Shared Family Care: Out-of-Home Care Programs for Serving Parents and Children Together

ABSTRACT

Helping children and parents remain together, despite significant parent or child problems, is a key objective of child welfare services. One option is to place whole families together into out-of-home settings. We searched peer-reviewed and gray literature and solicited input from international networks to identify the range of family placement programs available. We identified three key types of “shared family care.” Shared Family Foster Care (SFFC) involves sharing of care and intensive modeling of effective parenting by a host family that engages in mentoring of the parent and parenting of the child. Shared Residential Care (SRC) programs involve sharing of care and intensive modeling of effective parenting by professional staff as they engage parents and children in what had often been child-only residential programs. Family Residential Treatment Programs (FRT) also place parents and children in residence together. FRT programs are often aligned with inpatient treatment units. Active programs that illustrate each type are described. Through this typology and detailed information of currently active shared family care programs, policymakers and program designers can consider which kinds of programs have the most potential for implementation and sustainability.

KEYWORDS:

• Shared family care
• families
• residential care
• parents
• modeling
• foster care

Children’s services are responsible to fulfill dual obligations (Berrick, 2017): protecting children (always) and preserving families (whenever possible). This has led to much movement toward family-centered care in health and human services (e.g., Kokerelias et al., 2019). Yet, there remains a significant concern that any form of out-of-home placement may be punitive to parents and traumatizing to children and parents and that every unnecessary placement should be avoided in favor of keeping parent and child together or achieving rapid reunifications (Eurochild, 2012). Yet, the challenges of returning children home are significant as the reentry to care rate, after reunification, is a concern in many countries (Hébert et al., 2018; Jedwab & Shaw, 2017; Parolini et al., 2018).

Another development in many countries is the decreased use of residential care. Leading American foundations (e.g., the Casey Foundations) have been looking for alternatives to residential care and federal and state policymakers are setting tight age and time limits on the use of residential care. The focus on deinstitutionalization and avoiding residential care is also a trend in Europe (UNICEF/Eurochild, 2021) and the UK (Thoburn, 2016). The work of the Better Care Network expresses some of these same concerns on an international scale, although this direction has not evolved as far as in the U.S.

In response to the need for more family-centered care, out-of-home care providers have developed programs that placed families together with their children and offered some combination of parenting supports, mentoring, family therapy, and a shared living environment for some or all days in a week. We refer to these programs as Shared Family Care, which combines aspects of in-home and out-of-home child welfare services. A key characteristic of Shared Family Care (SFC) is that it keeps parents and their child(ren) together (Barth, 1994).

The increased emphasis on family-based care may point to an opportunity to expand “shared family care” (Barth, 1994), or “whole family care” (Baxter & Cummins, 1991) where children and their parents can avoid the harms of separation but achieve safety through placement together in out-of-home care. Such two-generation approaches (AECF, https://www.aecf.org/topics/two-generation-approaches/) have the virtue of endeavoring to equip both parents and children with the supports and skills needed to thrive. These models also are responsive to concerns that parents involved with child welfare services are often traumatized by their own past, or current, experiences of family violence. Service programs that reduce events that may generate trauma – to parents and children – are very much favored, given our growing understanding of trauma’s threats to health and well-being (e.g., Marsman, 2021; Widom et al., 2012).

Brief History of Shared Family Care

Previous incarnations of SFC display a range of programming and structural possibilities, with some versions of SFC programming in operation for at least 40 years. The first such program that we know of was Sweden’s Barnbyn Ska (Hessle, 1988). This program was generated from the work in a traditional residential treatment setting that determined the need for a less authoritarian, top-down program; staff and families shared living spaces and endeavored to flatten the differences between professionals and parents, while engaging in meaningful treatment and child protection. A second early program was Mead House, which operated out of a large home that could house 8–10 families in Heathrow, London. Staff families also boarded there and were available 24 h a day 7-days a week to help with mentoring and crisis intervention. A third model was “Whole Family Care” in Minnesota, USA (Cornish, 1992) that placed parents with developmental disabilities and placed these families with host families who provided modeling of family living and case management. The Shared Family Care program in northern California (Barth & Price, 1999; Price & Wichterman, 2003) operated very much like a treatment foster care program but included single mothers (and some single fathers) in care with one or more of their children.

In addition to sharing the commitment to caring for parents and children together, these programs had other commonalities. Each of them operated for at least a decade – some for two. The programs had a funding arrangement that in part drew on the major funding streams that supported traditional placements of children away from their parents. Each of them spawned considerable interest and many visitors, but no substantial replications. Unfortunately, none of them conducted rigorous evaluations, and all are now closed – largely because there are no funding streams to support this kind of program or because the conventional way of placing children apart from their parents is so deeply rooted in current systems of care.

