Are We Practicing What We Preach? Family Partnership in Therapeutic Residential Care for Children and Youth

ABSTRACT

This study presents a tiered conceptualization of family partnership developed by the Family-Run Executive Director Leadership Association (FREDLA) with examples of strategies from the literature. This sub-study was part of an overarching systematic review project that aimed to review the literature on family partnership in relation to youth outcomes. The tiers of family partnership include family involvement (i.e. family’s inclusion in their child’s care); family engagement (i.e. collaboration between TRC and families); family-driven (i.e. families as full partners). This review included thirty studies (n = 23 family involvement, n = 7 family engagement, n = 0 family-driven). The most common family involvement methods were family therapy and family visits to the program, primarily, delivered face-to-face. The most common family engagement method was activities, therapies, and skill building occurring at the home with family present. Methods of measuring family partnership primarily included the use of administrative data. Implications for research and practice include the provision of research that evaluates the effects of family partnership on outcomes important in the TRC setting and the development of research-practice and family-research collaborations to increase the uptake of effective family partnering methods.

KEYWORDS:

• Family engagement
• residential care
• family involvement
• residential treatment
• youth

Therapeutic residential care (TRC) plays an important role in the healthcare continuum providing mental health services for children and youth who experience severe mental, emotional, and behavioral challenges. The International Work Group for Therapeutic Residential Care proposed key principles for TRC programs serving high-risk youth, including the use of a “multidimensional living environment designed to enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs in partnership with their families and in collaboration with a full spectrum of community-based formal and informal helping resources (Whittaker et al., 2014, p. 24, emphasis added) .” A key component of this definition is family partnership which has garnered increased attention from families, youth, advocates, TRC programs, and policymakers.

For decades, there have been calls for increased family partnership in the TRC setting (American Association of Children’s Residential Centers, 2009b; Blau et al., 2010). In this developing body of evidence, there is conceptual confusion on what family partnership in TRC involves. This study presents a tiered definition of family partnership (involvement, engagement, driven) that reflects variance in authenticity and intensity. The definitions and associated methods applied in the research were derived from the Family-Run Executive Director Leadership Association (FREDLA), a national family-run organization and association of local and state family-run organizations supporting families of children and youth with mental health challenges. In this sub-study of a larger systematic review project, we reviewed studies focused on family partnership in reference to youth outcomes in the TRC setting and categorized family partnership methods into tiers based on the definitions provided by FREDLA (Family Run Executive Leadership Association, 2023). A tiered conceptualization and associated family partnering methods were applied to determine how consistent extant research is with consensus-based best practices called for by major national advocacy organizations (e.g., The Association for Children’s Residential & Community Services and Building Bridges Initiative).

Best Practices Call for Increased Family Partnership

Advocates and social movements have stressed the value of family partnership for decades (Carey et al., 2019). Of key importance is the Family Movement, a sub-arm of the larger Disability Rights Movement that began as early as the 1940s in multiple countries, including England, France, Australia, Canada, and the US (Carey et al., 2019). The movement’s battle cry, “nothing about us without us,” was a call to action for the active participation of families through shared decision-making in children’s care (Carey et al., 2019). The gray literature (i.e., materials produced by organizations outside academic settings) has also argued for greater family partnership in TRC for years. There are multiple reports on the benefits of family partnership, including how to bolster family partnership in various settings, including TRC (American Association of Children’s Residential Centers, 2009a, 2009b, 2009c; Blau et al., 2010; Building Bridges Initiative, 2012). One organization that has produced several reports illustrating the role of family partnership is the Building Bridges Initiative (BBI). BBI provides a framework for addressing the gap between TRC and community-based services, particularly around length of stay, collaboration, transitional support, and care philosophies. BBI principles include family-driven and youth-guided care, cultural and linguistic competence, clinical excellence and quality, accessibility, and community involvement (Blau et al., 2010).

In one report, BBI highlights existing literature (Building Bridges Initiative, 2015) by reporting that consistency and frequency of contact between youth and the family are important for reunification and program completion (L. J. Lee, 2011; Leathers, 2002; Sunseri, 2001). Further, while many youths do reunify with their families of origin, it is critical for all families to maintain a level of contact, if safe to do so, because the family’s well-being influences the placed child, even if the child is not being reunified (Geurts et al., 2012). Further, having ties to their family of origin provides the child with “personal history and identity” (Mapp & Steinberg, 2007). BBI suggests that for TRC programs to find and engage families, a paradigm shift must occur in which there are unconditional family connections, a focus on permanency, prioritization of family-finding efforts early, and engagement of community partners in these efforts (Building Bridges Initiative, 2015).

