Strengthening foster placements for looked after children: Development of an evidence- based tool for assessment and car

Strengthening foster placements for looked after children: Development of an evidence- based tool for assessment and care planning Steve Rock & Stacey Thomson CAMHS Research Unit Institute of Psychiatry

Background • Instability related to elevated risks • Placement breakdown has been highlighted in recent national practice guidelines (DCSF, 2009; NICE, 2008) • Work completed for an inner London Fostering and Adoption Service funded by CLAMHS

Project overview Systematic review Care plan audit Focus group Tool development Stakeholder consultation Piloting tool CLAMHS consultation

Vignette - Greg Background: Greg is a 14 year-old boy who was first placed in foster care aged 3 following the death of his mother and his father’s inability to assume care as a consequence of mental health problems and substance abuse. While his father’s condition has improved for periods and he has been able to look after Greg and his 11 year-old sister, Greg has been placed in 14 different foster homes over the past 11 years, 4 of which have broken down prematurely. Greg is bright teenager but he has generally underachieved at school and has been described by teachers as a disruptive influence. While he does not have any diagnosed mental health problems, his tendency to have aggressive outbursts has at times been problematic for his foster carers.

Vignette - Greg Immediate circumstances: Two weeks ago Greg was moved to a new placement directly from another foster placement where he was placed with his sister for 3 months. Greg had smashed a window in the carer’s home following an argument with his girlfriend, which led the carers to end the placement. Greg’s sister has remained in the previous placement as it was not possible to find a new placement at short notice that could accommodate them both. His new placement is in the same area as the previous one so he has not had to move school and can see his friends and sister easily. His new carers are in their late forties, are married and have a son of their own who is 12 years old. They have been fostering for 5 years and social worker’s describe them as carers with excellent parenting skills who have high expectations of children in their care in terms of their behaviour and academic achievement. They know that Greg has experienced a high number of previous foster placements but they are unaware of his behavioural problems and do not have a detailed knowledge of his history. In the first two weeks of the placement Greg has been rather withdrawn but has not presented with any challenging behaviour.

Vignette - Greg • In your opinion, what factors presented here are salient to the risk of placement breakdown? (Background/Immediate) • Are there any protective factors? • What else would you want to know?

Systematic review

Systematic review • Why? provided foundation of the project, evidence upon which everything else is based. • Research using either placement moves/placement breakdowns as an outcome measure.

Systematic review – including qualitative evidence Synthesis of qualitative and quantitative evidence • Provides better understanding of processes Example: Quant: previous breakdowns/ placement moves predicts future instability Qual: Children have described a sense of detachment following a placement breakdown

Systematic review Results • Over 100 stability factors identified. • Synthesis of data led to grouping of factors according to several themes

HISTORICAL/BACKGROUND FACTORS (RISK) HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship* Social worker factors - Change in social worker PLACEMENT INSTABILITY

HISTORICAL/BACKGROUND FACTORS (RISK) Child factors - Age (older) - Gender (male) - History of abuse - Care History - History of mental health problems - History of behavioural problems Birth Parent factors - Receiving benefits - Death of mother - Substance abuse - Criminal activity - Mother evaluated negatively by social worker

HISTORICAL/BACKGROUND FACTORS (PROTECTIVE) • Child factors • - Age (older) • - Gender (male) • - History of abuse • - Care History • - History of mental health problems • - History of behavioural problems Child Factors - First placement was Kinship care - Health conditions/ Learning difficulties Carer factors - Age (older) - Long/stable marriage - Good parenting skills/experience Social worker factors - Trained in issues around separation

CIRCUMSTANTIAL/PLACEMENT FACTORS (RISK) Child factors - Behavioural problems at placement - Carer concerned about threat to family/destruction of property* - Recent PBD* - Unexpected behavioural problems* Placement factors - Presence of other children - Separated from siblings - Court-ordered placement - Out of area placement/change in school - Carer not provided with info on child* - Carer’s children loss of freedom* Carer factors - Wants company for own child - Experience of stressful events - Unrealistic/unmet expectations of child* Relationship factors - Child-carer relationship problems - Birth parent hostility towards SW - Birth parent-child contact difficulties - Contact issues stressful for carers* - Birth parent-carer conflict is a stressor for carers* - Poor Carer-SW reason for PBD* Social worker factors - Change in social worker

