What are the outcomes for youth placed in group and institutional settings?

Group and institutional placements¹ are costly on many levels. They generally produce poorer outcomes for youth than family-based settings, pose roadblocks to the timely achievement of permanency, and cost up to 10 times more than placement with a family. A breakthrough 2021 report focused on young people’s direct experiences of group and institutional placement concluded that these settings often fail to offer consistent caring relationships and frequently are experienced as punitive, prison-like, and traumatic. 

Over the past 10 years, the child welfare field has seen a 35% reduction in the number of youth living in group and institutional placements nationwide, with decreases in nearly every state.² While this is encouraging, any amount of time that a young person spends in an institutional placement is too long.

More than two-thirds (68%) of the young people in group placements are between the ages of 14 and 17², and 63% are male. Black, multiracial, and American Indian/Alaska Native youth continue to be overrepresented in group and institutional settings. Therefore, ending the need for group and institutional placements is a key strategy for reducing disproportionate harm to young people of color in the child welfare system. 

While short-term, clinically indicated mental and behavioral health treatment may need to be provided in group or institutional settings, federal policy stipulates that those settings be time-limited, trauma-informed, judicially reviewed, and focused on engaging the young person’s family during and after treatment, with the goal being a swift return to family and community life. For more information, see: How are some child protection agencies attending to Qualified Residential Treatment Program requirements?

The remainder of this brief summarizes research on the experiences and outcomes of youth placed in group or institutional settings, and includes resources to support jurisdictions in reducing or eliminating their reliance on these settings. 

Impacts of group or institutional placement

All young people need consistent, nurturing adults in their lives in order to form healthy attachments and develop positive social and emotional skills. There is a role for high-quality specialized institutional treatment services³ — such as those offered through Qualified Residential Treatment Programs (QRTPs) or through the behavioral health system — but that role is limited, and the duration a young person spends in such settings must be short term. It is important to note that young people also can receive effective behavioral treatment in family-like settings through therapeutic foster care, wraparound services, and mobile crisis services. 

Research demonstrating effectiveness of group and institutional placement on youth is limited. While modest short-term benefits have been identified in a few instances,⁴ effects do not appear to be sustained.⁵ Overall, research indicates that youth who experience group placements:

• Have higher re-entry rates after exiting to reunification than youth in other types of out-of-home care settings.⁶
• Are almost 2.5 times more likely than their peers in foster care to become delinquent.⁷
• Have poorer educational outcomes than youth in family foster care, including lower test scores in basic English and math.⁸
• Are less likely to graduate high school, when compared to youth in family foster care.⁹
• Are at risk of physical abuse when they are placed in group settings.¹⁰
• Are less likely to achieve permanency than those raised in non-relative foster families.¹¹
• Lack opportunities to develop critical life skills and positive relationships.¹²
• Experience group or institutional placements as prison-like, punitive and traumatic.¹³

Alternatively, according to an extensive research review¹⁴, when compared to children and youth who have been placed in group or institutional settings, those placed in family foster homes:

• Have fewer placements.
• Spend less time in out-of-home care.
• Are less likely to be re-abused.
• Are more likely to be placed near their community of origin. 
• Are more likely to be placed with their siblings.

Research that supports ending the need for group placement

The following research underscores the negative impacts of group and institutional placements: 

Think of Us. (2021). Away From Home: Youth Experiences of Institutional Placements in Foster Care

• This breakthrough qualitative research report provides a detailed examination and understanding of the lived experience of young people who have recently lived in institutional placements — much of it told from their perspectives.

American Orthopsychiatric Association. (2014). Consensus Statement on Group Care for Children and Adolescents: A Statement of Policy of the American Orthopsychiatric Association

• This consensus statement of a group of internationally recognized researchers provides 10 reasons why group and institutional settings can be detrimental to the well-being of young people, and includes the research base for each.

State Policy Advocacy and Reform Center. (2013). Therapeutic Foster Care: Exceptional Care for Complex, Trauma-Impacted Youth in Foster Care

• This report describes therapeutic (treatment) foster care, and compares it to traditional foster care and residential treatment (p. 2).

Barth, R. (2002). Institutions vs. Foster Homes: The Empirical Base for a Century of Action

• This formative report looks at four outcome areas for youth in group or institutional settings: safety and well-being; permanency/re-entry; long-term successes of children; and costs of out-of-home care. It includes an insightful comparison of how young people in different out-of-home care settings perceive their care (p. 4).

Guides and strategies for action

The following resources offer strategies for child welfare leaders interested in reducing their reliance on group and institutional placements. For a detailed overview of strategies and jurisdictional examples, please see Ending the Need for Group Placements, as well as Casey Family Programs briefs focused on efforts to reduce or eliminate group and institutional placements in New Jersey, and Virginia.