The Association for Children’s Residential & Community Services (ACRC) published several position papers highlighting that TRC programs needed to redefine themselves to become more engaged in their local communities and shift to a family-driven approach (American Association of Children’s Residential Centers, 2009a, 2009c). In a family-driven approach, organizations no longer provide services to families but instead fully partner with families and view families as experts who drive and guide care (American Association of Children’s Residential Centers, 2009c). The rationale behind moving to family-driven care is that this method facilitates equal partnership promoting healing, reduces marginalization and isolation, and families are viewed as experts providing important information and feedback (American Association of Children’s Residential Centers, 2009a).

Multi-Level Influences on Family Partnership in TRC

While there have been recent efforts to increase family partnership in TRC, there is ambiguity around how family partnership is conceptually defined and operationalized in the research and, therefore, in practice. Carman and colleagues (2013) describe the continuum of family partnership with the understanding that partnership is individualized because some families may have restrictions on involvement due to custody or other issues. Rather, considerations such as interests, goals, capacity, and potential legal restrictions must be considered in deciding which partnership level works for individual families (Carman et al., 2013). The three nested concepts influencing family partnership are grouped into child/youth level (referred to as patient in Carman, et al.“s model), organizations, and society (Carman et al., 2013). At the child/youth level, multiple individual and family factors influence the partnership, such as motivation, knowledge, attitudes, and beliefs. Also critical is the family’s prior experience with the child-serving systems, which include child welfare, juvenile justice, education, and behavioral health, which may be especially stigmatizing and challenging to navigate for the families who access TRC (K. Herbell & Banks, 2020). The organization’s characteristics also influence how much family partnership is actualized. Policies, practices, and organizational culture strongly influence families” ability to engage and their perception that their input is valued and used for change (Carman et al., 2013). Policies promoting family engagement include open visitation, consistent contact with the care team, teletherapy for families who cannot physically be present, and family-centered discharge planning. The societal level recognizes that families and organizations are nested within a broader socio-political environment influenced by laws, insurance payers, and social norms (Carman et al., 2013).

An Australian scoping study of family partnering in TRC (McNamara, 2020) identified trust building between staff and family caregivers as fundamental to effective partnering. Findings suggest that staff expertise in, and commitment to, building strong relationships between parents and children and within sibling groups or significant others, is critical. Healing family trauma and estrangement can be supported by ensuring optimum family access and inclusion within the program. Inviting families to participate in meals and outings was an example of this. Whole family admissions (i.e., therapeutic work with all family members) and therapeutic work within the family home were also beneficial. Those practices are also profiled in recent Australian case studies published by McIlwaine et al. (2020) and Seymour et al. (2020). The Australian scoping study (McNamara, 2020) suggests that equity and empowerment strategies, especially collaborative decision-making, can support diverse family, family-like, and community relationships. The voices of advocates and families are clear that family partnership is critical in TRC. In this study, we draw on a larger systematic review project and present examples from the literature that exemplify the different family partnership methods.

Conceptualization of Family Partnership Tiers and Study Purpose

To understand family partnership and its operationalization, our research team partnered with FREDLA, the national representative and advocate for family-run organizations and their executive directors in the United States. FREDLA provides technical assistance, education, and expertise on policies affecting children’s mental health care systems. FREDLA developed the tiered conceptualization of family partnership and categorized family partnership into individual, programmatic, and organizational levels (see Figure 1; Tolou-Shams et al., 2022). The individual level, called family involvement, is concerned with the family’s involvement in their child’s care. Involving the family is typically the responsibility of TRC staff and includes maintaining contact with the family, family therapy, or parent training. Family involvement may also include collecting data from children and families pre and post-admission to develop an understanding of parent participation or satisfaction with their child’s program.

Figure 1. Family partnership: What does it look like in residential care?.

The second level, family engagement, refers to mutual, respectful, and culturally responsive relationships at the program level between families and staff that are goal-directed to enhance child and family well-being. From a data-driven standpoint, family engagement includes collecting data from children and families to improve the services and supports provided in TRC continually. Family-driven is the third level and incorporates families as full partners in all service planning, delivery, and evaluation. Families are recognized as eminent experts on their children; therefore, they drive the decisions regarding the services and supports they receive and inform and evaluate the available services and supports offered to families. The premise for this sub study arose from a systematic review project that aimed to synthesize studies that explored the relationship between family partnership and youth outcomes (e.g., educational, social, mental well-being, and behavioral). The purpose of this sub study was to describe the different levels of family partnership and provide exemplars of family partnership methods from the literature.

