Creating a System of Quality Therapeutic Residential Care

NECA Conference, Sao Paulo, November 27, 2014

Prof. James P. AnglinSchool of Child and Youth Care

University of Victoria, BC, Canada

Let’s clarify our terms…Over the past decade, international documents have sometimes viewed “institutional care” and “residential care” as synonymous, and

as “having negative consequences both for individual children and for society at large”. (Stockholm Declaration on Children and Residential Care, 2003)

Two international movements underway1. A move at United Nations level to

eliminate “congregate care”, largely in eastern European and southern (African) countries

“the continued proliferation of inappropriate forms of institutional care, the strain placed on kinship carers by the impact of HIV/AIDS, and the movement of children out of vulnerable families onto the street continue to challenge progress in this area” (Better Care Network strategic plan, 2014-2017]

2. A rethinking and reappreciation of residential care in western European and North American countries

The focus is increasingly on therapeutic residential care (TRC) in cottage or home-like settings, sometimes with individual homes in the community and sometimes with multiple homes on one property.

And sometimes the wires get crossed…In August of 2012, the U.S. Annie E. Casey Foundation sponsored a symposium in New York City on the effectiveness and place of residential care within a state or community’s child welfare system.

Those in attendance [don’t know who]reached a consensus that residential care was not appropriate for children because of two primary reasons; the lack of precision parenting (services and programs do not focus on the individual child’s needs) and that children are less likely to form appropriate attachments in group care.

This conclusion must have been drawn either on the basis of ideology (e.g. “every child should live in a family”) and in ignorance of contemporary developments in the field.

First, it is a core principle of therapeutic residential care to focus on each individual child’s best interests. Small settings and adequate staffing with strong therapeutic models do allow for such individualized and personalized care.

Second, group residential care is needed precisely because some young people with complex needs need to develop self-regulation skills and trusting relationships in a non-familial setting (i.e. a 24-hour staffed home) in order to be ready to live in a family setting, whether of origin, kin, foster or eventually of their own formation.

There have been a number of attempts to eliminate residential settings in the past in the UK, USA and Australia, but none has been successful.

In 2002, I published a study of well-functioning homes

It was the stories of the turnarounds told to me by young people who had lived in well-functioning group homes that convinced me that they had a role and purpose in the out-of-home care system.

One young woman had been through 32 foster homes in 6 years…

WHO IS THE SLOW LEARNER HERE?

The touchstone of good residential/ group home careThe struggle for congruence in service of

the best interests of childrenBut all programs think they are acting in

the best interests of the children in care, when in fact many are not, or at least not consistently

Congruence means that there is consistency, reciprocity and coherence within and across all levels of agency functioning

Levels of Group Home OperationExtra-agencyManagement/LeadershipSupervision and ClinicalCarework/TeamworkChild and Family

Basic psycho-social processesCreating an extra-familial living environment – the prime task of managers

Responding to pain and pain-based behaviour – the key challenge for careworkers

Developing a sense of normality – the basic need for young people in care

All positive changes can be traced to 11 interactional dynamics listening and responding with

respect; communicating a framework for

understanding; building rapport and relationship; establishing structure, routine

and expectations; inspiring commitment;

Interactional Dynamics (cont’d)

offering emotional and developmental support;

challenging thinking and action; sharing power and decision-making; respecting personal space and time; discovering and uncovering

potential; and providing resources.

The Framework Matrix for Understanding Group Home Life and Work

I Creating an extra-familial living

environ-ment

II Responding to pain and pain-based behaviour

III Developing a

sense of normality

Basic Psychosocial Processes

Levels of Group Home Operation

Youth 1 and Family

Carework 2 & Teamwork

Supervision 3

Extra-agency 5

Management 4

Interactional Dynamics

e) Inspiring commitment

g) Challenging thinking & action

c) Building rapport & relationship

h) Sharing power & decision-making

b) Communicating a framework for understanding

d) Establishing structure, routine & expectations

a) Listening & responding with respect

f) Offering emotional & developmental support

i) Respecting personal space & time j) Discovering & uncovering potential

k) Providing resources

Core Theme: CONGRUENCE IN SERVICE OF THE CHILDREN’S BEST INTERESTS

COHERENCE

RECIPROCITY CONSISTENCY

Moving from “last resort” to positive option in the system of carePlacing workers need to accept that well-

functioning group care is positive for the right young people, at the right time

There needs to be a move away from a mechanical formula for placement that leads to multiple foster home “breakdowns” before a residential placement

Child welfare systems need to invest in developing and maintaining well-functioning group care

Workers need to carefully assess the level of care, supervision and intensity required by youth

The challenge of decision rulesFor example:All children have a right to live in a

family (except those who can’t)Try (all) less intrusive services before

more intrusive alternatives (but less intrusive for whom?)

Place a child in residential care only as a last resort (which may mean years of misplacements and pain)

Every child has a right to permanency and stability (but what do we do to ready them for such a place?)

Others?