Defining Shared Family Care

SFC has been described as involving the planned provision of out-of-home care to parents and their children so that the parent and the host caregivers (supported by professionals) simultaneously share the care of the children and work toward independent in-home care by the parent (Barth & Price, 1999). This definition contains several conceptual dimensions of SFC: (1) parents and children living together; (2) the host family, staff, or structural components of the program provide support or care for needs of the children and share the care of the children with parents during at least some portion of their time out-of-home; and (3) the program employs a team, that also includes professionals, to help the families obtain skills and resources. Unlike other service settings with a single identified patient, a Shared Family Care program may focus primarily on the needs of the parent (including their substance use or parenting capacity), or the needs of the child (intensive mental health or behavioral care). A Shared Family Care program recognizes, by design, the importance of preserving the family as a cohesive unit that is most stable when parents and children have a positive reciprocal relationship that promotes family healing and growth. Some of the programs (e.g., KINGS) are explicitly focused on both youth and their parents (Ploeg & Wanders-Mulder, 2020), but all of the programs may vary in the extent to which they focus on youth or parents – depending on the needs of the dyad. Programs with young children tend to focus on the parents (as the agents of change for children) but also recognize that children may be traumatized or otherwise dysregulated from past family difficulties and may also need trauma-informed interventions.

The concept of serving whole families together can be operationalized very broadly and certainly is much larger than the slice we take in this paper. At the turn of the last century, the Children’s Defense Fund (CDF) published a compendium on “Whole Family Care” that identified 50 family care programs serving diverse populations, including families involved with domestic violence, substance abuse, teen parenthood, and homelessness (Allen & Larson, 1998).

All of these programs endeavored to comprehensively address the needs of parents and children together, but few included having the parents and children reside together – other than at home – except for substance use disorder residential programs. SFC programs all have some capacity for real-time interventions to de-escalate conflict and promote safety in high-risk families. This capacity was heavily stressed by the developers of Brynbyn Ska and Mead House as a way to prevent or rapidly respond to events that might de-stabilize a family and endanger family members.

Research Evidence Supporting SFC

Research on SFC programs is very limited. No conclusive studies show impact on bottom-line child welfare services outcomes as time in care, reentry to care, or cost of care. No studies have rigorously compared SFC to other forms of care. The strongest study was 2003) study comparing outcomes for children in SFC with treatment foster care. Nearly 60% of participants graduated successfully, and 71% of those moved into independent housing – others moved to live with relatives or to transitional housing. About 15% of the children reentered foster care, which was lower than a comparable sample of other children in local treatment foster care programs who had left foster care at about the same time.

In the USA in the mid 1990s, the Pregnant and Post-Partum Women’s Initiative (PPWI) funded small residential programs for substance using mothers and young children. These projects provided comprehensive, culturally, and gender-specific treatment. Preliminary aggregated data collected in a national cross-site evaluation of 24 of these projects show encouraging findings with respect to infant mortality and morbidity, treatment retention, and completion rates, and behavioral changes in the participating mothers at six months post-discharge (Clark, 2001). However, some of these projects closed early (sometimes because of lack of mother-baby dyads to justify the high costs of the program) or could not provide data for the evaluation. Local evaluations reflect other benefits of treatment and challenges of operating programs that required full occupancy to pay for the high costs of staff and overhead. No cost data have yet clearly demonstrated the efficiencies and benefits of these projects compared to no treatment or other forms of treatment. Some of these PPWI programs continue to operate with local funding and other forms of federal support as part of a larger universe of programs totaling nearly 800 (Wilder Research and Volunteers of America, 2019).

Aim of the Present Study

The aim of this paper is to describe the current landscape of shared family care programs, serve as a starting point for establishing common terminologies to characterize the various kinds of shared family care programs, and provide illustrations of programs in each of the three identified subcategories of SFC. Given the continued decline in the use of child-only residential care programs and the concomitant desire to find less formal and less traumatizing strategies for helping families, this knowledge could spur innovation and evaluation that will lead, if the science indicates, to a larger role for shared family care in the next decades.

Method

Procedures

To describe the current landscape of shared family care programs, we sought to identify any shared family care programs currently being implemented in different countries. We contacted 13 (inter)national networks of residential and foster care scholars (see Table 1) and our own professional networks with a short questionnaire to distribute to other scholars in the field.

Table 1. The (inter)national networks of residential and foster care scholars approached.

Academic Workplace Youth at Risk (The Netherlands)

Baptist Coalition for Children and Families (US)

The Board of Child Care (BCC) (US)

The Child Welfare League of America (CWLA)

Eurochild

The board of the European Scientific Association on Residential and Family Care for Children and Adolescents (EUSARF)

International Association of Outcomes Based Evaluation and Research (IAOBER)

International Research Network on Transitions to Adulthood from Care (INTRAC)

FICE International and FICE Netherlands

The International Work Group for Therapeutic Residential Care (TRC)

The Netherlands Youth Institute (Residential Youth Care network)

SOS Children’s Villages (international and Dutch association)

The research group Residential Youth Care of the University of Applied Sciences (Leiden, The Netherlands)

Note. The networks that responded are in bold.

The questionnaire asked about (i) the name and contact information of any programs that place whole families together into out-of-home settings; (ii) knowledge of any relevant (scientific or gray) literature on shared or whole-family care; and (iii) any other considerations on this topic. This outreach yielded responses from 29 professionals, mainly scholars, who shared their ideas on shared family care, and together mentioned 36 programs that could be potential examples of this model. These programs were supplemented by 10 additional programs known to the authors prior to approaching the networks and through social media channels such as LinkedIn. Altogether, a total of 46 potential shared family care programs were identified for further examination.