Methods

Parent Systematic Review Procedures

To identify studies for the larger systematic review project from which this sub-study was derived, we first searched the literature using the following databases: CINAHL, SCOPUS, PubMed, Web of Science, Medline, Psych & Behavioral Sciences Collection, and Psychinfo. The literature search was completed in November 2020 with no date restrictions. The research team created a list of terms that addressed the research question, including youth, mental health, TRC, and family partnership. The team generated a list of search terms and expanded the search terms list using keywords from published literature. The string of search terms included (Child* or young person or teen* or youth* or young people or juvenile adolescen*) AND (behavioral problems, social-emotional problems, externalizing, internalizing, behavio* problems, aggres*, violen*, criminal behavio*, antisocial behavio*, delinquen*, anxi*, depress*) AND (residential treatment or residential care or residential placement or residential intervention or group home or congregate care or residential facility or looked after children or out of home care or therapeutic residential care or specialist residential care or residential children’s home or residential home or edge of care or institutional care or 24 h settings or family style group care or family type home or family home) AND (family-centered or family centered or family engagement or family involvement or parent involvement or parent engagement or parent support or family participation or family driven or family focus or family partnering or parent liaison or parent peer coordinator or therapeutic specialist or family oriented or family outreach or family navigator or family allied or family based or working with families). The Boolean operator “NOT” was used to exclude studies: (geriatric or elder-care or palliative or end-of-life).

Covidence facilitated the literature review. Covidence is an online platform streamlining identifying, screening, and selecting studies. Eligibility criteria for the parent systematic review project were: a) the focus was on children and adolescents with mental, emotional, and behavioral disorders; b) inclusion of a family partnership program or practice; c) examination of the relationship between family partnership and youth outcomes, and d) setting is TRC defined as living environments that “enhance or provide treatment, education, socialization, support, and protection to children and youth with identified mental health or behavioral needs in partnership with their families (Whittaker et al., 2014, p. 24).” Case studies, literature review articles, conference proceedings, and studies focused on populations or settings such as educational residential care, juvenile justice-focused residential care, or substance-use-focused residential care were excluded. In the title and abstract screening phase, two study team members independently assessed the studies for alignment between the a priori eligibility criteria. Studies in which both reviewers agreed that the study met eligibility criteria moved forward to the full-text screening. When there was a disagreement (i.e., one person voted that the study met eligibility criteria, and another voted that the study did not meet eligibility criteria), a third-party tiebreaker reviewed the title and abstract and determined if the study met the eligibility criteria.

Sub-Study Procedures

From the included studies in the parent systematic review, we selected a subset of studies to exemplify different family partnership methods. Two team members independently extracted each article. Information that was extracted included study details (e.g., design), TRC program details (e.g., program size), sample (e.g., sample size), family partnership tier (i.e., family involvement, family engagement, family driven), and associated methods. As with the title and abstract screening and full-text screening, conflicts in extraction were resolved via discussion and consensus among team members. Categorizing studies into pre-defined family partnership tiers was a challenge in that some studies did not cleanly fit into one category. For example, some studies described phone calls and family visits (family involvement) and activities that occur at home with the family (family engagement). The study team collectively examined the family partnership methods described in each study and came to a consensus on studies that fit criteria for more than one family partnership tier. Studies that had elements of family engagement were classified as such even if they had elements described in the family involvement tier. We used descriptive statistics (frequencies, percentages) for this analysis to describe the family partnership tiers, associated methods, and measures.

Results

Of the 30 studies included in this literature review, 23 met the definition of family involvement, and seven met the definition of family engagement. No studies met the criteria for family driven. Table 1 displays the included study’s family partnership tiers and the associated methods.

Table 1. Family partnership tiers and associated methods.