CIRCUMSTANTIAL/PLACEMENT FACTORS (PROTECTIVE) Placement factors - Kinship care (vs. foster care) - Presence of other children - Placed with siblings - Voluntary placement - Opportunities for child to develop - Carer has good knowledge of child’s history Carer factors - Good social/family support network - Saliency of resources/support impacts on carer commitment* Relationship factors - Committed/ attached child/carer - Birth parent co-operative - Increase in birth parent contact - Frequent SW-child contact - Good Carer-SW rapport - stable/supportive SW-child relationship*

Project overview Systematic review Care plan audit

Care plan audit

Care plan audit Why? • Effective care planning is a priority for the local authority • Placement stability is a priority nationally • Currently no guidance on care planning around placement stability

Care plan audit The purpose of this audit was to establish: • The extent stability factors derived from the evidence base are identified by social workers • The extent to which stability factors identified by social workers are reflected in action plans.

Care plan audit Method • Searched care plans for stability factors identified in review • Identified/evidence of intervention planning • N=53, aged 0-15, referred for foster care between 1st Sept ’09 and 31st Dec ’09

Care plan audit Findings – overview • Variability in level of information recorded. • Overall, there was no consistent approach to planning around placement stability.

Care plan audit Conclusions • Inconsistency/absence of information not surprising in the context of care plan design/lack of guidance → Forms designed around 7 areas of developmental need • Information recorded in other documents • Care planning around placement stability in need of more attention

Project overview Systematic review Care plan audit Focus group

Focus group

Focus group Purpose • Get SW perspective on issues around care planning/ audit findings • Use SW experience to generate ideas for improving practice

Focus group Key themes • Care plans are NOT a document social workers use to help them formulate around placement stability- use other documents. • ‘always thinking about it’ • Adding more ‘check boxes’ or supplementary documents to the care plan was NOT likely to develop a more structured approach to care planning– just more paper work.

Focus group Key themes • Statutory visits - placement stability is at the forefront of thinking. • The notion of a pre-statutory visit checklist explored – a good way of promoting a structured approach to thinking and planning around placement stability.

Project overview Systematic review Care plan audit Focus group Tool development

Development of assessment tool

Development of assessment tool Based on the review findings, audit and focus group……. • Pre-statutory visit checklist (background/immediate/protective factors) • Checklist guidance notes

Using the checklist

Using the guidance notes • P2- Immediate factors 4. SIBLING PLACEMENTS Generally placements are more stable if siblings can be placed together. Although in some circumstances such as when one sibling poses a serious risk to the other, it is necessary to place them separately. If a child has been separated from their sibling it may be helpful to consider: Ensuring the child is happy with frequency and quality of contact arrangements with their sibling(s). When a child has previously played a care-giving role, separation can be particularly distressing due to anxiety about their sibling’s well-being.

Corresponding evidence • Sibling placements –There is consistent evidence that separation of siblings predicts instability and joint placement promotes stability. Sibling separation can be particularly distressing for children who previously played a significant care-giving role in relation to their sibling.

A preventative measure • The checklist and guidance were designed to help social workers ensuring the stability of EXISTING placements.

Project overview Systematic review Care plan audit Focus group Tool development Final consultations and Pilot

Consultation with LFAS Use of the tool in practice • LFAS would like to maintain emphasis on care planning. • Pre-visit checklist/guidance notes to be used to inform care plans. • Checklist to be used as point of reference for Independent Reviewing Officers. • Have stability factors identified in the checklist been incorporated into CPs?

Piloting the tool Method • Informal use - not tied to documentation/ care planning Sample • 8 social workers Focus Group

CLAMHS Consultation Input from CLAMHS Psychology • Using less psychological/formulation-orientated language • Linking the guidance notes to relevant local services

Back to Greg…… Have a go at using the checklist and have a look at the corresponding guidance notes when you have identified a risk factor/ the absence of a protective factor.

Group exercise • How does the tool reinforce good practice? • How does the tool add to or extend existing practice? • What are the practical issues around integrating the tool into practice? • How might the information be used to inform care planning? • How else might the tool be used in practice?

Discussion points • Does using the checklist and guidance notes help? • How might you think about addressing these factors in care plans? • Can you foresee any issues around using these tools?

Strengthening foster placements for looked after children: Development of an evidence- based tool for assessment and car