What We Excluded

Our review does not include a very common form of shared family care that involves drug and alcohol treatment programs for pregnant and parenting women (PPW) that also offer substance abuse treatment, coaching and support for effective parenting of infants (Barth, 1994). These programs have a long history in the USA (Clark, 2001) and hundreds continue there (Wilder, 2019) and, we believe, internationally (e.g. Brijder, 2022). Similarly, we did not include whole-family residential responses to women who experience domestic violence and need shelter, which have more than a half-century of history and operate all across the world (Baker et al., 2009). We also excluded family-accepting homelessness programs (Bassuk et al., 2014), although family homelessness programs and SFC share the key characteristics of preventing mother-child separation. Finally, we excluded programs that included shared parenting in short-term assessment programs focused on whether parents should continue to care for their children or the children should be moved into out-of-home care.

For each of the 46 potential shared family care programs, we searched the internet and published literature for information about the program. We aimed to collect basic information on who is served through the program (i.e. the population), where it is located (i.e. the physical setting and type of living arrangement), what its focus or content is (i.e. programing goals and services offered), and how it is structured or administered (i.e. macro-level features). These domains have been used to describe and classify other program models, including family care programs (Allen & Larson, 1998) and alternative education programs (Aron, 2003), and have similarly served as a framework in our exploration of the current landscape of shared family care programs.

Analysis

For each of the programs, several rounds of coding were conducted. In each round, the available descriptive program material was coded in Microsoft Excel by at least two authors to ensure robustness. Overall, the coding process and analysis were treated as a heuristic process (Saldana, 2016). Initially, the 46 potential shared family care programs were coded by the authors according to whether the program places families together with their children in a residential program that offers some combination of parenting supports or mentoring, family-therapy, and a shared living environment for some or all days in a week (coded as “yes,” “no,” or “unsure”). For programs coded as “unsure” due to sufficient information to make this assessment, program staff were contacted to solicit additional information.

After discussing differences in coding and coming to consensus, 12 of the 46 potential shared family care programs were ultimately judged not to be shared family care under our definition. Exclusion reasons were: addressed parenting through intensive (community-based) in-home services rather than in an out-of-home setting (n = 7); residential placement of children alone, not together with their families (n = 3); focused exclusively on parenting assessment (n = 1) and focused exclusively on respite care (n = 1). In addition, four drug and alcohol treatment programs for pregnant and parenting women were excluded for the reasons described under “Procedures” and three programs were excluded because we had too little information available to code and efforts to contact program staff were unsuccessful. Finally, we decided to exclude non-operational programs, which led to the omission of four additional programs.

From the initial list of 46 programs, 23 operational programs remained that were considered shared family care, i.e. that offered some form of parenting support through out-of-home care. Despite the many differences among these 23 programs, some common elements at the core of these programs were apparent. Based on these common elements, through an iterative coding process, the programs were organized into three types of shared family care that are introduced and described fully in the Results section. Extended descriptions of a few active programs that typify each category are described as well.

Results

Three categories of shared family care interventions emerged from the review of existing programs. The categories differentiate the programs on the extent to which the program’s focus is on treatment rather than effective parenting as well as by whom the effective parenting behaviors are being modeled. The resulting three categories are:

1. Shared Family Foster Care (SFFC): sharing of care and intensive modeling of effective parenting by host families;

2. Shared Residential Care (SRC): sharing of care and intensive modeling of effective parenting by professional staff;

3. Family Residential Treatment (FRT) programs: specific therapies and support focused on parent/child well-being and/or parenting, often as part of intensive mental health treatment in a hospital or restricted setting, but no explicit sharing of the care of the children and intensive role modeling.

Across all three categories of shared family care programs, parents and children are placed together and thus maintain a household while concurrently working on their own personal issues through a therapeutic program. Shared Family Foster Care (SFFC) and Shared Residential Care (SRC) are similar in that parents receive feedback about their parenting and living skills on an ongoing, in vivo basis and across many and diverse parenting and living tasks. Both provide innumerable opportunities for observation and support of effective parenting. They differ in that SFFC families are temporarily placed in the home of a host or mentor family and SRC families come to live in shared housing on the grounds of a residential care center and share the care of the children with professional caregivers.

Furthermore, Family Residential Treatment (FRT) differs from SFFC and SRC because FRT does not include explicit sharing of the care of children with a host family (as in SFFC) or staff (as in SRC). FRT thus contains fewer opportunities for intensive role modeling and support of effective parenting within daily interactions, informal relationship building, and help with practical tasks of daily living. (Observations included informal interactions and via surveillance cameras.)

In FRT programs, families are supported through social work practice, peer support, and specific treatment approaches like individual therapy for the parent, child (e.g. play or creative) therapy for the child, or parent-child group therapies. Thus, parents do receive feedback from social workers and/or other parents on aspects of parenting and family functioning. However, this feedback on parenting skills is treatment focused, through training sessions, clinical debriefings, or, perhaps, more immediately when there is a crisis. It therefore differs from the direct and ongoing feedback that is so characteristic of SFFC and SRC programs. Table 2 describes the geographic location of the shared family care programs included in our review.