Authors and year	Family partnership tier	Methods
Vander Stoep, Bohn, & Melville, 1991	Involvement	Family therapy
Baker and Blacher (1993)	Involvement	Phone calls, Family visits the program, Youth goes home for visit (staff present), Family has opportunity to provide input (i.e., care planning), Parent support groups
Carlo (1993)	Involvement	Parent training (e.g., didactic learning opportunities through parent educational support groups), Family visits program (e.g., experiential learning opportunities such as participation in birthday parties or meal preparation), Youth goes home for visit, Parent support group
Savas et al. (1993)	Involvement	Family therapy, Phone calls, Family visits program, Other: Contact between family and staff
Laufer (1994)	Involvement	Youth goes home for visit
Tam and Ho (1996)	Involvement	Family therapy, Phone calls, Family visits the program, Youth goes home for visit, Other: Family signs consent form at admission; Contact between staff and family
Leichtman and Leichtman (2001)	Involvement	Family therapy, Other: Orienting staff to communicate with family; Counseling adolescents to deal with family issues
Landsman et al. (2001)	Involvement	Family therapy, Parent training (i.e., parent empowerment through skill building), Transport for families to attend events, Phone calls, Family visits the program, Youth goes home for visit, Other: The REPARE model integrated parents into TRC and TRC staff into homes, seeking to ensure a smooth transition for parents and children.
Lakin et al. (2004)	Involvement	Family therapy, Phone calls, Family visits the program, Youth goes home for visit
Ryan and Yang (2005)	Engagement	Activities, therapies, & skill building happen at home with the family present, Family therapy, Phone calls, Family visits the program, Youth goes home for visits
de Boer et al. (2007)	Involvement	Family therapy, Parent training (e.g., parent coach), Phone calls, Family visits the program, Family has opportunity to provide input (e.g., care planning meetings), Support groups, Other: Contact between staff and family; Daily journal completed by staff and given to parents; In-home support
Grupper and Mero-Jaffe (2008)	Involvement	Phone calls (tied to youth behavior), Family visits the program (e.g., family days and summer camps), Youth goes home for visit
Tahhan et al. (2010)	Engagement	Activities, therapies, & skill building happen at home with the family present, Family input into types of services offered frequency of services/supports, and modality of services/supports, Families leading training events for families, Families provide recommendations, RT provides resources for family chosen trainings and programming, Parent education groups and conferences designed to review child’s progress
Holstead et al. (2010)	Engagement	Family input into types of services offered, frequency of services/supports, and modality of services/supports (i.e., families had complete and full access to youth allowing for visits any time of day), Activities/therapies happen at the home with the family present, not just at the TRC, Families provide recommendations, RT provides resources for family chosen trainings and programming, Families co-lead programming (i.e., Families were viewed to be the leaders of the team)
L. J. Lee (2011)	Involvement	Family therapy, Family visits the program, Youth goes home for visit
McConnell and Taglione (2012)	Involvement	Family therapy, Parent training, Phone calls, Family has opportunity for input, Other: Clinical consultation (i.e., ongoing, frequent, and purposeful collaboration with all members of the youth’s care team)
Madden et al. (2012)	Engagement	Family input into types of services offered, frequency of services/supports, and modality of services/supports (i.e., Wraparound service model that (1) works with the family to develop a plan of care for the child based on the family needs and strengths; (2) assists the family in problem solving; and (3) provides on-going support to the child and family prior to reunification during the planning phase, as well as once the child is reunified with the caregiver and reintegrated into the community), Activities/therapies happen at the home with the family present
Trout et al. (2012)	Involvement	Family therapy, Parent training (Common Sense Parenting), Other: Family consultants
Robst et al. (2013)	Engagement	Activities, therapies, & skill building happen at home with the family present, Family therapy, Phone calls, Family visits the program, Youth goes home for visit, Family has opportunity to provide input (i.e., care planning)
B. R. Lee et al. (2013)	Involvement	Family has opportunity to provide input (i.e., Family involvement meetings were scheduled for youth transitioning to develop a transition plan using shared decision making. Meeting included family members, professionals, and child)
L. J. Lee (2013)	Involvement	Phone calls, Family visits the program
Robst et al. (2014)	Engagement	Activities, therapies, & skill building happen at home with the family present, Family therapy, Phone calls, Family visits the program, Youth goes home for visit, Family has opportunity to provide input (i.e., care planning)
Ringle et al. (2015)	Involvement	Parent training, Other: In-home family consultant provided near discharge who provided “intensive in-home family services”
Huefner et al. (2015)	Involvement	Family therapy, Phone calls, Family visits the program, Youth goes home for visit
Merritts (2016)	Involvement	Family therapy
Hoogeveen et al. (2017)	Involvement	Family therapy, Phone calls, Family visits the program, Youth goes home for visit, Family has opportunity to provide input
Van Wijk-Herbrink et al. (2017)	Involvement	Family therapy, Family visits the program, Youth goes home for visit
Trout et al. (2020)	Involvement	Family therapy, Parent training (Common Sense Parenting), Other: Family consultants
Rovers et al. (2019)	Engagement	Activities, therapies, & skill building happen at home with the family present, Family therapy, Parent training (i.e., parent empowerment with skills needed for successful discharge), Family visits the program, Youth goes home for visit (staff present), Other: Contact between family and staff
Sunseri (2020)	Involvement	Family visits the program, Youth goes home for visit