Children’s Rights. (2021). Families Over Facilities

• This toolkit is adaptable for any jurisdiction that seeks to eliminate unnecessary group and institutional placements. The strategies center around the following three goals: prevention of entry into care; increasing the use of kin placements; and decreasing the population currently placed in group and institutional placements.

Capacity Building Center for States. (2017). Working with Children and Youth with Complex Clinical Needs: Strategies in the Safe Reduction of Congregate Care

• This guide highlights an array of evidence-based practices, promising practices, and strategies to safely reduce the use of group and institutional placements, and to help child welfare administrators, supervisors, workers, and private agencies limit those placements appropriately. The report includes an assessment to assist child welfare agencies conduct a systematic review of their policies and practices and identify areas for improvement.

Chapin Hall & Chadwick Center. (2016). Using Evidence to Accelerate the Safe and Effective Reduction of Congregate Care for Youth Involved with Child Welfare

• This research review examines federal and state policies as well as clinical guidelines, and suggests that group and institutional settings should be used only as a short-term treatment alternative to address complex, acute mental health problems.

Southern Area Consortium of Human Services. (2016). Literature Review: Alternatives to Congregate Care

• This literature review highlights a range of alternative strategies to group and institutional placements, including: evidence-based behavioral health interventions; services and supports for home-based caregivers; foster family recruitment, support, and retention; treatment foster care; time-limited placements; and systems reform.

Annie E. Casey Foundation. (2009). Rightsizing Congregate Care

• This report explores key levers of change that promote the rightsizing of group and institutional settings. It includes an in-depth look at how five jurisdictions used those levers of change.

1 Consistent with federal definitions and guidance for the Adoption and Foster Care Analysis & Reporting System (AFCARS), the term “group and institutional placements” refers to non-family based placements that house young people in large, medium, or small congregate settings, including emergency shelters, group homes, institutions, and residential treatment facilities, centers, campuses and cottages with 24-hour shift care or house parents. “Group homes” are defined as placement settings that house 12 or fewer youth, while an “institution” is defined as housing more than 12. For additional information, see: www.acf.hhs.gov/sites/default/files/documents/cb/afcars_elements_definitions.pdf and www.acf.hhs.gov/cwpm/public_html/programs/cb/laws_policies/laws/cwpm/policy_dsp.jsp?citID=150.
2 Public AFCARS data obtained from the National Data Archive on Child Abuse and Neglect Data at Cornell University.
3 Pecora, P. J., & English, D. J. (2016). Elements of effective practice for children and youth served by therapeutic residential care. p. 2. Retrieved from: www.casey.org/media/Group-Care-complete.pdf.
4 Lee, B. R., & Thompson, R. (2008). Comparing outcomes for youth in treatment foster care and family-style group care. Children and Youth Services Review, 30(7), 746–757. Retrieved from: https://doi.org/10.1016/j.childyouth.2007.12.002.
5 De Swart, J. J. W., Van den Broek, H., Stams, G. J. J. M., Asscher, J. J., Van der Laan, P. H., Holsbrink-Engels, G. A., Van den Helm, G. H. P. (2012). The effectiveness of institutional youth care over the past three decades: A meta-analysis. Children and Youth Service Review, 34, 1818–1824.
6 Barth, R. P. (2002). Institutions vs. foster homes: The empirical base for the second century of debate. Retrieved from http://bettercarenetwork.org/sites/default/files/Institutions%20vs%20Foster%20Homes.pdf.
7 Ryan, J. P., Marshall, J. M., Herz, D., & Hernandez, P. M. (2008). Juvenile delinquency in child welfare: Investigating group home effects. Children and Youth Services Review, 30, 1088-1099. Retrieved from: https://doi.org/10.1016/j.childyouth.2008.02.004
8 Annie E. Casey Foundation. (2015). Every kid needs a family: Giving children in the child welfare system the best chance for success. Retrieved from http://www.aecf.org/m/resourcedoc/aecf-EveryKidNeedsAFamily-2015.pdf.
9 Ibid.
10 Ibid.
11 Children’s Rights. (2021). Families over facilities: Ending the use of harmful and unnecessary institutions and other group facilities in child welfare systems. https://www.childrensrights.org/wp-content/uploads/2021/03/CR-Families-Over-Facilities-Report.pdf.
12 Think of Us. (2021). Away From Home Youth Experiences of Institutional Placements in Foster Care. Retrieved from https://www.thinkof-us.org/case-studies/away-from-home.
13 Ibid.
14 Barth, R. P. (2002). Institutions vs. foster homes: The empirical base for the second century of debate. Retrieved from http://bettercarenetwork.org/sites/default/files/Institutions%20vs%20Foster%20Homes.pdf.