Table 2. Geographical location of shared family care programs (N = 23).

	Shared Family Foster Care (SFFC)	Shared Residential Care (SRC)	Family Residential Treatment (FRT)	Total
	N	N	N	N
North America	1	2	1	4
US	0	2	1	3
Canada	1	0	0	1
Europe	0	9	7	16
Sweden	0	1	0	1
The Netherlands	0	5	4	9
Switzerland	0	2	3	5
Italy	0	1	0	1
Asia (Middle East Region)	0	1	0	1
Israel	0	1	0	1
Oceania	0	0	2	2
Australia	0	0	1	1
New Zealand	0	0	1	1
Total	1	12	10	23

What Shared Family Care Programs Look Like

The 23 programs are geographically diverse in location, suggesting a wide reach for the idea of shared family care and the implementation of these programs. Appendix A provides a listing of each program by category and some descriptive information. Here, we summarize some of the key findings about these program characteristics.

The Population

The shared family care programs we found serve a diverse array of populations. Examples include: families of children with special needs (e.g., severe behavioral or psychiatric problems); families of parents who are facing significant adversities related to mental illness, addiction, and recovery, intimate partner violence, or limited cognitive functioning; often young (pregnant) parents; families at risk of separation and out-of-home placement of the child (i.e., families under pressure of authorities to improve the situation of the children, due to a concern for their development and safety); and families experiencing long term and complex problems in various areas of life (i.e., both behavioral health and social-economic).

Physical Setting and Type of Living Arrangement

The physical living environment is a key attribute of a shared family care program. There is wide variation in the types of settings where shared family care is provided. Examples of types of living arrangements we found include: Family homes that, akin to foster care or kinship care, deliver shared family care in a single-family home. Families live together with family foster parents or mentors; Supervised cottages or apartments on residential campuses. This type of living arrangement may provide proximity and connection to other families experiencing shared family care.

Programming Goals and Services Offered

The heart of the shared family care model includes the overall goals and day-to-day activities of the program. Although not all programs had a clear goal description, different programs focus on reducing parental problems and stress, improving parenting skills, and strengthening parent-child relationships. Through varied activities, any shared family care program can work toward these more implicit goals as well as its own more explicitly stated program goals. The types of activities we found included all kinds of intensive family support, such as intensive supervision and role modeling, coaching and mentoring of parenting skills; case management; quick access to a team of professionals. The programs also include different activities for the parents (e.g. parent support groups) and children (e.g. activities in a child-care center).

Program Descriptions

To further illustrate the three types of shared family care, we have provided detailed program summaries of a few existing programs.

Shared Family Foster Care

As Table A1 in Appendix A shows, we identified just one currently operating program that met our definition of shared family foster care.

Canada Live-In Family Enhancement (LIFE)

Live-In Family Enhancement (LIFE) emerged in Manitoba, Canada, to promote family enhancement in every phase of child welfare cases (Deane et al., 2018) for families seeking to re-unify. Metis Child, Family, and Community Services, an Indigenous agency, developed a shared family foster care model approach in which parents were fostered along with their children. The LIFE model had parents and children move in full time to a foster home together with a family mentor for 8–12 months (Metis Child, Family, and Community Services, 2014).

LIFE makes a range of services available for both parents and children, including coaching and support in parenting on a moment-to-moment basis, seven days per week. Families can also access attachment-based parenting training, anger management training, substance abuse relapse prevention, employment assistance, help with nutrition and budgeting, support with issues at school or daycare, and a range of other resources needed to become competent and nurturing families (Metis Child, Family, and Community Services, 2014).

The goals and focus of foster parent and staff activities include: (1) establishing predictable routines; (2) parenting practices; (3) building trust; 4) broadening the circle of support by repairing relationships; (5) managing the household; and (6) obtaining secure housing and income. The LIFE program is funded from per diem amounts normally paid to foster parents as well as stipend for food costs paid through Employment and Income Assistance for low-income households (Deane et al., 2018).

An evaluation study found that 27 families with 39 children were served in a 7-year period (2008-2015; Deane et al., 2018). Anecdotally, 75% of children whose families completed the LIFE program stayed with their families and have not re-entered care (LIFE Program Director, personal communication, August 9, 2018). LIFE also shows signs of additional benefit to families such as stronger parent-child attachment, improved parenting skills for caregivers, strengthened social support for families, and newly acquired household management skills.

Shared Family Residential Care

We identified 12 programs that met our definition of shared family residential care (see Table A2 in APPENDIX A for more details). We have provided a detailed summary of just one (based on Tener et al., 2018 and interviews with program developers) because it is a longstanding program and one that demonstrates the use of several kinds of staff – from volunteers to licensed clinicians – of staffing shared family residential care.

Israel’s Shabtai Levy Mothers’ Unit works with mothers on the brink of losing their children to foster care. The program houses 8–10 women and their children up to age 6. Participants must demonstrate an interest in retaining custody of their children and be part of a community with other women. Mothers generally stay for over one year before returning to independent living in the community. At times, mothers choose to discharge from the program without their children. (The children, then, enter foster care).

