Needs and Support Services for Specialist Foster Carers
Held in Birmingham, 14 June 2005
Report written by Linnie Price, Research Officer, research in practice
This symposium report is divided into the following sub-sections. If you wish to make a short cut to any of these, click on the relevant section heading.
Introduction
Specialist foster carers provide consistent care for young people with complex needs and requirements. This includes children with disabilities, children in residential schools without a home to return to, children on remand and children with mental health and behavioural problems. In fact any child whose needs are frequently demanding and challenging and require a consistent response could be said to require specialist foster care. Such carers are expected to have the same skills and qualities as other foster carers, but with more time and energy to devote to the young person. Whilst these extra qualities are often reflected in payment structures, the demands on these carers are great. This symposium looked at the research underpinning specialist foster care, and asked how effective such programmes have been in practice. It examined evaluated models of training and support, revealed gaps in provision of support services and gave examples of innovative practice.
Speakers
Chairs:
Eleni Ioannides Director of Bury Social Services, Health and Housing
Colleen Eccles Development Manager, research in practice
Speakers:
Kate Cairns Training Director for Akamas. Kate, her partner and 3 children have provided permanence within their family home for 12 children. Akamas is a consultancy and training company producing and providing online and face to face accredited qualifications in child care and management.
Helen Jones Policy Advisor for Looked After Children, DfES
Ian Sinclair Professor of Social Work, University of York
Chair’s opening address
There is a variety of definitions of specialist foster care, which has been described as ‘foster care with knobs on’. We now need to define the knobs. The aim of the day is to come away with a definition.
Presentation 1:
Some Issues in Specialist Foster Care by Ian Sinclair
There is a need to define specialist foster care by identifying what marks it out, and a need for clarity on how such markers might be justified and on what lessons for practice and policy might arise from them.
Defining specialist foster care
Specialist foster care can be defined in various ways. Commonly used markers are enhanced status and fees for carers, the special groups it may serve or a distinct purpose, such as the provision of shared care or treatment. It is often seen as highly intensive with an agreed time-frame and a theoretical rationale, such as attachment theory. It is worth examining the case for specialist foster care as marked out in these different ways
The case for professional status and fees for specialist foster carers
There is evidence that most but not all carers wish to be paid. Moreover the more they are paid the longer they are likely to continue caring. The rise of the independent sector, providing higher levels of support and higher fees for foster carers represents a challenge for Social Services Departments. Professional status and fees for specialist foster carers is a logical response to these pressures. At the same time there is a danger that these fees may devalue the work of other foster carers. All carers wish to be seen as part of a team.
The case for specialist foster carers for children with disabilities
It is said to be difficult to find carers for children with disabilities. There is an unresolved question over whether it is better to, as it were, have specialist carers who are trained to deal with children with impairments or to recruit carers who are willing to care for such children and who can then be trained to deal with the specific impairment their foster child has.
The case for Specialist foster care for children with challenging behaviour
Looked after children with challenging behaviour raise issues of containment and cost. Some children go through a number of placements and others can live neither at home nor in foster care. While residential care may be believed to be the solution to containing challenging children, there is evidence that it can exacerbate delinquent behaviour, and that any benefits it achieves tend to erode when the young person leaves. ‘Poorly’ functioning residential homes are associated with bullying, thoughts of suicide, high levels of criminal conviction and even sexual assault. In addition the cost of residential care is high: £64,000 per annum is probably average. There is evidence that specialist foster care can offer many young people with challenging behaviour the possibility of containment in a more humane setting at lower cost.
The case for specialist shared care
Longer-staying foster children face a dilemma. There is evidence that in comparison with those who remain looked after, those who return home are more likely to be abused, less likely to do well at school, and more likely to display a variety of difficult behaviour. By contrast those who remain do not acquire a home for life, often move around the system and face numerous difficulties on leaving care. In practice very few of these children want to resolve this dilemma by being adopted. Most, however, do want to have ‘the best of both worlds’ seeing more of their families but also living with or staying in close contact with their foster carers. Ways of meeting the children and young people half way include a ‘crisis cooling’ period for adolescents who are ‘blowing up’, ‘shared care’ whereby children spend some of the week in foster care and some with their parent(s) and ‘through care’ whereby children remain in close contact with their foster carers and stay with them at times after they have ceased to be looked after.
