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 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 and ongoing reflective practice. 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 developmentally enriched living environments and to create a sense of normality for youth. CARE is organized around six principles related to attachment, trauma recovery, and, ecological theory. The principles state that child care practices must be:

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

CARE consultants follow a standardized set of steps to train and support staff over the 3-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 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

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 youth’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 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 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-year implementation process
  • Funding for 3 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.

Education and Training

Prerequisite/Minimum Provider Qualifications

There are no educational requirements to become a trainer of trainers. Anyone interested in becoming one must attend a training of trainers course and pass the written test to be certified.

Education and Training Resources

There is a manual that describes how to deliver this program, and 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 is obtained:

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 train-the-trainer 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 are trained in CARE principles through a 5-day training program. CARE educators must be recertified regularly.

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 2019). 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 3-4 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 three-year 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. Support during the sustainability agreement includes continued support through onsite visits, training, on-going data collection and survey analysis, 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 recommendations.

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. Retrieved from

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). Preventing behavioral incidents in residential child care: Efficacy of a setting-based program model. Prevention Science, 17, 554-564. doi:10.1007/s11121-016-0649-0

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 comparison groups, outcomes, measures, 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 postintervention follow-up: None.

Nunno, M. A., Smith, E. G., Martin, W. R., & Butcher, S. (2017). Benefits of embedding research into practice: An agency-university collaboration. Child Welfare, 94(3), 112-132.

Type of Study: Interrupted time series design
Number of Participants: Not specified


  • Age — 8-18 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were youth in a therapeutic residential care system.

Location/Institution: Waterford Country School

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The current study examined the impact of Children and Residential Experiences (CARE) on the interactional quality among staff and youth in therapeutic residential care. Data were collected over 12 years and divided into a 6-year baseline phase prior to the start of CARE in January 2009 and a 6-year implementation phase. Measures utilized include the Organizational Social Context (OSC) and behavioral report incidents. Results indicate that CARE implementation reduces the prevalence of critical incidents, and that reductions are sustained following the 3-year implementation period. Limitations include lack of randomization, lack of control group, reliance on self-reported measures, and lack of follow-up.

Length of postintervention follow-up: None.

Additional References

Holden, M. J. (2009). Children and Residential Experiences: Creating conditions for change. Arlington, VA: 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. London, UK: 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: March 2017

Date Program Content Last Reviewed by Program Staff: June 2018

Date Program Originally Loaded onto CEBC: July 2017