The Mothers’ Unit is located in a very large apartment with an attached Kindergarten. Each mother gets a room for herself and her child and can access the shared living space. Activities include dyadic and group training on life skills and parenting. The activities strengthen women’s psychosocial well-being and boost capacity to manage the pressures of group living, uphold high expectations for parenting, and transition to maintain a healthy family life in the community. Mothers receive a stipend that covers their housing costs and provides an opportunity for learning budgeting.

The Mothers’ Unit has many volunteers and two types of professional staff: social workers and paraprofessionals. Social workers facilitate the therapeutic and educational groups. Paraprofessionals are a blend of homemakers, coaches, and care coordinators. They work 8-h shifts alongside the women to help them learn the basics of managing a household, feeding their children healthy meals, providing structure and affection to their children, and developing bedtime routines.

In a study by Tener et al (2018), preliminary findings suggested that the Mothers’ Unit is cost-effective in helping women maintain the custody of their children and to live safe lives. The Mothers’ Unit allows these women to address prior trauma and find a safer path forward. Anecdotally, former residents return to visit the Mothers’ Unit for events and check in with staff and volunteers with whom they have important relationships.

Family Residential Treatment Programs

We identified 10 programs that met our definition of family residential treatment (see Appendix A).

Psychiatric Clinic Thurgau

The Psychiatric Clinic in Thurgau, Switzerland, provides inpatient treatment to mentally ill mothers or fathers (not parents together) and their young children (age 0 to 5). The length of stay is three months on average and determined based on the needs of each family. The program has the capacity to serve five mothers or fathers with their child (maximum two children) at a time.

The Psychiatric Clinic provides therapeutic activities for both the parents and their children. For the parents with mental health needs, they can participate in individual, couple, family, and group therapies, art, music, and movement therapy, psychopharmacological care, relaxation exercises, talk groups, mindfulness groups and skills groups, and sports. Children can participate in play therapy, physical, speech and occupational therapy, and creative arts therapies. Day-to-day care is provided by a day-care center within the ward, which offers the children an age-appropriate daily routine with room for social and creative development. Therapies that promote parent-child interaction are also provided.

A variety of professionals are involved with the treatment. These include therapists and other mental health providers. There is a team of child and adolescent psychiatrists, psychologists, social workers, and early childhood educators who are available to treat the children. They try to strengthen the parents’ skills and to support their needs. In the context of the day-care center, the parents learn how the early child educators works with their child. Day-care is provided to the children for 5 hours a day. The treatment costs for the parents are fully covered by the health insurer for the parent. Parents have to pay a treatment fee of 50 Swiss franc per day for each child. The remaining costs are covered by the Psychiatric Clinic. At this time, there are no outcome data available.

Discussion

The aim of this paper is to describe the current landscape of shared family care programs, serve as a starting point for establishing common terminologies to characterize the various kinds of shared family care programs, and to provide illustrations of programs in each of the three identified subcategories of SFC. We also described some existing models of shared family care. Results from our investigation led to several conclusions, as described below.

We found three categories of SFC. However, the prevalence of these subtypes varied, with only one SFFC program, 11 SRC programs, and 14 FRT programs. We noted that although in each shared family care program the family, as a collective unit, is the putative client, the need for shared family care may be driven by the child (e.g. severe behavioral or psychiatric problems), parent(s) (e.g. mental illness), or some combined dynamic (e.g. safety risks in the family). Shared family care programs generally identified themselves as serving clients or families with a particular problem, e.g. teen pregnancy and parenting. In reality, however, families in shared family care programs are likely to face multiple and complex challenges (cf. Allen & Larson, 1998).

The population of focus or expressed need is likely to determine the explicit goals of any shared family care program. However, there were some common features found across the different shared family care programs we examined: addressing the intergenerational cycle of family dysfunction; protecting children’s safety; encouraging parents to get help and remain in treatment and related services; strengthening the parent-child relationship and helping parents prepare for living independently (Allen & Larsen, Allen & Larson, 1998, p. xiv-xvi).

Despite the long-held belief, beginning in 1970s, that shared family care programs meet the critical needs of children, families, and service providers, we found only a few dozen shared family care programs currently active around the world. Indeed, the activity in the U.K., Sweden, and the U.S. that originated in the 1990s and 2000s had largely dissipated.

Most evident of this lack of momentum was that we found only one active shared family foster care program. In talking with providers interested in this program model, we identified a practical challenge that may limit shared foster family care. Specifically, licensing regulations allow foster families to host several unrelated foster children; however, if children are placed in the foster home with their biological parent, it becomes more difficult for any other foster children to be hosted in that home. Given the limited number of foster families, agencies prioritize hosting youth over whole families to serve more clients.

We saw more activity in the shared residential family care sub-sector with a robust expansion in the U.S. among the Baptist Children’s Homes. These programs retooled their physical plants previously focused on housing only children and retrained their staff to model parenting and support families, suggesting a path for other traditional residential care programs. Although the Baptist Children’s Homes funded these shared residential family care through philanthropic donations, programs in the US could also consider exploring funding supports through Family First.