Family Involvement

The most commonly described family involvement methods were family therapy (n = 19) and family visits to the program (n = 18). The least commonly described family involvement methods were transport for families to attend events (n = 1) and support groups (n = 4). Figure 2 displays the frequency of family involvement methods. Sixteen studies described youth visiting home without staff; however, one study described staff being present for home visits (Baker & Blacher, 1993). Most studies described phone calls as accessible to children regardless of their behavior. Eighteen studies described family visits to the program, with one study describing family days and summer camps (Grupper & Mero-Jaffe, 2008) and another describing experiential learning opportunities such as participation in birthday parties or meal preparation (Carlo, 1993).

Figure 2. Frequency of family involvement methods.

Of the eight studies that described parent training, one described didactic learning opportunities through parent educational support groups (Tahhan et al., 2010); two described the use of the program Common Sense Parenting (McIlwaine et al., 2020; Trout et al., 2012), one described a parent coach (de Boer et al., 2007), and two studies described parent empowerment with skills needed for successful discharge (Landsman et al., 2001; Rovers et al., 2019). Of the six studies that described family input, four described care planning (Baker & Blacher, 1993; de Boer et al., 2007; Robst et al., 2013, 2014), and one described family involvement meetings scheduled for youth transitioning to develop a transition plan using shared decision-making (B. R. Lee et al., 2013). Meetings included family members, professionals, and the child (B. R. Lee et al., 2013). Some of the “other” family involvement methods included: orienting staff to communicate with families and counseling adolescents to deal with family issues (Leichtman et al., 2001); implementing a parent empowerment and skill-building intervention (Landsman et al., 2001); clinical consultation (McConnell & Taglione, 2012); and daily journals completed by staff and given to parents (de Boer et al., 2007).

Family Engagement

The most common family engagement method was activities, therapies, and skill building occurring at the home with family present occurring in all seven family engagement studies (Holstead et al., 2010; Madden et al., 2012; Robst et al., 2013, 2014; Rovers et al., 2019; Ryan & Yang, 2005; Tahhan et al., 2010). The next most commonly employed family engagement method was family input into type, frequency, and modality of services (Holstead et al., 2010; Madden et al., 2012; Tahhan et al., 2010). Figure 3 displays the frequency of family engagement methods. One study described engagement as families having complete access to youth, allowing for visits anytime (Holstead et al., 2010). Another described a wraparound service model that allowed families to develop a tailored care plan, assisted families with problem-solving, and provided ongoing support through reunification (Madden et al., 2012). For families co-leading programming, one study described this as families being viewed as team leaders (Holstead et al., 2010). Family engagement methods not described by studies were: choosing and/or co-leading parent training events, families evaluating the program and policies; parent peer support offered; parent support groups offered by another parent.

Figure 3. Frequency of family engagement methods.

Measurement of Family Partnership

Methods for measuring family partnership included administrative data (n = 19) followed by surveys (n = 6), interviews (n = 5), and observation (n = 1), with some studies reporting multiple measurement modalities. Administrative data sources often included a contact log documenting when a family member had contact with the youth or staff (Holstead et al., 2010; Huefner et al., 2015; Lakin et al., 2004; Ryan & Yang, 2005). Family involvement was measured through formal databases such as the Provider Monthly Report Database, which records care episode information, including admission and discharge data, demographics, and family involvement (Robst et al., 2014). Surveys included psychometrically validated surveys such as the Child and Adolescent Functional Assessment Scale (Hodges, 1989, 1997) and the Family APGAR (Good et al., 1979). Most studies reported developing surveys such as a youth perspective survey on family involvement (Laufer, 1994) and a clinician-administered measure of family involvement in family therapy sessions (Vander Stoep et al., 1991). Interviews included those with primary caregivers (de Boer et al., 2007) and staff (Baker & Blacher, 1993). Observational methods included observation of family interactions and observation for intervention fidelity (B. R. Lee et al., 2013).

