.
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