Through our review, we identified that Family Residential Treatment Programs have the most significant international presence. These programs can accommodate a wide variety of client populations and treatment needs. Considering the value of the family in promoting therapeutic healing, keeping parents and children together during intense treatment services may increase the effectiveness of clinical progress and decrease trauma. However, none of the programs have existing research outcome data. Therefore, we recommend evaluation studies with rigorous designs. First, though, the likelihood of support for scaling up, or at least maintaining smaller programs, needs to be established in each jurisdiction endeavoring to create such a program.

We had expected to find more Shared Family Foster Care programs than we did. We know that many families informally take in their extended and fictive kin when there is a crisis and had seen that recruiting families to provide SFFC was not difficult (Barth & Price, 2005). The challenges of starting and maintaining SFC programs is, however, much larger than a staff recruitment problem. Indeed, the Texas Baptist Children’s homes (Gibson & Noble, 1994) were able to reduce staff when they converted their children’s cottages to family cottages because they could rely on parents to help look after the children and could end overnight supervision.

We also came to understand, from our interviews, that holistic funding for whole families is difficult as budgets are often sliced up between parent programs (e.g., housing and domestic violence shelters), children’s programs (residential treatment, education, and children’s behavioral health). Considerable effort is needed to blend funds. This effort tends to dissipate over time and with changes in personnel in the conventional parent and child serving programs. Also, the logistics of housing are increasingly difficult. Parents who have housing may be reluctant to leave it in order to move into an SFC program – for fear of not being able to find something similar after their stay. Finding housing stock for the program, itself, is also a challenge. LIFE, described above, has thrived despite these constraints because housing is set aside for First Nation families and has been allocated for use in their SFC program (Deane et al., 2018)

One of the longest standing US programs, SHIELDS for Families, operated for 25 years providing family-centered treatment and services in an 86 unit apartment complex (Icenhower, n.d.) but was eliminated when Los Angeles County received federal funding to focus on adult substance use disorder treatment. One of the few programs that seems to be growing is the Baptist Children’s Shared Family Care program, which began in Texas, and has spread to other states – all funded by donations to Baptist Children’s Homes.

Despite the conceptual appeal of shared family care, our exploration uncovered little empirical evidence of their efficacy. We believe this will change as the concerns about the high costs and modest benefits of separating children from their parents continue to be captured and as the parental advocacy movement expands across the globe (International Parent Advocacy Network, 2022). Although living under the rules of a shared family care program is not going to address those who perceive governmental supervision as a violation of parental rights, these programs do endeavor to offer an alternative to the separation.

We are a long way from answering the question of which type of shared family care program works for what “kind” of family. Indeed, we have limited evidence to go on to recommend expanding access to SFC. The basic premise that the best interventions build skills for use in environments that best approximate the circumstances in which they will be most needed, is still the strongest argument for SFC expansion. Existing programs should be encouraged to conduct systematic inquiries to build knowledge about both the implementation of shared family care programs as well as measuring the outcomes of families served. Evidence of post-placement safety, stability, and well-being for both parents and children would strengthen the case for this program model.

Current or developing shared family care programs could also benefit from a membership organization or subgroup within an existing membership organization. In the U.S., the Association of Children’s of Residential and Community Services (ACRC) might be a logical home, given their international reach and current membership of residential programs. A membership organization can both support the existing members in networking and sharing knowledge and also support the development of emerging programs. The three subtypes of programs identified in this paper could be further scrutinized and, if sustained, lead to corresponding best practice models.

In conducting our analysis, we encountered several limitations. Although we attempted to complete a systematic search of current programs, we recognize that our results are likely not exhaustive of all programs, especially outside of English-speaking contexts. Shared family care programs may exist that are not represented in our typology. Our efforts to categorize each program into one of the three typologies we identified was imperfect. We often wished to have more information about each program than what was available. Studies that compare outcomes or costs are almost entirely missing from the literature. The role and function of staff within programs were of greatest interest to our analysis but were often the most difficult details to discover.

Next Steps

This review may help policymakers and program administrators who are interested in shared family care to contact the identified programs that might be well suited to implementation in their jurisdictions. Current programs are encouraged to partner with researchers and evaluators to identify program elements and measure outcomes. Government agencies and NGOs are looking for innovative ways to respond to families – many of them families of color, who have experienced considerable oppression – in the least traumatizing way, possible. They may have a new openness to shared family care. Given the implementation of programs by agencies that also provide child-only residential or family foster care, it may be possible to conduct two-group comparative designs or even possibly randomized-controlled trials. Even if rigorous research designs are not widely feasible, there is much to learn about what key dimensions of programs result in successful reunifications and transitions back to community living. Some attention to describing, in more detail, what might be the common practice elements of shared family care can build on the findings in this paper. Yet, without outcome research, the possibilities of a deeper understanding of which program elements are most influential will remain beyond our reach.

As there is international interest in this innovation, we would encourage one of the international organizations concerned about out-of-home care to take leadership in developing some elements of what going to scale might involve. These would include holding research meetings, establishing an implementation clearinghouse, finding ways to flexibly fund SFC, and taking a look at how these family-centered programs align with those for substance use disorder, intimate partner violence, and homelessness.