Discussion

This sub-study provides a snapshot of the TRC literature regarding family partnership in reference to youth outcomes. Thirty studies were included in this literature review to exemplify how family partnership is operationalized. Family therapy was the most commonly described family involvement method, with just over half of all studies (63%) describing the utilization of family therapy. Family therapy is widely employed in TRC to foster connection and strengthen relationships among family members (Merritts, 2016). Family therapy in TRC is associated with decreased lengths of stay, improved function, and discharge to less restrictive settings (Lanier et al., 2020). Family therapy takes on many forms in TRC, and while seemingly ubiquitous for the support of youth with serious challenges manifested in the home, school, and community, some research suggests that family therapy is not uniformly or universally delivered in TRC. A recent analysis of a national survey of US-based TRC programs indicates that some form of family therapy is implemented in approximately 77% of TRC programs (K. Herbell & Ault, 2021). A broader body of literature beyond TRC suggests that greater “engagement” leads to better outcomes, higher quality, and safer care at reduced costs (Carman et al., 2013). While family therapy is critical in the care plan for youth and families, some family therapy modalities may be uni-directional in that the clinician directs the sessions by educating families on pre-set goals that the family may not determine. However, other family therapy models, such as multisystemic or multidimensional family therapy are bi-directional and collaborative between the care team and family. Therefore depending on the model, there can be a perceived power imbalance with some family therapy models, and it is questionable whether it is truly a family involvement method due to its transactional nature and families’ limited capacity to make decisions. While family therapy is appropriate and necessary for many youth and families experiencing TRC programs, family therapy is only one element of family partnership.

Expanding Beyond In-Person Delivery

Across studies, family therapy was nearly exclusively delivered face-to-face at the TRC program. It should be noted that this literature review began in November 2020 in the early stages of the COVID-19 pandemic when the use of telehealth was relatively nascent in TRC. Recent US national pre-pandemic data indicate that only 17.2% of TRC programs in the US offered telehealth (K. Herbell & Ault, 2021). We acknowledge that there have been studies conducted since this literature review was completed that illustrate the usefulness of telehealth as a means of reducing family separation for youth residing away from their families in juvenile justice settings (Tolou-Shams et al., 2022). However, the known issues with access and engagement for families in TRC pre-date COVID-19. Previous research documents that family involvement tends to be lower for families who live further away from the TRC program (Huefner et al., 2015; Kruzich et al., 2003; Robst et al., 2014). Few studies described providing transportation to families (e.g., Landsman et al., 2001). While providing transportation incurs a financial cost to the TRC program, transportation is essential for families who may not have access to reliable transportation and becomes an issue of equity if not provided. Consistent with a family-driven philosophy, families should be met where they are. Telehealth could be a means to engage families as telehealth removes some of the barriers associated with engagement, such as transportation (Langarizadeh et al., 2017).

Visitation as a Means of Preparing for Transitions

The second most common family involvement method was family visits; this was discussed in 58% of studies. Importantly, family visits to programs were more common than the youth going home for visits. This disparity has implications for the effectiveness of TRC and outcomes for youth and families, especially because many youth transition from TRC back to their home communities (Huefner et al., 2010; Ringle et al., 2012; Trout et al., 2010). It is hypothesized that youth can, too often, regress in the community because the environment they enter post-discharge (i.e., home, neighborhood, community) remains unchanged (Leichtman & Leichtman, 2001). Additionally, families frequently have not had intervention or targeted skill-building focused on the home environment while their child is in TRC (K. S. Herbell & Breitenstein, 2021). Skill development is difficult to practice and generalize when the primary practice method is through families visiting the highly structured TRC environment. When youth do not have an opportunity to go home, their families are deprived of the opportunity to bond with their children and practice the skills they are learning in TRC.

One method of preparing youth and families for discharge is offering home visits. It has long been argued that discharge planning should begin upon admission (McCurdy & McIntyre, 2004). However, some research shows that, on average, discharge planning begins six months post-admission (Nickerson et al., 2007). Family preparation is largely through increasing the length and frequency of family therapy and home visits (Nickerson et al., 2007). Children who go on home visits are nearly six times more likely to complete their program (Sunseri, 2001), and home visits have been associated with significant decreases in length of stay (Knecht & Hargrave, 2002). Yet, studies document that TRCs can impose restrictions on home visits – some report that as many as 60% of youth may be experiencing such restrictions as consequences being imposed in relation to undesirable behaviors (Walter & Petr, 2008). Given the necessity for home visits and their positive outcomes, it must be emphasized that home visits are not privileges to be earned (Walter & Petr, 2008); they should be a core element of the program.