The case for treatment
The dilemma of ‘home or away’ may also highlight the need for children themselves to contribute to improving their situation as a means to prevent them ‘bobbing round the system’ and enabling them to return home. In the past residential care set out to meet this need by providing ‘treatment’. With the virtual demise of residential care this concept has almost disappeared from the language of social work. This creates an argument in favour of foster care providing treatment. There are promising American models for this, for example those in which foster carers and carers are trained in the same parenting skills so that the young person experiences a coherent approach in the two settings.
The case for a rationale
Specialist foster care needs a rationale. Research suggests that the behaviour of foster children is partly influenced by their own personalities and temperaments, by whether they want to make the placement work and by ‘spirals of interaction’ whereby carers and child increasingly get on the wrong side of each other. So there needs to be attention to ways of influencing behaviour (social learning theory), to understanding and responding to what children want and to nipping negative spirals ‘in the bud’. The child’s own foster family, their school, and their relationships and contact with their own family also influence behaviour and outcomes. Relationships with families are complex, and complicated by previous histories of abuse. It is quite possible for the same child to have beneficial contact with one member of their family and detrimental contact with another. Good practice depends on knowing what the child feels about these contacts, on thinking realistically about the purposes of contact, and on acting creatively to achieve them.
The Role of Specialist Foster Care within the System
Deciding the length of a specialist foster placement will depend on factors such as whether it includes treatment with a fixed time frame. Specialist foster care is often given a fixed time span of six months, but evidence suggests that the minimum necessary time for a therapeutic effect may well be longer at say 18 months. This brings the danger that specialist schemes will ‘silt up’ and cease taking new cases. A further danger is ‘new clutch’ syndrome in which the introduction of a new service may cause problems in the existing system. Finally there is also the issue of cost, particularly as the most difficult children (with the highest failure rates) will be placed. There is therefore a need to think carefully about how specialist foster care will fit into the system.
Conclusion
Most of the principles of specialist foster care should apply to all foster care. For example all carers should have appropriate status and be treated as part of the team. There is, however, a case for some specialist foster care, both to cater for exceptionally difficult young people and to test new approaches, which should be rigorously evaluated. New schemes should be integrated with the overall child welfare system and the lessons from their success spread out more widely.
Questions and discussion on presentation 1
Audience: Could the speaker offer any advice or strategies to avoid specialist foster care becoming an elitist part of the fostering service which is resented by other foster carers?
Speaker: No. This is a big issue. Aware of no research. Audience invited to comment
Audience: In Staffordshire, other carers self-eliminated because of the nature of the requirements of specialist foster care. The need is to be specific about the tasks of specialist foster care to avoid jealousy. Other carers can then be clear it is not for them.
Audience: Is there research on the profiles of young people who benefit the most?
Speaker: The differences have not yet been evaluated over here. Evidence from the US suggests a behavioural approach is successful when young people’s problems are mainly behavioural but it is not known if they are successful for attachment problems, for example. What is known in the UK is that some very difficult young people can be contained.
Audience: A question about costs. Part-time foster carers to support families are paid much less than other foster carers. Shared care should be cheaper. Cost-effectiveness should be judged long term, in terms of prevention of escalation of problems.
Audience: A question about treatment foster care. The US has a very different population, which raises issues about transferability. Treatment foster care could be used inappropriately by Local Authorities to bring young people back from expensive out of county residential placements. It is important to get the right children for the programme.
Speaker: A possible solution would be to cascade, which would free up residential places by using foster care. We need to know how specialist foster care fits into the wide spectrum of provision.
Audience: Specialist foster care is a service model. There are different ways it could be run, and no uniform outcomes are possible. The US has a huge variety of treatment programmes with the same principles, but variation according to the population served.
Speaker : Some things apply to all foster care, but there is an enormous variety of specialist foster care in the US. It is not known what works and for whom.
Comments from the Chair
There is a need for clarity about the expectations of all parties involved.
