Children and Residential Experiences (CARE)

3  — Promising Research Evidence
3  — Promising Research Evidence

About This Program

Target Population: Child care staff, clinical staff, and agency administrators working with 6- to 20-year-old children and youth living in group and residential care settings

For organizations that serve children ages: 6 – 20

Program Overview

CARE is a principle-based program designed to enhance the social dynamics in residential care settings through targeted staff development, ongoing reflective practice, and data-informed decision-making. Using an ecological approach, CARE aims to engage all staff at a residential care agency in a systematic effort to orient practices in order to provide trauma-informed and developmentally enriched living environments and to create a sense of normality for children and young people. CARE is organized around six principles related to attachment, trauma, resiliency, and ecological theory. The principles state that child care practices must be:

  • Relationship-based
  • Trauma-informed
  • Developmentally focused
  • Competence-centered
  • Family-involved
  • Ecologically oriented

Cornell University CARE consultants follow a standardized set of steps to train and support staff over the 3–4 year implementation period. An essential activity is the formation of a local Implementation Team with multilevel representation that provides support, modeling, and mentoring to staff at all levels as they incorporate CARE principles into their work. This approach is designed to cultivate personal investment and ownership among all staff levels at the agency

Program Goals

The goals of the Children and Residential Experiences (CARE) model are:

  • Improve relationship quality between staff and children/adolescents
  • Increase the use of trauma-informed practices by staff
  • Improve social and emotional functioning among the children and adolescents
  • Reduce the number of high-risk behavioral incidents such as aggression, property destruction, and running away
  • Reduce the use of physical restraints and other restrictive practices
  • Improve academic achievement and overall functioning in school or vocational settings among children and adolescents
  • Increase contacts between children and their families while in care
  • Increase agency's capacity to collect, analyze, and use data in decision-making
  • Reduce staff turnover

Logic Model

The program representative did not provide information about a Logic Model for Children and Residential Experiences (CARE).

Essential Components

The essential components of the Children and Residential Experiences (CARE) model include:

  • A practice model based on 6 core principles
    • Relationship-based: Form healthy models of adult-child relationships and build capacity for future relationships
    • Trauma-informed: Use professional practice that is sensitive to the children's trauma history
    • Developmentally focused: Provide normative developmental experiences and adapt expectations to meet individual needs
    • Competence-centered: Foster self-efficacy and competence for dealing with life circumstances
    • Family-involved: Understand and adapt to families' cultural norms and promote active family involvement
    • Ecologically oriented: Enrich the physical and social environment to create a therapeutic milieu
  • Committed leadership and an implementation team that guide and facilitate agency-wide training and technical assistance to help personnel at all levels of the facility learn to use the 6 principles to enhance interactions with children and staff by focusing on strengthening attachments, building competencies, adjusting expectations to account for children's developmental stage and trauma history, involving families in the child's care and treatment, and enriching dimensions of the environment to create a more therapeutic milieu.
  • On-going agency-wide incorporation of the 6 principles in leadership, policies and procedures, training and professional development of staff, supervision, and all interactions with children and families.
  • Consistent application of the 6 principles within and across all levels of the agency, including administration, supervision, clinical care, education, and direct care.

Program Delivery

Recommended Intensity:

This is a comprehensive agency-wide program model. The program's core principles are incorporated into the culture of the organization and guide its interventions and treatment philosophy on an ongoing basis.

Recommended Duration:

Implementation of the program typically requires 3-4 years. Once implemented, the program continues indefinitely as a framework that guides the treatment philosophy of the organization as it provides out-of-home care and treatment to its clients.

Delivery Settings

This program is typically conducted in a(n):

  • Foster / Kinship Care
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)


This program does not include a homework component.

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Commitment of agency leadership to at least a 3- to 4- year implementation process
  • Funding for 3–4 years of implementation assistance through training and technical assistance
  • Time and resources to provide training for all staff
  • Time and resources for regular implementation meetings for key staff
  • Staff available to commit the time and effort to lead local implementation and serve as trainers for agency personnel
  • No specific concrete resources are viewed as essential, as the program is adaptable to the real-world setting in which it is implemented.