What characteristics of group homes need to be considered for placement?• Group homes are not families; a strength for

some young people (level of intimacy)• Child expected to fit in with family versus

group home designed to adjust to needs of the child

• Sense of ownership of home and contents• Number of carers and children present,

potential relationshipsShifts of staff versus 24/7/7 parentsIntensity and consistency of therapeutic

carePresence of on-site supervision

We are at an exciting time in the evolution of our understanding of why some young people struggle with the challenges of everyday life…

and the role quality residential care for young people can play in helping these young people to turn around and learn to self-regulate.

Therapeutic residential care is the term being used internationally for trauma-informed and therapeutic relationship-based approaches

A recent development is the convergence of the emerging field of neuro-biology and child and youth care

Especially the work of Bruce Perry (MD, PhD)

Brain research is now demonstrating that:

Early childhood traumas alter the development of neural pathways in the brain;

but thanks to neuroplasticity, consistent, nurturing caregiving over the course of everyday life can help to create new pathways;

through creating a sense of safety, human connections and “scaffolding” for self-regulation.

I recommend The Boy Who was Raised as a Dog and other stories from a child psychiatrist’s notebook (2009)

Dr. Perry’s research has demonstrated the importance of therapeutic relationships in healing the effects of childhood trauma

“We learned that some of the most therapeutic experiences do not take place in “therapy”, but in naturally occurring healthy relationships… “ (p.70)

“People, not programs, change people.” (p. 80)

There is growing international evidence that implementing strong therapeutic residential care models is having a positive impact on the quality of care provided and the child outcomes being achieved.

Strong models target the whole residential agency (and preferably the child protection system) to implement a principle-based approach that truly serves the best interests of children.

An effective system needs to be congruent within and across all levels

So, what is the evidence for its effectiveness?

The criteria for “evidence-based practice” are based on the medical drug-trial model, and require “randomized control trials” (RCTs) which are expensive, challenging and raise ethical issues to do in residential care.

However, recent non-RCT evaluations of therapeutic models in the State of Victoria (Australia), Northern Ireland and the USA (Cornell University) have shown positive and promising results, and findings from even more rigorous studies will be available in the near future.

From TRC Evaluation (Verso Consulting, State of Victoria, Australia, 2011)

Significant improvements in placement stabilityChildren and young people placed in a TRC have experienced far greater stability compared to their previous experience.

Significant Improvements to the quality of relationships and contact with familyThe children and young people in TRC have experienced and sustained significant improvements to the quality of contact with their family during their period in TRC.

Sustained and significant improvements to the quality of contact with their residential carers over time in the TRC pilotsChildren and young people in the TRC pilots are developing and sustaining secure nurturing, attachment-promoting relationships with residential carers in the TRC Pilots.

Increased community connectionChildren and young people in the TRC Pilots were more likely to engage in community activities or have a part time job than young people in general residential care.

Significant improvements in sense of SelfChildren and young people in the TRC have experienced and sustained significant improvements in their sense of self, indicating improved mental health.

Increased healthy lifestyles and reduced risk takingChildren and young people in the TRC experienced a reduction in risk taking which was evident over time in reduced episodes of negative police involvement (although not immediate), police charges and secure welfare admissions.

Enhanced mental and emotional healthAcross the SDQ and HoNOSCA measures, the children and young people in the TRC experienced improvements and significant reductions in the mental health symptom severity.

The development and implementation of therapeutic residential care is a movement towards congruence across an entire agency and, ideally, the whole child welfare/protection system.

To be effective, every person in an agency/system needs to be:knowledgeable about therapeutic principles, values

and practice methods; working consistently in alignment with therapeutic

principles and values, andsupported in an ongoing way (‘scaffolding’) to put

them into practice.

It takes an agency about 3 years to make the initial transition, but the residents notice and respond to the change right away

Residential care is not rocket science,

It’s far more complex than that!

ReferencesAnglin, J.P. (2002). Pain, Normality and the Struggle for Congruence: Reinterpreting Residential Care for Children and Youth. Binghamton, NY: Haworth

Anglin, J.P. (2012). The process of implementing the CARE program model. Paper presented at EUSARF/CELCIS Looking After Children Conference, September 6, Glasgow, Scotland.

Holden, M.J. (2009). Children and residential experiences: Creating conditions for change. Arlington, VA: Child Welfare League of America.

Holden, M.J., Anglin, J.P., Nunno, M.A. & Izzo, C.V. (2014) Engaging the total therapeutic residential care program in a process of quality improvement: Learning from the CARE model. In Whittaker, J.K, del Valle, J. F. & Holmes, L. (Eds.) (2014) Therapeutic Residential care for Children and Youth: Developing Evidence-Based International Practice. London: Jessica Kingsley Press.

Kahn, W.A. (2005). Holding fast: The struggle to create resilient caregiving organizations. New York: Brunner-Routledge.

Lee, B.R. & Barth, R.P. (2011). Defining group care programs: An index of reporting standards .Child and Youth Care Forum, 40 (4), 253-266.

Li, J. & Julian, M.M. (2012). Developmental relationships as the active ingredient: A unifying working hypothesis. American Journal of Orthopsychiatry, 82 (2) 157-166.

What are the implications for Brazil?

Let’s discuss…