Presentation 2: Needs and Services: The Children’s Perspective by Helen Jones
Current challenges
Looked after children and other vulnerable children have a very poor outcome, both in care and when they leave. Their needs are complex and they have difficulties in a number of domains in their lives. Current trends show an increase in length of stay in care, although slightly fewer children are entering care. There are real difficulties in co-ordinating service provision, and a number of workforce issues in terms of both supply and demand.
The current policy context
Every Child Matters considers looked after children in Change for Children, aiming to improve all children’s lives across the five outcomes. It raises questions about where looked after children should get to in relation to parity with other children, which is a particular challenge for the most vulnerable children. It supports effective integration of children’s services built around needs, which is a major task for local and central government as well as for the voluntary and community sector.
The Children’s Workforce Strategy is currently in consultation, and all are invited to comment on the proposal.
Effective multi-agency commissioning is needed to develop services for children with complex needs. Every Child Matters focuses on stability and highlights the role of planning to achieve permanence; which raises questions about what counts as permanence. Long-term fostering can be an important option for permanence, with a focus on continued support for foster carers. Through the introduction of independent reviewing officers there will be independent scrutiny of the care planning process for children to ensure that it is appropriate and purposeful in identifying an the right permanency option for the child.
New models and evidence-based models
Research and innovative practice gives new understandings of the origins and impact of children’s difficulties and behaviours, for example research on the impact on brain development of early abuse and neglect. There is a range of evidence-based interventions for children, families and carers which can be used across settings. Rethinking is needed on provisions for children and young people with the greatest needs, and on better understanding of costs and effectiveness;what we pay for, and how we measure effectiveness.
Wrap-around services
There is a need to think about the matrix of services; specialist, targeted and universal, so that all children’s needs are served. Looked after children may need specialist, targetedand universal provision.
Choice protects grant
This grant is for £113 million over three years to support measures to improve placement choice and stability for looked after children, focusing on foster care. A small proportion of funding is retained to fund such national policy initiatives and materials to support foster care recruitment and better commissioning.
Choice Protects policy initiatives
Among the many national policy initiatives to improve the conditions of the workforce dealing with children with high levels of need is the funding and setting up of a national helpline to provide independent advice and information for foster carers 24 hours a day, and work to provide support for foster carers subject to allegations. (There is great variability among Local Authorities in how this stressful situation is dealt with, resulting in the loss of foster carers). There is also work to improve training opportunities and a national award scheme for adults who have made a positive difference for children.
Children and young people who are looked after
Forty-three per cent of children enter care because of abuse and neglect, with poverty the key underpinning factor. There is also a relationship between poverty and poor health, and of young people under 21 in prison, 40% have experienced the care system.
Mental disorder and looked after children
A graph was shown illustrating the prevalence of three types of mental disorder in relation to type of placement – foster care, placed with birth parents on care orders, residential care and independent living. While ‘hyperkinetic disorder’ showed little relationship to type of placement apart from a lower prevalence among young people living independently, prevalence of ‘conduct disorders’ was highest in children in residential care (56%) and lowest in those living with birth parents (28%), while that of ‘emotional disorders’ was lowest (9%) among children in foster care and highest (20%) in those placed with birth parents.
Impact of childhood abuse and neglect
Childhood abuse and neglect is associated with disorganised attachment and sensory chaos leading to poor sensory development and loss of curiosity.The result is a lack of engagement with their environment and significant impact on educational achievement.
Correlations of disturbed attachments
Disturbed attachments can lead to poor impulse control associated with being aggressive and accident prone, oppositional behaviour with carers, problematic peer relationships, less competent social behaviour, less empathy and lower self-esteem.
Policy agenda for looked after children
The focus of the policy agenda for looked after children is to improve life chances, placement choice and stability, educational attainment and services and interventions.
Permanence
A child’s wellbeing is dependent on permanence. The three elements of permanence are legal, physical and emotional.
A healthy environment
A healthy environment provides a supportive personal relationship, stimulates curiosity, provides opportunities to safely exercise choice, provides a safe environment to facilitate cognitive growth and creativity, is free from violence and fear and strengthens the sense of self. Current policy initiatives to promote a healthy environment are 1. Healthy Care, 2. Wellbeing, Creativity and Play and 3. Social Pedagogy research.