Manuals and Training

Prerequisite/Minimum Provider Qualifications

There are no educational requirements to become a CARE educator. Anyone interested in becoming one must attend a training of educators' course offered at the organization and pass the written test to be certified.

Manual Information

There is a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:
  • Martha J. Holden, Director of the Residential Child Care Project
    Cornell University
    dept.: Bronfenbrenner Center for Translational Research

    phone: (607) 254-5337
Training Type/Location:

Onsite training is provided as part of an implementation agreement and contract with Cornell University. During the implementation period, Cornell consultants collaborate with agency leadership to assist the agency in fully implementing the CARE model. Consultation includes leadership retreats during which agency leaders are trained in the CARE model and principles. In addition, Cornell consultants conduct a 5-day training-of-educators event during which CARE Educators are prepared to train other agency staff in the CARE model.

Number of days/hours:

Leadership and Implementation Team members are trained in the CARE principles and develop an agency-specific implementation plan through a 4-day manualized program. CARE educators are trained in CARE principles and training methods through a 5-day manualized program. Agency staff members are trained in CARE principles through a 5-day training program. CARE educators must be certified.

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Children and Residential Experiences (CARE) as listed below:

As part of the implementation process, baseline surveys are administered to assess organizational culture, perceptions of safety, current status of the organization's crisis management system, and alignment of staff knowledge, beliefs and practice with the CARE principles. The CARE consultants present findings from this assessment at an agency leadership retreat, and help participants consider how several aspects of culture (proficiency, resistance, rigidity) and climate (stress, engagement, functionality) may have implications for the upcoming CARE implementation process. The surveys are administered only as part of an agreement with Cornell University.

Formal Support for Implementation

There is formal support available for implementation of Children and Residential Experiences (CARE) as listed below:

Cornell University supports agencies with Implementation of CARE through a 3-4 year implementation agreement and contract (see the CARE Information Bulletin 2022). At the start of the implementation agreement, the agency is assigned a CARE team comprised of 2 to 3 Cornell faculty members specializing in CARE content and organizational implementation strategies. These CARE consultants provide onsite assistance 2–3 times a year for a total of 30–33 days of on-site activities throughout the implementation period. Cornell consultants also provide on-going support through regular email, teleconferencing, and video conferencing.

During the implementation period, agency leaders are trained in the CARE model, the 6 core principles, and organizational change strategies during a 4-day leadership retreat. In addition, agency personnel are trained as CARE educators and certified to conduct the CARE training curriculum with agency staff.

Technical assistance visits include observation and feedback, training and coaching for frontline supervisors, developing routines for reflective practice, assistance with survey administration and data analysis, and addressing organizational barriers to create a more therapeutic milieu. After implementation is complete, there is a 3-year sustainability agreement that includes 6-8 days of onsite visits and continued email communication, teleconferences, videoconferences and access to annual regional, national, and international events. Agencies can apply for CARE Agency Certification once CARE is fully implemented. Support during the sustainability agreement includes continued support through onsite visits, training, on-going data collection and survey analysis, certification assessment visit, and on-going certification of agency staff to deliver CARE training throughout their organization.

Fidelity Measures

There are fidelity measures for Children and Residential Experiences (CARE) as listed below:

The CARE staff surveys (administered annually) measure staff's knowledge and beliefs about effective childcare practice as well as their actual practices to optimize children's residential experiences in order to track alignment with the 6 CARE principles. Essential elements of the CARE program model have been identified and fidelity tools that assess the structures and processes necessary to sustain the CARE model have been developed and are being tested. These measures are used by the leadership team as a self-assessment process as well as by the Cornell consultants to provide feedback and recommendation for continued improvement and agency CARE certification.

Implementation Guides or Manuals

There are implementation guides or manuals for Children and Residential Experiences (CARE) as listed below:

There are a number of manuals and guides that assist in the implementation process including:

  • System-wide Leadership Retreat Workbook (multiple site implementation)
  • Leadership Retreat Workbook
  • Midterm Leadership Retreat Workbook

Research on How to Implement the Program

Research has been conducted on how to implement Children and Residential Experiences (CARE) as listed below:

Anglin, J. P. (2019). Translating the CARE program model into practice: Lessons learned from the pioneer agencies on changing agency cultures and care practices. Children and Residential Experiences: Creating conditions for change, 11–16.

