There has long been a call to improve the quality of care for children in residential placement, and a recent publication by the Residential Child Care Project (RCCP) in Children and Youth Services Review in January revealed new approaches can be adopted to change agencies for the better. Investigators found that improving the agencies that provide care — with a sustained focus on shaping the agency’s environment into one that can help children succeed — could be the solution.

RCCP worked with 13 agencies that provide residential care for children in the southeastern U.S. to implement a three-year agency improvement program called Children and Residential Experiences, or CARE. Created in 2005 by the RCCP with support from the South Carolina Association of Children's Homes and Family Services, the Duke Endowment, and the South Carolina Department of Social Services, the focus of CARE is to create an environment that prioritizes positive relationships and social interactions between adults and children.

CARE centers around six scientifically grounded principles to help foster this environment —guiding agencies toward programming and practices that are: developmentally focused, family-involved, relationship-based, competence-centered, trauma-informed, and ecologically oriented.

“The CARE approach runs somewhat in contrast to the prevailing behavioral approach … The theory there is ‘how do we eliminate behaviors or reduce problematic behaviors,’” said Charles Izzo, Ph.D., senior research associate at the Bronfenbrenner Center for Translational Research (BCTR) and co-principal investigator on the project. “The theory of change that we’re working from, and providing evidence for, says that by understanding what kids need developmentally, relationally, and therapeutically, and providing support to meet those needs, you can end up reducing the behaviors that everyone is so concerned about.”

To evaluate the efficacy of CARE, the 13 agencies were split into two cohorts and agency staff at all levels of the organization were surveyed annually about their perceptions of the agency and how they approach their work with children. Questions focused on each staff member’s knowledge and beliefs regarding CARE principles and how they approached their work with children.

The research team found that the knowledge of and belief in the CARE model, for all agencies, increased at the end of the first year of implementation, and remained at nearly the same level at the end of the second and third years.

“You don’t often see that when you’re implementing a complex program like CARE,” said Elliott G. Smith, Ph.D., research associate with RCCP. “It’s very unusual to see it so consistent across 13 agencies implementing CARE in their own ways.”

When it came to staff putting those beliefs and knowledge into practice, significant improvement was not evident until the end of the third year for a majority of agencies.

Since CARE is a new approach, staff at the agencies are still feeling their way through the process, even three years in, said Izzo. But it has unlocked awareness by the staff that there is a better, more individualized way to care for children.

“This is a guided, calibrated process of promoting greater flexibility within these organizations,” Izzo said. “CARE allows staff to release some of the rigid boundaries of their roles. Some of the caregivers have said they feel liberated to give the type of care that kids need. A license to love the kids. A license to be affectionate, which before may have been frowned upon.

“Understanding what kids have been through and how the trauma they have experienced impacts their ability to think and adapt well in difficult circumstances, to be able to manage their own emotions, and interact adaptively with kids in their environment is very powerful.”

That was echoed in some of the responses from agency staff during the annual surveys. “[We] focus on the causes of the behavior, not the behavior itself,” said one agency employee. “[CARE] helped me be more aware of trauma in their lives,” said another.

In all, the researchers point to two key factors that can help an agency change its method of childcare for the better: a commitment by the agency’s leaders to adopt a new approach to childcare and establishing a team within the agency that is tasked with aligning the agency’s priorities and operations with the new approach. Those factors, combined with a sustained effort, can lead to better care for children.

This study, combined with previous research showing that CARE led to fewer behavioral incidents and better relationships between children and caregivers, gives the research team even more evidence demonstrating the positive impact of implementing the CARE model in residential child care settings.

His reasoning: Given the unique nature of our analytic approach in those studies, this is the most accurate way to describe those findings. 

“It’s another brick in the wall to show that CARE is effective. We were able to move behavioral incidents, kids were telling us that relationships with staff have improved, and now this piece of evidence makes us feel confident about the results,” said Smith.

Other co-authors include Deborah E. Sellers, Ph.D., director of research and evaluation for RCCP; Martha J. Holden, M.S., RCCP director; and Michael Nunno, D.S.W., senior extension associate with BCTR.