Healthy Care
The bedrock of Healthy Care has been the participation of children and young people in setting the agenda for the local authority audits. Other characteristics are opportunities to share good practice, local flexibility to meet a national standard (an audit tool is built in), a national regional and local strategic support network and an holistic approach and training for carers. A model using peer trainers alongside health workers is being developed.
Wellbeing, Creativity and Play
The aim of this initiative is to improve health and wellbeing and attachments through creativity and play. Existing use of creative arts and play will be mapped, an evidence-base identified, and tools developed, such as the play resource magazine ‘Carers Can’, developed after work with foster parents showed that some were not comfortable with playing with children. Local strategic partnerships will include museums, libraries and galleries with a focus on making these accessible to looked after children.
Social Pedagogy
Social pedagogy is about bringing up children in the broadest sense, implying an holistic understanding of children’s needs which includes care, health and education. There is a focus on such activities as art, drama and sport.
Current research
The Department of Health has commissioned research on social pedagogy as a training methodology for residential care from the Thomas Coram Research Unit, which is currently completing its outcomes study. New work about foster care is being commissioned, and the consultation document on the workforce strategy includes social pedagogy, which is also being explored by Sure Start for early years workers.
Multi-Dimensional Treatment Foster Care (England)
In 2003-4 councils with social services responsibilities were invited to bid for pump priming funding with their partners, to develop an alternative provision for children and young people with the most complex needs. This was a response to the success of using treatment foster care as a therapeutic intervention in Oregon. There is also some UK experience such as the ROSTA Project in Liverpool and Coram Family’s Fostering New Links.
The programme is targeted at young people aged 10-16 who are displaying severe levels of challenging and/or anti-social behaviour, self-harming and/or involved in crime and at risk of a custodial sentence and likely to have had a number of placement changes.
The aim of the programme is to stabilise young people in foster care placements close to their own communities, offering them an holistic package which addresses mental health, behavioural, emotional, social and educational needs. This package of interventions aims to improve life chances for young people and to build capacity in relevant agencies.
Goals of treatment foster care
The goals are to encourage normative and pro-social behaviours, achieved by providing close supervision; Clear and consistent limits with follow-through onbreaking rules, limited access to negative influences, the teaching of new skills for forming relationships with peers and and adults, the encouragement of academic skill development and parenting and conflict management training for families are all part of the package, with academic support for young people and support for families in parenting skills and conflict management.
Staff roles
There is a staff team with specific roles in relation to the child, birth family and foster carer which form a net around the young person: a Programme Manager, a Programme Supervisor, therapists for the child and the birth family, a skills worker and a consulting psychiatrist.
What is required?
The programme requires that foster carers are key players in the therapeutic team, that there is a partnership between social care, CAMHS, education and youth justice, and that the team is willing to follow the model of social learning theory of cognitive-behavioural work. There needs to be an infrastructure able to provide interventions with the child and carers in all spheres, including education and leisure. Fundamental to the success of the programme is the provision of 24 hour support.
Evaluation
The universities of York and Manchester are contracted to evaluate the programme. A continuing audit process will collect base data on who, what, where and when. There will be independent assessments of the young person on psychological disorders, crime, school functioning, peers and identity and on the family of origin’s skills and relationship quality. The aim is to identify what works, if possible through using a randomised control trial.
Multi-agency commitment
Commitment is necessary from social services, education, Youth Offending Teams and health commissioners and providers. This requires a multi-agency steering group with regular attendance from senior staff in all agencies, and also links with other local strategic planners for children such as CAMHS strategy and the looked after children group.
The role of the Maudsley Team
The team at the Maudsley are contracted to provide training across sites to ensure fidelity to the model, with a named person for each site. The team work on model adaptation, train staff and carers and provide clinical supervision and support.
Progress
The first placement was in April 2004. Thirty-three children have been admitted to the programme and 21 are currently in a placement.
Reasons for placement breakdown
Reasons for placement breakdown include inadequate mental health assessment, where the level of need was unclear, management pressures to take inappropriate placements and where the child is older than 14 or 15. At this age young people find it difficult to give up freedoms. Placements have failed because of previous experience of the freedom of residential care or where the child is in voluntary care and persuades their family to take them home.