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Izzo, C. V., Smith, E. G., Holden, M. J., Norton-Barker, C. I., Nunno, M. A., & Sellers, D. E. (2016). Intervening at the Setting Level to Prevent Behavioral Incidents in Residential Child Care: Efficacy of the CARE Program Model. Prevention Science, 17, 554-564.

Type of Study: Interrupted time series study
Number of Participants: 11 agencies


  • Age — Not specified
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were agencies from a statewide association of residential care agencies.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
This article examined the impact of CARE on the prevention of aggressive or dangerous behavioral incidents involving youth living in group care environments in 11 agencies. Measures included monthly administrative reports of behavioral incidents and the Organizational Social Context (OSC). Results indicate that there were significant program effects on incidents involving youth aggression toward adult staff, property destruction, and running away. Effects on aggression toward peers and self-harm were also found but were less consistent. Staff ratings of positive OSC predicted fewer incidents, but there was no clear relationship between OSC and observed program effects. Limitations include lack of randomization, comparison group lacked contemporaneous outcome assessment during entire 3-year program period, reliance on agency-collected administrative data, and lack of follow-up.

Length of controlled postintervention follow-up: None.

Izzo, C. V., Smith, E. G., Sellers, D. E., Holden, M. J., & Nunno, M. A. (2020). Improving relationship quality in group care settings: The impact of implementing the CARE model. Children and Youth Services Review, 109, Article 104623.

Type of Study: Quasi-experimental design
Number of Participants: 688


  • Age — Cohort 1: Mean=14.5 years; Cohort 2: Mean=15.2 years
  • Race/Ethnicity — Cohort 1: 19% Non-White; Cohort 2: 39% Non-White
  • Gender — Cohort 1: 41% Male; Cohort 2: 73% Male
  • Status — Participants were children in group care agencies.

Location/Institution: Southeastern United States

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of this study was to test whether Children and Residential Experiences (CARE) led to improvements in relationship quality between direct care providers and residents. A stepped-wedge design was used in which one cohort of agencies began CARE immediately and a second cohort waited 12 months before beginning, allowing them to serve as a comparison group during the waiting period. Measures include the Youth Perceptions of Relationship Quality (YPRQ), the Inventory of Parent and Peer Attachment (IPPA), the Strengths and Difficulties Questionnaire (SDQ), and the Organizational Social Context (OSC). Results indicate that after accounting for clustering at the agency and cottage levels and controlling for several important covariates, child perceptions of relationship quality increased significantly in the three years after CARE implementation began. The strength of the CARE effect was stronger for residents with several previous placements, but did not differ by age, gender, race, length of stay, Department of Social Services (DSS) referral, or problem behavior. Limitations include lack of true no-treatment comparison group, limited generalizability due to the number of agencies included and method of inclusion, and limited assessment of other agency-level factors.

Length of controlled postintervention follow-up: None.

Additional References

Holden, M. J. (2009). Children and Residential Experiences: Creating conditions for change. The Child Welfare League of America.

Holden, M. J., Anglin, J., Nunno, M. A., & Izzo, C. (2014). Engaging the total therapeutic residential care program in a process of quality improvement: Learning from the CARE model. In J. Whittaker, F. del Valle, & l. Holmes (Eds.), Therapeutic residential care for children and youth: Developing evidence-based international practice. Jessica Kinsgley Publishers.

Holden, M. J., Izzo, C., Nunno, M. Smith, E. G., Endres, T., Holden, J. C., & Kuhn, F. (2010). Children and Residential Experiences: A comprehensive strategy for implementing a research-informed program model for residential care. Child Welfare, 89(2), 131-149.

Contact Information

Martha J. Holden, MS
Agency/Affiliation: Cornell University
Phone: (607) 254-5337
Fax: (607) 255-4837

Date Research Evidence Last Reviewed by CEBC: October 2020

Date Program Content Last Reviewed by Program Staff: April 2020

Date Program Originally Loaded onto CEBC: July 2017