Measurement of Family Partnership

The most common method of measuring family partnership was through administrative data. While administrative data is advantageous for accessing large amounts of representative case files, administrative data is often limited to the types of data to which researchers have access. These data include billing codes and “counts,” such as the number of phone calls a youth makes to their family. While methodologically strong, administrative data do not account for the family voice, particularly families’ preferences and insight into the family partnership methods employed in the TRC. Outside of the TRC literature, Simons et al. (2018) leveraged different perspectives on juvenile justice to create a measure of parental participation in family-centered activities according to three domains: attending a family meeting, average number of visits, and willingness of parents to participate in measures. A similar method could be replicated in the TRC literature in which co-developing a family partnership measure, tool, or checklist with families on how they would prefer to be supported, followed by a rigorous psychometric evaluation, could be the next step for advancing the quality of practice in this domain.

Implications for Research

There is a consensus among youth, families, TRC programs, and policymakers that family partnership is critical to TRC. Family partnership research partially aligns with family and advocate voices and the best practices outlined in the gray literature. The belief in family partnership is evident, but belief alone does not change practice. Change in practice takes intention, ongoing effort, and a willingness to share power with families. While advocacy organizations call for authentic family partnership, more work is needed to develop an evidence base of effective implementation methods and outcomes with implications for dissemination, sustainability, and funding of family partnering practices. The study presented here has implications for research, including 1) research designed to evaluate the effectiveness of family partnership and 2) the development of research-practice and family-research collaborations.

Research Designed to Evaluate the Effectiveness of Family Partnership

There is a growing body of literature that suggests that positive outcomes occur when families are actively engaged in TRC programs, including reduced child disruptive behaviors (e.g., Robst et al., 2013), shorter lengths of stay (Kruzich et al., 2003), and permanency (i.e., permanent placement either through reunification, kinship placement, or adoption; L. J. Lee, 2011). Other studies report mixed findings, such as greater family involvement being associated with longer lengths of stay (Robst et al., 2013). One study reports that the effect of family involvement on youth outcomes depends on the type and timing of family involvement activities (Huefner et al., 2015). The next steps for this team include calculating the effect size of the pooled family partnership studies in the parent study to establish the effect of family partnership on youth outcomes.

There are several other research implications, including that researchers must explicitly define how they work with families in published studies. Researchers should continue to describe in detail the innovative components of the TRC program, practice change, or intervention. However, they must also describe the full spectrum of family partnership methods (e.g., visits, peer support, informing programming) so that, as a science, we can begin to understand what elements of family partnership are essential so that the impact of family partnership can be fully estimated. For progress to be made in TRC, consistent language must be used. In this study, we applied a model developed by FREDLA that uses inclusive, respectful, and preferred language (Tolou-Shams et al., 2022). Consistent language goes beyond family partnership and encompasses other related terms such as “residential care,” “therapeutic residential care,” “residential intervention,” “residential treatment,” and “residential program.”

While there is some evidence that family partnership leads to improved outcomes, it is largely unknown what specific family partnership methods are the active ingredients that contribute to positive outcomes. How combinations of family partnership methods lead to positive youth outcomes remains unknown. Are there more potent methods? For example, does parent peer support (i.e., family driven) yield better outcomes than a clinician-guided parent support group (i.e., family involvement)? These questions are limited by the state of the science, more broadly concerning peer support. The state of the science regarding peer vs. clinician-led interventions is limited because of the few rigorous studies examining the efficacy of peer-led family support on outcomes (Hoagwood et al., 2010). While growing and showing promising evidence of effectiveness, sustainability, and scalability (Acri et al., 2017), further testing of peer-led interventions (e.g., navigation, family peer advocates) generally and more specifically within the TRC setting is urgently needed.