Intensive fostering
The Anti-Social Behaviour Act has the provision for young people to serve a period of the sentence in the community, and foster care may be appropriate provision for this. Scoping work has been commissioned which is likely to build on existing remand schemes. Children and young people are currently being placed andthere may be scope for local collaboration on treatment foster care.
What children say about being in care
‘They can support us by getting to know us, really knowing us. The things that we feel strongly about, that we believe in…Children in care just want someone to take an interest in them’
Questions and discussion on the presentation
Audience: How was the inadequate mental health assessment perceived to be inadequate?
Speaker: Mental health assessments are not all done by CAMHS and there can be a lack of mental health evidence to assess suitability for placement, for example on children’s level of functioning or where there is undiagnosed learning disability. Resources are then wasted because wrongly targeted.
Audience: Are placements likely to break down for all, or only some 14-15 year olds?
Speaker: Not all, but some very streetwise 14-15 year olds don’t last. Those who do stay do well. We need to learn more about engaging them.
Audience: Some things may have successfully changed even for those that don’t stay.
Speaker: For one boy the programme successfully engaged his birth family and got him back in school, even though he didn’t last in the programme.
Presentation 3: Supporting foster care: protecting families and networks from the impact of trauma by Kate Cairns
Unmet Infant Needs
Kate Cairns discussed the experience of working with children whose needs in relation to attachment and recovery from trauma have not been met, and for whom there are likely to be huge issues relating to dependency and stress. The infant brain is patterned by human response. Appropriate responses in infancy build awareness of feelings, empathy and pleasure in social interaction which are patterned into the structure of the developing brain. Children who lack these experiences think and feel with a physiologically different brain, and may be unable to recognise feelings in themselves and others or to find joy in social interaction. They find it difficult to manage impulses, rage, destructiveness and aggression, and do not know why they do things, making them vulnerable to overload. Their cognitive development is impaired; they can lack an internal calendar or clock (leading to missed appointments), the ability to distinguish fact from fantasy (leading to being labelled as liars) the ability to distinguish between ‘mine’ and ‘yours’ and they have poor understanding of cause and effect. These impairments arising from unmet infant, cause major difficulties for carers.
Secondary Traumatic Stress
A model for understanding and managing the impact of living and working with traumatised children is based on the theory that secondary traumatic stress can result from caring for such children, and can present with similar injuries to those of the children. People who are empathic and/or have unresolved personal trauma are particularly vulnerable. Signs and indicators of secondary stress are distressing emotions such as anger, tearfulness and fearfulness, unexplained changes in health affecting sleep and eating patterns or resulting in physical illness, and such manifestations of physiological arousal as jumpiness, nightmares and hypervigilance. Carers can then switch off to the child without realising they are doing so, losing the connection with the child’s trauma. This is why supervision is important in foster care.
A sign that carers are developing secondary traumatic stress is impairment of everyday function, bringing such changes of behaviour as missed or cancelled appointments, decreased use of support networks, diminishing self-organisation such as lateness and lack of self-care and an increase in feelings of isolation, alienation and lack of appreciation. It can resemble burn-out. The result is real changes in both performance and morale. Performance can be reduced in quality and quantity, mistakes are more frequent, tasks are avoided, and there can be an increase in perfectionism, obsessiveness, exhaustion and irresponsibility. Manifestations of effects on morale are loss of confidence, apathy, dissatisfaction, negativity, detachment and feeling incomplete, where the carer takes on the dynamics of the disordered child. Secondary traumatic stress disorder can impact on the entire fostering network as carers withdraw and become more impatient and less appreciative of one another. This leads to an increase in conflict, poor communication and a persecutor/victim/rescuer dynamic. For some traumatised children then, everywhere they go, adults are in conflict.