Shared family care will not expand and achieve its potential without policy support. Recent legislative efforts in the United States, like Family First Prevention Services Act (FFPSA), explicitly aims to prevent youth from being placed away from their family and thus may be philosophically aligned with the ideals of shared family care. Further, FFPSA has limited youth placement in residential programs, which has created interest from residential providers with a physical plant to support congregate care models to consider re-tooling their services. Yet, the expectation that programs can prove their efficacy – without a source of funding for the necessary research work – is daunting. A targeted demonstration program to expand and test SFC approaches would be a valuable next step.

Disclosure statement

No potential conflict of interest was reported by the authors.

APPENDIX A:

Characteristics of Shared Family Care Programs by Type

Table A1. Existing shared family foster care programs.

SFC program	Population served	Physical setting	Programming goals and activities
(1) Live In Family Enhancement (Canada LIFE program)	(mostly indigenous) parents at risk of neglect or having youth placed into care	Families live in a foster home together with a family mentor	Provide supports around trauma, loss, substance misuse, and domestic violence (see more details in paper).

Table A2. Existing shared family residential care programs.

SFC program	Population served	Physical setting, Personnel & Duration	Programming goals and activities
(1) Family Care Program (Texas Baptist Children’s Home, US)	Vulnerable children and families referred by church or providers	Up to 5 families housed in each cottage with resident staff supervision and role modeling	Children often attend public schools, parents attend High School or employment classes. Program includes group work, parent training, and religious services (see more details in paper).
(2) Family treatment program (Ranch Ehrlo Society, US)	Families wishing to reunite with child(ren) in care	Each family has their own home, with their own keys. Staff available 24/7 as needed, but will only come as scheduled or invited.	Many structured activities: group sessions: parent support/education group; recovery group; horse therapy; writing group; compassionate parenting.
(3) Shabtai Levy Mothers’ Unit (Israel)	Mothers assessed as neglectful or physically and emotionally abusive toward their child(ren)	Eight to ten women reside at the unit at any given time, with up to two children each.	Treatment includes individual emotional, dyadic and group therapy; skills training for cooking, budget management, and relationships (see more details in paper).
(4) KINGS (Accare, the Netherlands)	Children with severe behavioral problems and their parents. The children and their parents are often facing significant adversities.	Each family lives in separate inpatient living unit. Therapy sessions and meetings are held in a central building. Family caregivers are available all day and on call at night.±6 week inpatient program.	Intensive EMDR trauma treatment for parent and child. Family caregivers have experience with cognitive-behavioral training and trauma-sensitive care. Caregivers train parents in validating positive child behaviors by using video feedback.
(5) Family training program Heizenholz (Switzerland)	Families with concerns about child well-being or to manage child behavior.	The center can accommodate up to 6 parents with children.	Parents facilitate changes in the situation of their children through discussion with staff, peer support, shared daily living, and trying out new problem-solving skills.
(6) Aeschbacherhuus Eltern-Kind Angebot [parent-child program] (Robert Aeschbacher-Stifting, Switzerland)	Parents and pregnant mothers who need help for themselves and their child and want to accept it.	The building complex includes four children’s living groups, several apartments, a large garden with a swimming pool, playgrounds. Ideally, a stay should not exceed one year.	Parents receive support in childcare, living, and parenting skills. Collaboration with the parents, their environment, their families and external care providers. Parents engage with the outside world (work, employment, further education etc.), children are looked after in the day-care center or attend public school.
(7) Gezinsbehandeling [Family treatment] Harreveld (Horizon, the Netherlands)	Parents are not capable of raising their children (0–18 years old), due to child’s behavioral problems, struggle with problems themselves and/or financial problems	Families live temporarily at one of three locations. Once every two weeks the families are allowed to go home for a weekend, so they can practice what they have learned.	Program works to calm the family, reduce parents’ stress, strengthen (parenting) skills, engage a social network that can support the parents in parenting, and reduce the behavioral problems of the children. Aftercare is provided to maintain the improved family situation.
(8) Baby House foundation (Netherlands)	Mothers who need temporary extra support in caring for their baby.	11 mother-child units divided into 3 phases of intensive support toward independence.	The Mother-Child Unit aims to offer (expectant) mothers shelter and support before, during and after the birth of their baby. The mother receives guidance in caring for the baby, creating a secure bond, and building a social network. Biological fathers can also be involved.
(9) Investigation flats (Sweden)	Families with allegations of maltreatment.	This facility is used as both a day treatment and 24-hour residential setting. The family stays, with social workers and care workers, for about four weeks	During the time spent in the investigation flat, the child’s and family’s situation are assessed. There are also elements of casework and family group work services.
(10) Gezinsopname [Family admission] (Mereo, the Netherlands)	Families with parenting issues, excluding parents with serious psychiatric of addiction problems	Farmhouse in the countryside, short-term intensive family admissions of five days.	Through making parents aware of their behavior and giving insights into mutual communication with their children, the family can start to acquire new behaviors. The program offers several fixed components such as the videotaping of breakfast conversations.
(11) Yulius Family Treatment (Gezinsbehandeling the Netherlands)	Families with stress on multiple domains.	Families live in own apartments for an average of 3–4 months. no 24/7 supervision, but family therapists can observe (in consultation with the family) via a one-way screen.	Treatment focuses on various aspects of the family (see more details in paper).
(12) Communities for pregnant women and mothers with children (Bologna, Italy)	Pregnant women, including minors, and single-parent families, struggling in carrying out parental duties; may have court involvement.	Two residential care units (rural and small town locations) structured as a big house with a lot of bedrooms, one for each family and some shared rooms (kitchen, bathroom, living room, garden). Rotating 24/7 staff. Families stay about 14 months, ranging from a few weeks to 45 months.	Mothers are supported in their parental roles with individual psychological support if needed, focused on their past, childhood, parenting problems or sometimes trauma. Group support is also provided.