Development of Research-Practice and Family-Research Collaborations

Research on family preferences for partnership from the perspective of families with lived experience of TRC is another key area of research. While the gray literature and voices of advocates are clear, systematic investigations that establish methods of partnering with families and how they prefer to be supported are needed. Research moving forward needs to collaborate with families and family-run organizations in applying various methods, including through the co-development of studies, advisory boards, and co-investigators. Such collaborations could establish an evidence base on how families prefer to be supported is a key next step. This evidence base could be built through research methodologies such as group concept mapping, a community-based participatory approach that yields an actionable framework in a language familiar to the community (Merritts, 2016). Methods such as group concept mapping may be leveraged to develop programs, initiatives, and measures. Relevant to future research, group concept mapping could be used to uncover the preferred supports for families in TRC settings. This study synthesized a subset of 30 studies from the literature. While we acknowledge that more studies describe family partnership without relating it to youth outcomes, there is likely even more family partnership occurring in this space than what is published. Family partnership methods are likely to be deployed in TRC settings. There is a sizable literature base on family partnership methods; however, the empirical literature on youth outcomes is limited. Family partnership practices may be evaluated informally via quality assurance or similar internal monitoring methods that do not reach the public via scholarly presentations or publications. We recommend that TRCs and researchers collaborate more actively to further contribute to the family partnership evidence base.

Limitations

Multiple factors limited the study findings. First, this project was a sub-study of a larger systematic review project. The studies presented here are meant to serve as examples. The findings should not be construed to represent all research on family partnership in TRC. There are additional studies on family partnership in reference to youth outcomes in TRC that were not included in this stub study. Further, adding additional databases and search terms (e.g., “family therapy”) may have improved the search strategy. All studies included were peer-reviewed articles, and there is a potential publication bias. Publication bias is particularly relevant regarding the data point on family partnership publications. The purpose of the overarching systematic review derived from this sub-study was to examine the relationship between family partnership and youth outcomes. Therefore, our exploration of family partnership was limited to studies with a youth outcome component. Additional studies, including those in the gray literature, offer unique perspectives on family partnership and describe innovative practices that likely meet the criteria for family driven. Although we did not exclude articles based on country, relatively few studies were conducted outside of the United States (77% of included studies were conducted in the US), which may limit the generalizability of study findings internationally.

TRC is often difficult to describe in research because of the different models, program components, and populations served. For example, family partnership may look very different for a family referred by the child welfare system versus a family referred through the school system. Few studies described referral sources; however, this is a key area for future research, particularly addressing how family partnership differs based on the populations served and the barriers to equitable family partnership in different TRC sub-populations. Additionally, our team excluded settings such as educational residential care, juvenile justice-focused residential care, or substance-use focused residential care. Using Covidence allowed the team to classify articles conducted in a different residential care setting as “wrong setting or population.” However, a limitation of Covidence is that we did not track the specific reasons as to why a study was excluded for wrong setting or population.

The existing TRC literature includes a broad array of programmatic components that are often minimally described. In our literature review, family partnership was also minimally described making it difficult for the study team to ascertain what family partnership methods were truly occurring. While our team had a model that included detailed definitions and examples, we could only give credit when there was an explicit mention of family partnership methods. There may be other methods occurring in TRC programs that are considered ubiquitous in TRC such as phone calls, family therapy, and visits. In the future, teams should consider contacting authors of published studies to ascertain additional family partnership methods that may have been occurring but were not included in the publication.

Conclusion

There is a need for more rigorous studies examining how combinations of family partnership methods impact the outcomes of youth and families in TRC. We also need to better understand from families’ perspectives how they prefer to be supported and engaged in care. This study suggests that the research voice and the family and advocate voice may not fully align yet. At the same time, a consensus exists regarding what we should be doing to engage families effectively in TRC programs. More is likely being undertaken in the field, including family-driven methods like parent-peer support. This study reinforces the need for more active collaboration between families, research, and practice to explore and develop family partnership implementation and dissemination methods, including measures of such methods. Families’ engagement and leadership must be critical elements in such initiatives. Family partnerships may enable well-informed outcome evaluations of existing practice and facilitate research that tests and refines new approaches to TRC.

Acknowledgments

The authors would like to acknowledge and offer their sincerest gratitude to the entire project team, including Bethany Lee, Lisa Holmes, Jonathan Huefner, and Steve Klee.

Disclosure statement

Millie Sweeney is the Director of Learning and Workforce Development at the Family-Run Executive Director Leadership Association.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This publication was supported, in part, by the National Center for Advancing Translational Sciences of the National Institutes of Health under Grant Numbers KL2TR002734 and UL1TR002733. The content is solely the authors’ responsibility and does not necessarily represent the official views of the National Institutes of Health.