Caring for Caregivers
Training, support and supervision can contribute to the prevention of stress disorders. Strategies for treatment include physiological self-management and psychological therapies and other therapeutic interventions. For prevention, training should include an understanding of secondary traumatic stress and stress management strategies. Personal and professional development are important to strengthen the carer’s sense of identity beyond their relationship to the child, and opportunities to participate in learning need to be made accessible. Support can be informal, via a knowledgeable network or a ‘trusted challenger’ who will pick up on problems which are being denied. Formal support can be provided through peer groups, mentoring and telephone help lines. Supervision by an agency social worker who visits and reviews regularly, and regular consultancy by a psychologist or therapist supplemented by occasional outside consultants as required can contribute to prevention. However secondary stress disorder cannot always be prevented. It can be treated through physiological self-management and a range of psychological therapies.
Key messages from research
People who live and work with traumatised children are caregivers. They need to be enabled and empowered to become recipients of necessary care. They need to acquire and sustain a non-anxious presence when exposed to trauma.
Questions and discussion on the presentation
Audience: What is the impact on a family’s own children of parents being foster-carers?
Speaker: This is not well explored. There is an impact. There are gifts as well. Trauma is transformative.
Agency-led parallel workshops
The ROSTA Project: Toby Biggins, Director of the ROSTA project, Liverpool.
This is the country’s first Treatment Foster Care project. Therapeutic Foster Care takes an inter-agency, multi-disciplinary team approach to provide therapeutic care with intensive support for young people with mental health problems. The workshop looked at the evidence base on which this service was developed and share messages for practice.
Keeping it Local: Sue Smith, Neighbourhood Care Team Manager, Birmingham Social Care and Health
An exploration of how family support childminders can provide a variety of placement options including overnights to support families and maintain children in their homes. This workshop had valuable messages for agencies focusing on the preventative services.
Direct work with foster children who have severe communication difficulties:
Michael Bridgman, Manager Specialist Fostering, Children’s Services and Cherie Buckland, Foster Carer within Specialist Foster Care, Norfolk Social Services.
This workshop gave an introduction to the specialist foster care service in Norfolk. While Norfolk does not strictly follow the Therapeutic Foster Care model, there are notable similarities in their approach. Norfolk has forged close and strong links with health and education to provide support for children with severe communication difficulties. Cherie, a Foster Carer in the Specialist Foster Care service, shared experiences of supporting autistic children. The workshop also aimed to develop a model to use in practice for supporting children with severe communication difficulties.
Support Care: Families helping Families. A new role for foster carers:Joy Howard, Fostering Network consultant to the Support Care Pilot.
This workshop presented for discussion the ideas and principles of a pioneering scheme in Bradford which offers specialist part-time foster carers a chance to become involved with families in difficulties, when children and young people are at risk of becoming accommodated. In its tenth year, Support Care has proved to be a highly successful preventative intervention. This has led to a Fostering Network, DfES supported pilot over 14 other Local Authorities who are setting up similar schemes.
Joy’s book on Support Care will be published by Russell House later this year.
Children who Foster: Tanya Rogerson, Senior Social Worker and Paula Gibbons Manager Fostering Service, North Tyneside Council.
This workshop was for those who are interested in taking action! The workshop not only outlined North Tyneside’s approach but offered support after the workshop for those wishing to set up a similar service. For the last 10 years North Tyneside have provided a monthly support group for the birth children and grandchildren of foster carers, to support them in sharing their home and families with looked after children, This workshop aimed to show how sensible and valuable this type of service is to the whole family.
Useful References
Nacro (2004) Remand Fostering, Youth Crime Briefing September 2004
JRF (2001) Kinship care for vulnerable young people. Joseph Rowntree Foundation
The Fostering Network (2004) Support for Foster Carers. Fostering Network Discussion Paper
Redding R.E. Fried C, Britner PA (2000). Predictors of Placement Outcomes in Treatment Foster Care: Implications for Foster Parent Selection and Service Delivery, Journal of Child and Family Studies, December 2000, vol. 9, no. 4, pp. 425-447(23)
Jivanjee P (1999) Perspectives on Family Involvement in Therapeutic Foster Care, Journal of Child and Family Studies, December 1999, vol. 08, no. 4, pp. 451-461(11)
Jivanjee P (1999) Professional and Provider Perspectives on Family Involvement in Therapeutic Foster Care, Journal of Child and Family Studies, September 1999, vol. 08, no. 3, pp. 329-341(13)
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