Table A3. Existing Family Residential Treatment (FRT) programs.

SFC program	Population served	Physical setting, Personnel & Duration	Programming goals and activities
(1) Mutter Kind Haus (Switzerland)	Pregnant women and women with their children who need protection	Inpatient house offering living space for seven woman and eight children	Promote development of the child and mother by well-trained, experienced staff who accompany the women in socio-pedagogical, educational, social and economic areas.
(2) Psychiatric Clinic in Thurgau {Station für Eltern Kind-Behandlung Switzerland), https://www.stgag.ch/fachbereiche/psychiatrische-klinik/psychiatrische-klinik-muensterlingen/psychotherapie/station-fuer-eltern-kind-behandlung/	Mentally ill mothers or fathers with children aged 0–5	Inpatient treatment unit with four mother/father – child treatment places.	Diagnostics and therapy for parent as well as the child and the parent-child interaction (see more details in paper).
(3) Behandlung von Müttern mit Baby [Mother-Baby treatment] (Klinik SGM, Switzerland)	Mothers with a mental illness who require inpatient treatment with babies	Inpatient stay (for up to 12 months). Single rooms specially tailored to needs of mothers and babies.	Support, advice and special therapy supports the mother’s recovery and the relationship with her child. The baby is looked after during the mother’s therapy times so she can concentrate on regaining stability.
(4) Family inpatient treatment [Gezinsopname] (Plinthos, the Netherlands)	Families that suffer(ed) severe domestic violence and families where postpartum depression paralyzes the life of mother, child and the whole family.	Short-term inpatient treatment	Strengthen parenting and restore safety through psychiatric treatment using interactions within and outside the family.
(5) Clinics De Stee & De Bron, Expertise Center for Treatment and Assessment of Parenting and Psychiatry (GGZ Drenthe, The Netherlands) https://ggzdrenthe.nl/media/01-folders/folder-informatie-voor-verwijzers-gezinspsychiatrie-g-gp009–0714.pdf	Families with babies (0–2) or children (3–12) facing adversities that impair family functioning, development, and/or safety.	Each family has their own bedrooms, toilet and shower. Families share a living room, dining room and kitchen. One apartment allows independent living to be practiced. Family trainers are present during the day and night. Treatment duration is about 4 months.	Obtaining a clear perspective for the child or children growing up at home with their parent(s) or (partially) with other caregivers. Parents have the optimal opportunity to learn and grow in parenting. The parent(s) can demonstrate that they can grow into a “good enough” mother or father.
(6) Granger Grove family care program (Unnamed NGO, New-Zealand)	Mothers who have experienced significant abuse, trauma, transience and instability and their children (0–5)	Mothers and children live in two-bedroom units with their own bathroom and a communal dining room, kitchen, lounge and laundry. Staff are available 24 hours a day to offer guidance and help.	Mothers learn new parenting and life skills and how to deal with health problems, access community resources, sort out relationships and gain an understanding of domestic violence, child abuse and trauma through educational and therapeutic classes and individual therapy for themselves and their children. Children attend an on-site preschool.
(7) Gezin Total, family treatment [Family Total] (Horizon, the Netherlands)	Families with long-term multiple and complex problems (psychosocial and/or psychiatric and social-economic), with children aged 0–18 years old.	Family treatment for 12 weeks. A family mentor is present in the family for six hours a day, phasing out to two hours a day. Maximum duration of 6 months.	Main goal is that the family has control over their own family life, in which the best home for all family members is chosen and realized. Residential family treatment can be part of family exploration phase (one week) or a “formation phase.”
(8) San Miguel Family Center (Yourtown, Australia)	Young homeless parents (up to 25 years old) and their children	Up to 3 years of fully furnished housing for up to 21 families, followed by up to 3 years of outreach support. Facilities include an activity center, swimming pool, children’s playground, tennis courts, and a community garden.	Help families tackle homelessness and underlying issues by offering a stable home, social interaction with other young families, skills for independent living, child development support, expressive therapy, play groups, counseling and advice.
(9) High and Intensive Care (HIC) Youth (Yulius, The Netherlands)	Young people from 12 years old with acute, serious psychiatric problems and their parents	Short clinical admission of a few days, in which one of the parents is present and stays with their child constantly.	To stabilize the crisis and offer peace. Parents are actively involved in the treatment by the family therapists, nurses, and sociotherapists.
(10) CHARM, LUND’s residential care program (Collaborative Burlington, USA)	Women who are expecting or have recently delivered babies and have a history of opioid use disorder	Residential care for moms and babies.	Moms receive intensive treatment structure, and safety via an inter-disciplinary team. Activities include nurse home visiting, outpatient substance abuse treatment, economic support, peer support, parenting education, children’s services and emergency needs, incentives.